Acute Coronary Syndromes

© Resuscitation Council (UK) ERC

Objectives
• To discuss the clinical spectrum of
ischaemic heart disease
• To recognise different presentations
of the disease process
• To discuss treatment of the different
clinical presentations encountered

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Fissuring Plaque

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Acute Coronary Syndromes
Clinical syndromes form spectrum
of the same disease process:

Unstable angina
↓
Non-Q wave myocardial infarction
↓
Q wave myocardial infarction
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 Stable angina
• Pain from myocardial ischaemia
– tightness/ache across chest
– radiating to throat/arms/back/epigastrium
– provoked by exercise
– settles when exercise ceases
• NOT an acute coronary syndrome

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 Unstable angina
• Angina of effort with increasing frequency and
provoked by less exertion
• Angina occurring recurrently and unpredictably - not
specific to exercise
• Unprovoked and prolonged episode of chest pain - no
ECG or laboratory evidence of MI

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Non-Q wave myocardial infarction
• Symptoms suggesting MI
• Non-specific ECG abnormalities initially
– ST segment depression
– T wave inversion
• Elevated cardiac enzymes
• Unstable coronary artery disease
– unstable angina
– non-Q wave MI

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Non-Q wave myocardial infarction

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Q wave myocardial infarction
• Prolonged chest pain
• Acute ST segment elevation
• Q waves
• Elevated cardiac enzymes
- creatine kinase
• Troponins

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Anterolateral myocardial infarction

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 New terminology
• Q waves (or a lack of them) take time to develop
clinically
• Treatment is based on the admission and
subsequent 12 lead ECGs
• Is ST segment elevation present or not ?
• STEMI or NSTEMI

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 STEMI
• ST Elevation MI
• Usually develops into Q wave MI
• Troponin positive
• However, early effective treatment
may prevent full thickness infarct

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 NSTEMI
• Non ST Elevation MI
• Usually do not develop Q waves
(but may do)
• May or may not be troponin positive
• Treatment may depend on other
clinical factors and history

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 Immediate management and
treatment in all
acute coronary syndromes
• A,B,C,D,E approach
• “MONA”
– Morphine (or diamorphine)
– Oxygen
– Nitroglycerine (GTN spray or tablet)
– Aspirin 300 mg orally (crush/chew)

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 Patients with ST Elevation MI
or MI with LBBB
Early coronary reperfusion therapy:

• Thrombolytic therapy
• Percutaneous transluminal coronary angioplasty (PTCA)
• Coronary artery bypass surgery (CABG)

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Left Bundle Branch Block

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Absolute contraindications to
thrombolytic therapy
• Previous haemorrhagic stroke
• Other stroke or CVA within 6 months
• Active internal bleeding
• Aortic dissection

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 Unstable angina and
Non-Q wave MI (NSTEMI)
‘MONA’
•
Heparin
•
continuous infusion unfractionated, or
–
subcutaneous low molecular weight
–
Intravenous nitrate
•
If ‘high risk’
•
glycoprotein IIb/IIIa inhibitor
–
Consider beta-blockers
•

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Any Questions?

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 Summary

• In acute coronary syndromes consider

A, B, C, D, E approach and ‘MONA’

• Start reperfusion therapy early if

indicated

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