2. Definition
• ACS include conditions that share the same pathophysiology of
myocardial ischaemic states due to coronary obstruction.( UA,
NSTEMI, STEMI)
• UA: develop at rest or minimal exretion and should be differentiated
from stable angina
• UA and NSTEMI are primarily differentiated by rise and fall in cardiac
enzyme
• STEMI occurs when there complete occlusion of a coronary artery,
ECG will show ST segmen elevations.
3. caveats
• AMI should be considered and excluded in older patient and diabetic
patients presenting with unexplained cardiac, respiratory and neurologic
symptoms
• Risk management tips
• Age and gender (although women are lower risk of MI than man) should’n rule out
diagnosis of ischaemia or infarction
• History of heart desease critical factor
• Consider implementing a policy old ECG retrieval, pre hospital ECG, and doing serial
ECG.
• Resting chest pain in patient with known HD should be considered an omnious
finding
• Detection correction of an obvious precipitating factor
12. Evaluation and Management
1. To confirm diagnosis by history, ECG and cardiac enzymes
2. To determine need for urgent reperfusion therapy
3. To correct the abnormal haemodinamic state
4. To relieve ischaemic pain
5. To reduce myocardial oxygen consumption
6. To initiate antiplatelets, anticoagulans and reperfusion therapy if
required
a) Monitor patient vital sign in critical area
b) Give O2 if SpO2 below 94%
c) Set iv canula perform blood test ( FBC, ur,cr, electrolyte, troponin)
13. cont
• Do Chest Xray: exlude other causes, to look complications, to expedite
transfer for cardiac chateteritiation.
• Start dual antiplatelets therapy aspirin and clopidogrel.
• Give sublingual GTN in patients with ischaemic type chest pain,
contraindicated in right ventricular infarction, severe aortic stenosis,
and Viagra consumption within 24hour.
• IV morphine should be avoided, only for unacceptable level of pain
• IV beta blocker may be harmfull, while PO beta blockers are helpful in
ACS
• Anticoagulants: LMWH, UFH, glycoprotein 2b/2a
16. cont
• If the patient in shock
• Do gentle rectal to look gastrointestinal bleeding
• Is bradicardic?
• Is tachycardic?
• Is patient have righ ventricular infarct?
• Do right side leads
• If yes fluid challenge 100-200 over 5 to 10 minute assess response.
• Can repeated if patient does not become breathlessness and there are no clinical sign of
pulmonary edema
• Start inotropes (iv noradrenalide 0.02mikro/kgbb/min titrated to response)
• Consider securing airway through RSI if patient going for PCI but unable to lie flat due
to respiratory distress
• Catheterized patient for urine output
• Admit to coronary unit.
