Hassan Ala Farid
M.B.Ch.B. – Resident
Internal Medicine Department
College of medicine / University of Basra
Acute Coronary
Syndrome
Objective : Able to diagnose ACS ( acute coronary
syndrome ) and start emergency measures to treat and
prevent further complications .
Overview
Acute coronary syndrome (ACS) includes :
1. unstable angina
2. STEMI
3. NSTEMI
Symptoms
Acute central chest pain , lasting > 20min , often
associated with nausea , sweatiness , dyspnea ,
palpitations.
ACS without chest pain is called ‘silent’; mostly seen
in elderly and diabetic patients , Silent MIs may
present with: syncope, pulmonary edema, epigastric
pain and vomiting ( be aware of this ! )
Risk factors
1. Age
2. male gender
3. family history of IHD (MI in 1st degree relative <55yrs).
4. Smoking
5. Hypertension
6. DM
7. hyperlipidemia
8. obesity
9. sedentary lifestyle
Signs
Distress , anxiety, pallor , sweatiness, pulse decrease
or increase , BP decrease or increase .
There may be signs of heart failure ( raised JVP,
basal crepitations) or a pansystolic murmur
(papillary muscle dysfunction/rupture , VSD) , leg
odema .
Tests
ECG :
1. Classically , hyperacute (tall) T waves, ST elevation or
new LBBB occur within hours of transmural infarction . T
wave inversion and development of pathological Q
waves follow over hours to days
2. In other ACS : ST depression, T wave inversion, non-
specific changes, or normal.
3. In 20% of MI, the ECG may be normal initially.
Sequential ECG changes following acute MI.
Inferior & Lateral STEMI
Anterior STEMI
Acute posterolateral STEMIA
LBBB
Tests
Cardiac troponin levels (T and I) are the most sensitive ( -Ve
after 6 hours from pain can rule out MI ) and specific ( + Ve can
rule in ) markers of myocardial necrosis . Serum levels raise
within 3–12h from the onset of chest pain, peak at 24–48h, and
decline to baseline over 5–14 days.
CXR: Look for cardiomegaly, pulmonary oedema .
Blood tests : FBC , U&E , glucose , lipids , base line PTT , PT ,
INR
Thrombolytic therapy
Early coronary reperfusion saves lives; decisions must be
taken quickly so seek senior advice early.
Look for typical clinical symptoms of MI plus ECG
criteria:
1. ST elevation >1mm in ≥2 adjacent limb leads or >2mm in
≥2 adjacent chest leads.
2. LBBB (unless known to have LBBB previously).
3. Posterior changes: deep ST depression and tall R waves
in leads V1 to V3.
Thrombolytic therapy
Benefit reduces steadily from onset of pain, target time is
<30min from admission; use >12h from symptom onset
requires specialist advice ( only if ongoing chest pain )
Do not thrombolyse ST depression alone, T-wave inversion
alone, or normal ECG.
Patients with STEMI who do not receive reperfusion (eg
presenting >12h after symptom onset) should be treated with
enoxaparin/unfractionated heparin .
Thrombolytic therapy
Absolute Contra-indications :
1. Previous intracranial haemorrhage.
2. Ischaemic stroke <6months.
3. Cerebral malignancy or AVM.
4. Recent major trauma/surgery/ head injury (<3wks).
5. GI bleeding (<1 month).
6. Known bleeding disorder.
7. Aortic dissection.
8. Non-compressible punctures <24h, eg liver biopsy, lumbar
puncture.
Thrombolytic therapy
Relative CI :
1. TIA <6 months.
2. Anticoagulant therapy.
3. Pregnancy/<1wk post partum.
4. Refractory hypertension (>180mmHg/110mmHg).
5. Advanced liver disease.
6. Infective endocarditis.
7. Active peptic ulcer ( not bleeding ulcer ) .
8. Prolonged/traumatic resuscitation
Further treatment
1. B - blocker, eg metoprolol 50 mg or atenolol 5mg or bisoprolol
2.5 mg unless contraindicated, eg asthma , acute LV failure or
heart block .
2. ACE-inhibitor: Consider starting ACE-i (eg lisinopril 2.5mg)
in all normotensive patients (systolic ≥120mm/Hg) within 24h
of acute MI, especially if there is clinical evidence of heart
failure or echo evidence of LV dysfunction.
3. clopidogrel 300mg loading followed by 75mg/day for 30 days
Further treatment
1. Statin ( atorvastatin 40 – 80 mg )
2. GTN: routine use now not recommended in the acute setting
unless patient is hypertensive or in acute LVF
3. Oxygen is recommended if patients have SaO2 <95%, are
breathless or in acute LVF .
4. Anticoagulation: An injectable anticoagulant must be used in
primary PCI. use enoxaparin ± a GP IIb/IIIa blocker or heparin
Right ventricular infarction
Confirm by demonstrating ST elevation in rV3/4 and/ or echo.
• NB : rV4 means that V4 is placed in the right 5th intercostal
space in the midclavicular line.
Treat hypotension and oliguria with fluids (avoid nitrates and
diuretics).
Monitor BP carefully, and assess early signs of pulmonary
oedema.
Intensive monitoring and inotropes may be useful in some
patients.
Acute management of ACS without ST-segment elevation
High-risk patients (persistent or recurrent ischaemia, ST
depression , diabetes, +Ve troponin)
Low-risk (no further pain, flat or inverted T-waves, or normal
ECG, and negative troponin):
Non - STEMI
Skills stations
1. Discover the ischemic changes in ECGs
2. Give thrombolytic therapy as indicated
3. Use infusion pump for heparin infusion
Any question ?
