DISMED 2011-2012

Acute
Coronary
Syndrome
Unstable
Angina

Def: Refers to a group of clinical presentations

that share a common pathology of
disturbance of an atherosclerotic plaque
leading to acute coronary ischemia.

Change in Stable Angina

Classified into:
1. Unstable angina (change in stable angina, recent onset angina, post MI
angina)
2. Non ST elevation MI (NSTEMI)
3. ST elevation MI (STEMI)

Physical examination:
1. Hypotension / hypertension
2. Diaphoresis
3. Pulmonary edema and other
sign of lf heart failure

Recent onset angina

Post MI angina

4.Extracardiac vascular disease

5. S4 maybe heard in pt with ischemia or systolic
murmur 2ry to mitral regurgitation
6. Other findings (cool,clammy skin and
diaphoresis in pt with cardiogenic shock)

C/P:

Investigation:
Pain or discomfort in chest or lf
arm
Rest angina usually last >20min
New onset angina
Increasing (crescendo) angina =
>frequent, longer duration, lower
in severity.
Shortness of breath (maybe
angina equivalent or symptom of
heart failure)
Atypical symptoms: arm, jaw,
neck,ear or epigastric discomfort.
Symptoms related to exertion or
stress and relieve by nitroglycerin.

ECG normal or show transient ST-T

wave changes
Lab investigation: Mild increase in
cardiac enzyme and troponin
Echocardiography may show transient
wall motion abnormality of LV
Radioisotope perfusion study show
reversible ischemia
Coronary angiography is the gold
standard for diagnosis of acute
coronary syndrome and consideration
of the management strategy

Risk Assessment:
High risk pt has any one of the following:
1. Clinical instability
2. Accelerating chest pain in the 48h before
presentation
3. Prolonged ischemic chest pain
4. Clinical evidence of heart failure
5. Hypppoootension
6. Ventricular tachycardia
7. ECG changes of ischemia
8. Positive cardiac biomarkers

DISMED 2011-2012

DD (Causes of chest pain):

Aortic dissection
Aortic stenosis
Myocarditis
Pericarditis
Cardiac neurosis
Esophageal spasm
Gastroesophageal reflux disease
Pneumothorax
Pulmonary embolism
Acute cholecystitis
Hypertensive emergency

Treatment:
Conservative medical ttt:
1.

2.

Anti ischemic
Control of pain by analgesics
Nitrates
B-blocker or Calcium channel blockers
Antiplatelet
Aspirin 160-325mg initial dose followed by 80150mg/day
Clopidogrel 300-600mg followed by 75mg/day
3. Anticoagulant
Heparin infusion and low molecular weight heparin
Other anti-thrombotics agent

Revascularization invasive ttt:

Indicated after failure of medical

ttt or early in high risk pt.
Early coronary angiography ang
angioplasty and stenting to rstore
the blood flow.

DISMED 2011-2012
-SNI- Group 8-