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Acute Coronary Syndrome


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Unstable angina , STEMI , Non-STEMI ... explained through scenarios.

Published in: Health & Medicine
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Acute Coronary Syndrome

  1. 1. Muhammad Awais Munir Roll # 346 Batch 2011-2016 Punjab Medical College Faisalabad
  2. 2.  45 year old man comes to your clinic for routine follow up. He gives history of chest pain on walking 500 meters on foot. There is no history of dyspnea, orthopnea. He smokes 2 cigarettes per day. He has got history of angioplasty of left anterior descending artery 5 years back.
  3. 3.  He is type 2 diabetic and hypertesive taking lisinopril and glimepiride 2 mg daily.  His pulse is 90/minute, B.P 145/90mmHg, R/R 14/minute, Temp. 98F°  Rest of examination is normal.  What is your diagnosis?
  4. 4.  55 years old male presents in emergency department with central chest pain radiating to left arm for last 20 minutes while sitting in his study room.
  5. 5.  He gives h/o chest pain on walking 1000 steps for last 2 years for which he is talking aspirin 75mg, clopidogrel 75gm, simvastatin 40mg and triglyceryl spray as needed.  What is your diagnosis?
  6. 6.  63 years old man known case of ischemic heart disease present in emergency with c/o chest pain for last 10 minutes while working in his garden. It is accompanied by cold sweating and palpitations.
  7. 7.  Pulse 96/-, B.P 160/110mmHg, temp. 98F°, R/R 18/minute ECG in shown below.  Cardiac enzymes are normal.
  8. 8.  65 years old female developed sudden central chest pain radiating to her left arm not relieved by nitrates. It is associated with cold sweating and sinking of heart.
  9. 9.  Pulse 100/minute, B.P 160/100mmHg, Temp. 98F°, R/R 15/minute.  Rest of examination is normal.  ECG is shown below.  Cardiac Enzymes are raised.  Trop T is positive.
  10. 10.  60 years old male presented with sudden severe cental chest pain for last 2 hours associated with cold sweating and sinking of heart not relieved by rest or sublingual nitrates.
  11. 11.  Pulse 90/min, B.P 180/90 mmHg, Temp 98F°, R/R 16/min  JVP is raised.  Resp examination shows bibasilar fine cackles.  ECG is shown below.  Cardiac enzymes are raised.  Trop T is positive.
  12. 12.  Unstable Angina  Non-ST-Segment Elevation MI (NSTEMI)  ST-Segment Elevation MI (STEMI)
  13. 13. NON- MODIFIABLE  Age  SEX  FAMILY HISTORY-----Event in 1st degree relative  <55 Male  <65 Female
  14. 14. MODIFIABLE  Smoking  Hypertension  Diabetes Mellitus  Dyslipidemia ◦ Low HDL < 40 ◦ Elevated LDL >100- 130  Lack of exercise  Obesity  Waist circumference  Lack of diet rich in fruit vegetable fiber  Homocysteinemia
  15. 15. Ethnic-Specific Values for Waist Circumference Ethnic Group Waist Circumference Japanese Men >85 cm (33.5 in) Women >90 cm (35 in) South Asians and Chinese Men >90 cm (35 in) Women >80 cm (31.5 in) Europeans Men >94 cm (37 in) Women >80 cm (31.5 in)
  16. 16. Unstable Angina STEMINSTEMI Non occlusive thrombus Non specific ECG Normal cardiac enzymes Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/- T wave inversion on ECG Elevated cardiac enzymes Complete thrombus occlusion ST elevations on ECG or new LBBB Elevated cardiac enzymes More severe symptoms
  17. 17.  Stable angina: Reproducibly by exercise or emotion, stress and relieved within 15-20 min by rest or sublingual nitroglycerine  Unstable angina (A) occurs at rest or mild exertion, usually lasts more than 30 min (B) new onset( within 1 month) (C ) crescendo type
  18. 18. Criteria.  H/o prolonged chest discomfort or angina equivalent > 30 min.  Presence of more than 1 mm ST- elevation in 2 consecutive chest leads or 2mm elevation in limb leads.  Presence of elevated cardiac biomarkers.  New onset left bundle branch block
  19. 19. • Chest pain resembles angina. • But lasts more than 30 minutes • It is more intense, not relieved by rest or sublingual nitrates. • Accompanied by dyspnoea, nausea vomiting, fatigue, syncope and cold sweating. • It may present as extreme exhaustion. • Impending fear of death • It may occur without chest pain in hypertensive, diabetic elderly, or post operative patients.
