Acute Coronary Syndrome I.

Definition/General Considerations * Types of acute coronary syndromes A) Stable angina: Substernal chest pain due to myocardial ischemia (increased demand or decreased supply), associated with exertion, and relieved with rest or T! " #ue to atherosclerosis and subse$uent narrowing %) &nstable angina'non"transmural infarct: &A if new, accelerating (occurs with less exerertion, lasts longer, or less responsive, or occurs at rest) " #ue to disrupted pla$ues that are being thrown, but not completely occluding () )*'Transmural infarct: +cclusive thrombosis or prolonged vasospasm in coronary artery " ,-. result in death due to sudden arrhythmia (v/ fib) * 0is1 factors for A(S: Age, gender, dyslipidemia, #), 2T , smo1ing, 32 " +thers: (ocaine use, hx of previous )*, obesity, elevated homocysteine, elevated lipoprotein (a) * (omplications 4) *nfarct extension ,) Arrythmias (v"tach and v"fib) 5) Acute (23, (ardiogenic shoc1 6) 7ericarditis: 3ibrinous or hemorrhagic 8) 7apillary or ventricular muscle rupture 9) :; aneurysm, )ural thrombus <) (ardiac tamponade with %ec1=s triad of: hypotension, distant heart sounds, elevated >;7 II. Clinical Findings * Signs and symptoms of various A(S A) Stable angina 4) Symptoms: ?xertional substernal chest pain that radiates to lower @aw, left shoulder, or left arm " )ay also see: ';'S+% " 0elieved by rest and'or T! ,) Signs: ?levated %7, tachycardia, diaphoresis, S6 %) &nstable angina: Similar to stable angina but occurs at rest and with less exertion () Transmural infarct: Similar to angina, but more severe, lasts A5- min, and doesn=t resolve with T! " )ay also see S+%, anxiety, and impending sense of doom * Silent ischemia occurs in: ?lderly, diabetics, and post"op patients III. Workup check blue book A) ?B! %) (ardiac enCymes of troponin and (B")% serially $9hrs x 5 or $Dhrs for ,6 hours 4) Troponin * " +nset: 6"9 hours " 7ea1: 4D",6 hours " #uration: <"4- days ,) (B")% " +nset: 6"9 hours " 7ea1: 4D",6 hours " #uration: 59"6D hours () ?xercise stress test: Angina, ST"changes, exercise intolerance, and decreased systolic %7 indicate myocardial ischemia #) ?cho: )easures abnormal wall movement and can assess ?3 " ormal ?3 E 88. ?) (oronary angiography: (onfirms presence and maps extent of (A#F define method of revasculariCation (7T(A or (A%!) IV. Laboratory Findings * Stable angina 4) ?B!: ST"depression and T"wave flattening ,) (ardiac enCymes: ormal 5) ?xercise stress test: )ay show mild ischemia 6) (oronary angiography: (onfirm (A#

* &nstable angina'non"transmural infarct 4) ?B!: ST"depression and T"wave flattening ,) (ardiac enCymes: ormal 5) ?xercise stress test: 0eveals signs of ischemia 6) (oronary angiography: (onfirm (A# * )*'Transmural infarct 4) ?B!: ST elevation and G"waves a) Hithin minutes: ST elevation b) Hithin hours: G waves and T"inversion c) ,6"6D hours: ST normaliCe, but G"waves and T"inversion remain d) Hee1s: G"waves remains, but T"wave normaliCes e) :eads " Anterior infarct: ;4";6 " *nferior infarct: **, ***, and a;3 ,) (ardiac enCymes: *ncreased 5) ?cho: Abnormal wall function, :;2I, etc/ 6) (oronary angiography: Stenotic lesions and obstructions noted V. Differential Diagnosis * ##x for types of A(S " See above * (atastrophic causes of chest pain E TA7&) (Tension, Aortic, 7?, &A, )*) 4) )* ,) &A 5) Aortic #issection 6) 7ulmonary embolism 8) Tension pneumothorax 9) ?sophageal rupture * +ther causes of chest pain (in order of fre$uency after catastrophic causes) 4) (hest wall structures: *ntercostal neuritis from herpes Coster and #), costochondritis ,) 7sychogenic factors 5) ?sophagus" ?shophagitis, !?0#, 7&# 6) onischemic myocardium 8) 7ericarditis 9) :ung: 7neumonia VI. reat!ent * !eneral treatment protocol A) 7harmacologic 4) )orphine decrease preload and decrease S S decrease myocardial +, use ,) +xygen 5) T! #ecrease preload and afterload " !ood for (23 6) ASA (prevent platelet aggregation decreases mortality), A(?i (decrease :; enlargement, afterload, and remodeling decrease mortalityF best for large anterior infarcts) 8) %eta"bloc1ers decrease contractility and arrhythmia decreases mortality " #on=t give to cocaine"users b'c of unopposed alpha adrenergic action " )ay use non"selective alpha and beta bloc1er (labetalol) in some patients 9) Statin: :#: J 4-<) **b'***a bloc1ers: +nly useful in those with &A who have ST changes and enCyme elevation D) (lopidogrel: +nly to patients with &A who have ST changes and enCyme elevation K) ?noxaparin: +nly to patients with &A 4-) t7A followed by *; heparin only in patients with )*'transmural infarct if cath lab not present %) (oronary revasculariCation 4) 7T(A: 3ailure of medical management, 8-. stenosis reduced by stents and **b'***a inhbitors ,) (A%!: 3ailure of medical tx, 5 or more vessels, , or more vessels in diabetic () :ifestyle 4) Stop smo1ing: , yrs after $uitting, )* ris1 E nonsmo1er ris1 ,) ?xercise: Strengthen heart, collaterals, and increase 2#: