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INTRODUCTION DEFINITION Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood flow

to the heart. Acute coronary syndrome symptoms may include the type of chest pressure that you feel during a heart attack, or pressure in your chest while you're at rest or doing light physical activity (unstable angina). The first sign of acute coronary syndrome can be sudden stopping of your heart (cardiac arrest). Acute coronary syndrome is often diagnosed in an emergency room or hospital. Acute coronary syndrome usually occurs as a result of one of three problems:ST elevation myocardial infarction (30%), non ST elevation myocardial infarction (25%), or unstable angina (38%). NSTEMI also known as non-ST segment elevation myocardial infarction is one type of heart attack, which is defined as the development of heart muscle necrosis results from an acute interruption of blood supply to a part of the heart muscle that is demonstrated by an elevation of cardiac markers (CK-MB or Troponin) in the blood and the absence of persistent ST-segment elevation in electrocardiography. SIGNS AND SYMPTOMS The cardinal sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with diabetes). Some may report palpitations, anxiety or a sense of impending doom (angor animi) and a feeling of being acutely ill.The description of the chest discomfort as a pressure has little utility in aiding a diagnosis as it is not specific for ACS CAUSES Acute coronary syndrome is most often a complication of plaque buildup in the arteries in your heart (coronary atherosclerosis) These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them. Eventually, this buildup means that your heart can't pump enough oxygen-rich blood to the rest of your body, causing chest pain (angina) or a heart attack. Most cases of acute coronary syndrome occur when the surface of the plaque buildup in your heart arteries ruptures and causes a blood clot to form. The combination of the plaque buildup and the blood clot dramatically limits the amount of blood flowing to your heart muscle. If the blood flow is severely limited, a heart attack will occur.


Older age (older than 45 for men and older than 55 for women) High blood pressure High blood cholesterol Cigarette smoking Lack of physical activity Type 2 diabetes Family history of chest pain, heart disease or stroke. For women, a history of high blood pressure, preeclampsia or diabetes during pregnancy DIAGNOSIS Electrocardiography (ECG): Electrocardiography finding of NSTEMI is usually associated with ST-segment depression, transient ST-segment elevation, or Twave inversion. Cardiac markers: Cardiospecific isoenzyme CK-MB (creatine kinase myocardial band), and cardiospecific proteins troponin T and troponin I are rises in NSTEMI. CK-MB starts to rise at 4-6 hours and falls to normal within 48-72 hours. Troponin T and troponin I start to rise at 4-6 hours and remain high for up to two weeks. Full blood count: Elevation of WBC count is usual. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may elevate. Chest X-ray: Assess for signs of lung edema. Echocardiography: It is done for assessing ventricular function and for detecting important complications. TREATMENT AND MANAGEMENT Patients should be admitted immediately to hospital, preferably to a cardiac care unit because there is a significant risk of death. (1) Bed rest with continuous monitoring by ECG. (2) Inhaled oxygen therapy. (3) Relief of pain by opiate analgegic: Intravenous morphine 10 mg or diamorphine 5 mg is usually used and may have to be repeated to relieve severe pain.

(4) Antiplatelet therapy: Antiplatelet drugs prevent platelet aggregation within coronary artery. A 300 mg tablet of aspirin should be given orally as early as possible then 75 mg daily should be continued indefinitely if there are no side effects occur. (5) Anticoagulant therapy: Anticoagulant drugs prevent reinfarction, and reduces the risk of thromboembolic complications. (6) Beta-blockers: Beta-blockers reduce arrhythmias, heart rate, blood pressure and myocardial oxygen demand, and relive pain. (7) Nitrates: Nitrates act as a vasodilator and relief pain. (8) Statins: Irrespective of serum cholesterol level, all patients should receive statin such as atovastatin, simvastatin, or rosuvastatin after NSTEMI. (9) ACE (angiotensin converting enzyme) inhibitors or ARBs (angiotensive receptor blockers): An ACE inhibitor such as ramipril, enalapril, captopril, or lisinopril is started 1 or 2 days after NSTEMI. (10) Coronary angiography and revascularization: All patients with NSTEMI should be considered for early coronary angiography and revascularization, either by PCI (percutaneous coronary intervention) or by CABG (coronary artery bypass grafting), especially where they are at medium to high risk patients. Early medical treatment is appropriate in low risk patients, and coronary angiography and revascularization reserved for those who fail to settle with medical treatment.

PATIENTS PROFILE Name: FA B-day: March 09, 1944 Age: 69 Sex: Male Status: Married Address: Cuyapo, Nueva Ecija Attending Physician: Dr. Josephine Tindungan Date Admitted: July 28, 2013 Chief Complaint: Chest pain Final Diagnosis: Acute Coronary Syndrome Non ST Elevation Myocardial Infarction