Acute Coronary Syndrome (ACS)

Week 10

Definition:
It is a set of signs and symptoms – due to decreased blood flow in the arteries
Could lead to HF, AF

Causes:
Usually a spontaneous rupture or fissuring of an atheromatous plaque in the coronary arterial wall

Thrombosis and obstruction in coronary artery (stops blood flow through the coronary artery)

Ischemic myocardial injury – no oxygen of the cardiac tissues

Classification:
Classified depending on death in cardiac muscle (also called myocardial infarction (MI))

No Myocardial Infarction Myocardial Infarction

Further divided into 2 types depending on ECG
Non-ST-segment ST-segment
Unstable Angina (UA)
elevation MI (NSTEMI) elevation MI (STEMI)
Ischaemia not severe enough to
cause myocyte injury (v small -61% -39%
troponin rise)
STEMI = complete obstruction of coronary artery (most dangerous)

UA and NSTEMI = still some blood reaching heart

Risk Factors
Modifiable Non-modifiable
 Smoking  Age
 Diabetes esp. Type 2  Male
 Hypertension  Family History
 Dyslipidaemia – increased cholesterol  History of angina
 Obesity
 Psychological factors
 Lack of exercise
 Diet low in fruit + vegetables and rich
in saturated and trans fats
 Diagnosis:
1. Patient History
 Age
 Past Medical History (hypertension, angina, etc.)
 Medication history
2. Symptoms
 Pain that is:
o Persistent (even when at rest), lasting > 15 mins
o Radiating to jaw, back, shoulder, neck, arm
o Crushing (not always)
o Increasing in intensity
 Sudden onset of pain
 Breathlessness, hypotension, dizziness, syncope, tachycardia + sweat/bradycardia +
N&V (depending on nerve activated i.e. sympathetic or vagal)
 Fever - Inflammation
 Leucocytosis – increased inflammatory markers
 4th heart sound – forceful filling of left ventricle

DDX for Persistent Chest Pain:

GORD Acute heart failure

Pneumonia Pulmonary Embolism

3. 12 lead ECG
 STEMI = ST-segment persistently elevated or new left bundle branch block
 NSTEMI/UA = normal ECG or depressed ST-segment or T wave inversion
4. Troponin Levels - only raised in MI
 STEMI/NSTEMI = Raised troponin lvls
 UA = normal troponin lvls

Management
2 Steps:

1. Acute Attack (i.e. current symptoms)

2. Long-term after patient stabilised including pharmacological and non-pharmacological
treatment

1. Managing Acute Attack

 Call 999 (admit pt to hospital)

 IV opioids (Morphine 10mg IV I/R)
 Aspirin 300mg orally (loading dose)
 GTN sublingual tablet
 P2Y12 Antagonist loading dose (Ticagrelor 180mg recommended, can also use
Clopidogrel 600mg, Prasugrel 60mg)
 O2 if sats < 94%
 B-blocker (metoprolol 5-15mg IV or 50-100mg PO)
 STEMI NSTEMI
WITHIN 2 HOURS 1. 1° percutaneous coronary 6 month mortality risk
intervention (PPCI) using GRACE tool
 Access via radial or
femoral artery If ≥ 3% = require cardiac
 x-ray guided insertion thru catherization within 72
OR aorta + into affected hours + revascularization
coronary artery via stenting or bypass
 insertion of balloon which is
filled + a stent to restore If < 3 % = start
blood flow pharmacological
treatment
FOR STEMI: WITHIN 6- 2. Fibrinolytic treatment (alteplase
24 HOURS 10mg IV/reteplase/streptokinase)
+ coronary stenting

Before Discharge:
 Echo scan – to check if MI has caused HF
o Assess LV function
o Assess EF – if < 40% = consider aldosterone antagonist (eplerenone)

Long Term Management (2° prevention, pharmacological):

All patients with ACS must be on:

1. Beta Blocker (lifelong) – C/I in asthma, NOT COPD. Decreases workload on heart.
 Bisoprolol 10mg OD
 Metoprolol 10mg BD

2. Aspirin 75mg daily (lifelong) – Prevents clots. Use clopidgrel if allergic.

 If has AF = using warfarin or DOAC
i. Stop aspirin at 4 weeks
ii. Lifelong dual therapy with P2Y12 antagonist

3. P2Y12 Antagonist (12 months unless AF)

 Ticagrelor 90mg BD, can also use clopidogrel 75mg and prasugrel 10mg

4. Statins (lifelong)
 Atorvastatin 80mg – can decrease to 20mg OD if renal function is low

5. ACEi (lifelong) – Improves outcome post-MI and decreases LV remodelling

 Ramipril 10mg OD
 Lisinopril 10mg OD
 Consider ARB if ACEi not tolerated (dry cough or angioedema)
i. Losartan 50-100mg OD

6. GTN Spray – 400mcg/puff. 1 puffs to relieve chest pain. Repeat twice in 5 minute intervals.
If no relief call ambulance.
7. If history of dyspepsia or over 75 consider PPI
Monitoring:

 Beta blockers = Monitor HR and BP

 ACEi = Monitor BP, renal function, U&Es
 Statins = LFTs, lipid profile, creatinine kinase, abnormal muscle pain/tenderness (report
weakness)

Non-Pharmacological:
 Diet
 Exercise
 Smoking cessation (champix, NRT)
 Cardiac rehabilitation and education
 Weight loss
 Avoid OTC NSAIDs (ibuprofen, aspirin, etc.)

Note: Consider implantable defibrillator as part of 2° prevention in patients with impaired left
ventricular function and ventricular arrhythmias (can reduce mortality).

Andrew Sturrock Questions: Code: l4acs on turningpoint

Which of the following would be an appropriate initial drug treatment for suspected ACS?
 
a. Aspirin 75mg STAT
b. Aspirin 300mg STAT
c. Aspirin 900mg STAT
d. Ticagrelor 90mg STAT
e. Prasugrel 10mg STAT
Ans: B

Which of the following is the first choice (NICE) P2Y12 receptor antagonist for use in combination with aspirin?
A. Clopidogrel 75mg daily
B. Eplerenone 50mg daily
C. Prasugrel 10mg daily
D. Spironolactone 50mg daily
E. Ticagrelor 90mg BD
 
Ans: E
Mr. A comes into your pharmacy and describes the sudden onset of chest pain. Differential diagnosis?
 
Angina
Unstable angina
NSTEMI
STEMI
Chest/respiratory infection
Tumour in lungs/chest area
MSK injury - pulled muscle
PE
Indigestion
Reflux (oesophageal disease often mistaken for MI by patient)
Recent breakup
 
Worst case scenario is MI - myocardial infarction
999 for further investigation + treatment
Which of the following is not recommended for secondary prevention?
A. Aspirin 75mg daily
B. Atorvastatin 80mg daily
C. Bisoprolol 10mg daily
D. Dabigatran 110mg BD
E. Ramipril 10mg daily
Ans: D