Acute Coronary Syndromes

Definitions

Result of plaque rupture!

Includes: Unstable angina, NSTEMI, STEMI

Unstable angina:

accelerating pattern of pain: frequency, duration, threshold of exertion, response to Tx

angina at rest

new-onset angina

angina post-MI or post-procedure (PCI, CABG)

MI diagnosis: Troponins (evidence of necrosis)+ 1 of the following:

Sx of ischemia (chest/upper extremity/mandibular/epigastric discomfort; dyspnea)

ECG changes (ST-T changes, new LBBB or pathological Q waves)

Imaging evidence (myocardial loss of viability, wall motion abnormality or intracoronary thrombus)

if biomarker changes are unattainable, cardiac symptoms + new ECG changes is enough

NSTEMI diagnosis: meets MI criteria without ST elevation or LBBB

STEMI diagnosis: meets MI criteria with ST elevation or new LBBB

Investigations

Troponins (elevated in 2-3 hours, peak in approx. 24 hours, and persist for 1-2 weeks)!

ECG (generalization): !

ST elevation (in 2 contiguous leads)=new LBBB in STEMI

ST elevation: 1 mm in limb leads, 2 mm in precordial leads

ST depression/T inversion in UA/NSTEMI

Q waves - loss of myocardium (if 1/2 of R wave)

CBC - rule out anemia as 2 cause of MI

K, Mg - monitor to prevent arrhythmias (ordered as part of electrolyte panel)

PT/PTT/INR - to assess bleeding state

Creatinine - to decide on ACEI

CXR - assessment of cardiomegaly, pulmonary edema (ischemia complication), aneurysm,

pneumonia

ECHO - questionable Dx, extent of infarct, overall Fn of ventricles, compilations (acute mitral
regurgitation, LV rupture, and pericardial effusion)

Management (general approach)

Treat acute problem!

General - ABCs, rest, oxygen, nitroglycerin (SL>IV), pain control (morphine IV, Nitroglycerine)

NSTEMI: BEMOAN (-blocker, Enoxaparin, Morphine, O2, ASA, Nitrates)

http://nstemi.org/nstemi-vs-stemi/

STEMI: Thrombolysis (within 30 min) vs PCI (within 90 min)

Nitroglycerin - vasodilates ( O2 supply); does not prevent mortality

The rest of the meds on this page decrease mortality/improve survival (!):!

ASA - platelet aggregation

Some patients may get Clopidogrel

Some may get IIb/IIIa inhibitors -

Heparin (Enoxaparin) - deactivates clotting factors (mostly Xa)

-blockers - contractility, HR ( O2 demand)

Treat underlying coronary disease:!

ACEI

Statins

Education

TIMI risk score for UA/NSTEMI

TIMI = thrombolysis in myocardial infarction
1 point each:
!
!
!
!
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Hx

Presentation

Age 65 yr

Recent (24 h) severe angina

3 risk factors for CAD

ST-segment deviation 0.5 mm

Known CAD (stenosis 50%)

Increased cardiac markers

Aspirin

Risk Score = Total Points

If TIMI risk score 3, consider early LMWH and angiography

STEMI complications and prognosis

Complications!

Arrhythmic (minutes-first few days):

acute ischemia, LV impairment, remodelling > ventricular arrhythmia

ischemia of conduction system>bradyarrhythmias, block

Mechanical (direct results of myocardial damage - 3-7 days):

Rupture of papillary muscle, ventricular septum, or free wall rupture

Mitral regurgitation (due to wall stiffness/remodelling)

Acute heart failure (left or right heart)

Inflammatory!

Acute pericarditis (day 1-6)

Subtype - Dressler syndrome (abnormal immune response to damaged myocardium)

Left ventricular thrombus (most common is apex of the left ventricle after an anterior STEMI)

Prognosis!

5-15% of hospitalized patients die

After discharge: 6-8% within first year, half of these within first 3 months; 4% per year following first year