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a constellation of symptoms related to
obstruction of coronary arteries with chest
pain being the most common symptom in
addition to nausea, vomiting, diaphoresis
often radiating to the left arm or angle of
the jaw, pressure-like in character
ACS is classified into:
• Pain occurring at rest –
duration > 20min.
• Worsening of chest pain,
increases in frequency,
• Angina becoming
resistance to drugs that
previously gave good
• NB! ECG – normal, ST
• Leading cause of death in US
• Thrombosis in atherosclerotic artery causes 90%
• A region of the myocardium is abruptly deprived
of blood supply due to restricted coronary blood
• Ischemia results and may lead to necrosis within
• FH : MI in 1st degree relatives <55 yrs.
• Obesity, sedentary lifestyle.
• HTN, DM.
Females, when compared to males:
with MI later in life.
-have poorer prognosis and high morbidity.
-are 2x as likely to die in the first weeks.
-are more likely to die from the first MI.
-have higher rates of unrecognized MI.
Study in US
• The pains are usually more
There are more associated
symptoms such as sweating,
palpitation, nausea, or
Duration is > 20 minutes.
Usual relieving factors such as
rest or GTN spray do not help.
May be silent in elderly or
Patients often tells you they
think they are going to die
(EXTREME distress, sweatiness,
anxiety, pulse, BP or ).
Brief History and physical Examination………
• Random BG.
• Lipid profile.
• CXR: but do not delay treatment waiting
• ST elevation, Q waves , hyper
acute T waves; followed by T
• Clinically significant ST segment
• > than 1 mm (0.1 mV) in at
least two limb contiguous leads
• or 2 mm (0.2 mV) in two
contiguous chest leads (V2 and
• Note: LBBB and pacemakers
can interfere with diagnosis of
MI on ECG.
NSTEM: ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) or normal ECG.
• The most sensitive and specific marker of myocardial
• Serum level increases within 3-12 hrs from the onset of
• +ve in both STEMI and NSTEMI, but –ve in U. angina.
Management of ACS
• Good IV access
• Supplemental O2
• Aspirin 300mg ; consider Clopidogrel 300mg too.
• Nitrates 1-2 tabs SL.
• Morphine 5-10mg IV.
• Beta blocker, eg Atenolol 5mg IV (unless Asthma
• Restore coronary perfusion : PCI or thrombolysis
in STEMI .
• Heparin (LMW) in NSTEMI and U.angina.
• Call cardiology fellow! …….. CCU.
• Bed rest 48hrs, continuous ECG monitoring.
• Daily Ex.
• Prophylaxis againest thromboembolism until fully
mobile (consider warfarin for 3 mo if large Ant.MI).
• Aspirin eg 75mg to decrease vascular events.
• Long term B blockers.
• Starts statin.
• ACE inhibitors in all pts ...stop if EF normal.
• Address modifiable risk factors eg smoking.
• If uncomplicated discharge after 5-7 days.
• ST elevation; >1mm in 2 or more limb leads or
>2mm in 2 or more chest leads.
• Newly developed LBBB.
• Posterior changes deep ST depression and tall R
waves in V1 toV3.
• Internal bleeding, recent surgery and severe
sufficient to cause
tissue damage & mild
ST depression +/T wave inversion on
ECG, non significant.
ST elevations on
ECG or new LBBB