Acute coronary syndromes

Acute coronary syndromes

Acute medical emergencies arising from complete or critical occlusion of one or more coronary arteries

Coronary artery occlusion

Pathophysiology
Rupture or erosion of fibrous cap of coronary artery plaque
Platelet adhesion/ aggregation

Thrombus formation, vasoconstriction

Types of ACS
Unstable angina Non-ST elevation myocardial infarction(NSTEMI) ST elevation myocardial infarction(STEMI)

Clinical features of NSTEMI

Sudden onset of chest pain or deterioration of pre-existing angina Pain typically radiates to left arm or jaw, pain may occur at atypical sites Other atypical features include feeling of indigestion, dyspnea, sweating 4th heart sound, cardiac murmurs Hypotension, crepts at lung bases

Differential diagnosis
Dissection of aorta
Pulmonary embolism Pneumothorax Peptic ulcer

Investigations
ECG May be normal especially during initial period

NSTEMI ST depression, deep T wave inversion STEMI ST elevation, LBBB, followed by T inversion and appearance of Q wave

Deep T wave inversion

ST-depression

ST elevation

Investigations

CK-MB Trop-T more sensitive, less specific

Management
MONA Morphine Oxygen Nitroglycerin Aspirin

Management -NSTEMI
Clopidogrel Low molecular weight heparin Glycoprotein IIB/IIIA inhibitors, Abciximab Beta blockers Atenolol, Metoprolol Statins, Atorvastatin, simvastatin ACE inhibitors Ramipril, Lisinopril

Management -NSTEMI
Coronary intervention Balloon vasculoplasty Coronary stenting Coronary artery by-pass grafting (CABG)

Stenting

Coronary artery By-pass grafting

STEMI
Infarction of full thickness of myocardium due to coronary artery occlusion/spasm

Clinical features
Sudden onset of chest pain or deterioration of pre-existing angina Pain typically radiates to left arm or jaw, pain may occur at atypical sites Other atypical features include feeling of indigestion, dyspnea, sweating, syncope 4th heart sound, cardiac murmurs Hypotension, tachy/bradycardia, crepts at lung bases

ECG changes
Inferior wall II,III, aVF Anerior wall V1-4 Septal V2-3 Lateral wall I,aVL, V5-6 Posterior wall reciprocal changes in V1

TIMI risk score in STEMI

Age>65 Age >75 History of angina History of hypertension History of diabetes Systolic BP<100 Heart rate >100 Killip II-IV Weight>67 kg Anterior MI or LBBB Delay to treatment >4 hrs 2 3 1 1 1 3 2 2 1 1 1

Score
0 1 2 3 4 5 6 7 8 9-18

Risk(% death at 30 days)

0.8 1.6 2.2 4.4 7.3 12.4 16.1 23.4 26.8 35.9

STEMI management (limiting the size of infarct)

MONA Bed rest Beta blocker GpIIb/IIIa inhibitors, followed by PCI Thrombolysis
Streptokinase Tissue plasminogen activator(TPA)

Relief of anxiety Avoidance of constipation

Complications
Heart failures Myocardial rupture Aneurysm formation VSD MR papillary muscle dysfunction/ruptyre

Complications contd
Conduction abnormalities Arrhythmias

Dresslers syndrome
20% of patients, most common in patients with STEMI, anterior wall, high cardiac enzymes 2-10 weeks after infarct Pericarditis, low fever