  20. 20. PHYSICAL EXAMINATION  Patients usually appear restless and in distress.  Tend to lie still.  The skin is cold and moist due to sympathetic discharge.  Breathing may be labored and rapid.  Fine crackles, coarse crackles, or rhonchi may be heard when auscultating the lungs due to heart failure.
  21. 21.  Increased blood pressure related to anxiety or a decreased blood pressure caused by heart failure.  The heart rate may vary from bradycardia to tachycardia.  On auscultation, the first heart sound may be diminished as a result of decreased contractility.
  22. 22.  A fourth heart sound is heard in almost all patients with MI, whereas a third heart sound is detected in only about 10% to 20% of patients due to failure.  Transient systolic murmurs may be heard due to papillary muscle ischemia  After about 48 to 72 hours, many patients acquire a pericardial friction rub
  23. 23. • Patients with acute ST- elevation MI are stratified into low and high risk groups on the basis of their initial physical examination. 1. Without pulmonary congestion or shock. (Klipp I). Mortality rate < 5%. 2. Mild pulmonary congestion or presence of S3(Klipp class II) favourable prognosis.
  24. 24. 1. Pulmonary edema(Klipp Class III) needs aggressive management. 2. Hypotensive patients with evidence of shock(Klipp class IV) 80% mortality rate
  25. 25. 4 groups of investigation are used.  ECG.  Cardiac biomarkers  Cardiac imaging.  Non specific indices of Tissue necrosis and inflammation.
  26. 26. ECG CRITERA OF ACUTE MI  Pathological q wave  T wave inversion  Convex ST-elevation above 1 mm. ECG CRITERA OF old MI  Pathological q wave  ST in baseline  T wave normal or inverted  Right ventricular MI(V 4 R)
  27. 27.  Tall R wave, ST segment depression and t wave inversions in V1 and V2
  28. 28.  Q wave infarction means infarction of full thickness myocardium  Non Q wave infarction means infarction of subendocardium
  29. 29.  Trop-T and Trop- I are raised after 3-12 hours of MI..>95% sensitivity and specificity Peak at 2 days. Elevated for 5-14 days.  CK-MB has sensitivity of 95 % when measured within 24-36 hours after the onset of chest pain. Increases within 3-4 hours of chest pain. Peak at 24 hours. And returns to base line at 48-72 hours.
  30. 30. Protein Molecular mass (kD) First detection Duration of detection Sensiti vity Specifi city Myoglobin 16 1.5–2 hours 8–12 hours +++ + CK-MB 83 2–3 hours 1–2 days +++ +++ Troponin I 33 3–4 hours 7–10 days ++++ ++++ Troponin T 38 3–4 hours 7–14 days ++++ ++++ CK 96 4–6 hours 2–3 days ++ ++
  31. 31. • If MI not detected on ECG, then two dimensional echocardiography is used which shows wall motion abnormalities and aids in management and decision. • It also shows RV infarction, ventricular aneurysm and pericardial effusion. • Myocardial perfusion imaging. Very sensitive but cann’t distinguish acute infarct from chronic infarct thus not specific for acute MI.
  32. 32.  Radioneucleotide ventriculography. Tc labelled RBCs are used which show wall motion abnormalities.  MRI. Can be used. It detects MI accurately.
  33. 33.  Immediate management.  The goal is to identify the patient for reperfusion therapy.  IN IDEAL CONDITIONS Goal is door to needle time of < 30 min and door to ballon time of < 90 min.  Relieves ischemic pain, provide supplemental oxygen, recognize and treat potential life threatening complication.
  34. 34. 10/ 50 ST elevation  12 h Aspirin Beta-blocker Eligible for fibrinolytic therapy > 12 h Fibrinolytic therapy contraindicated Not a candidate for reperfusion therapy Persistent symptoms ? Fibrinolytic therapy Primary PTCA or CABG Other medical therapy: ACE inhibitors ? Nitrates Anticoagulants Consider Reperfusion Therapy No Yes Modified from Antman EM. Atlas of Heart Disease, VIII; 1996 ST elevation Aspirin Beta-blocker  12 h > 12 h Eligible for fibrinolytic therapy Fibrinolytic therapy Fibrinolytic therapy contraindicated Primary PTCA or CABG Not a candidate for reperfusion therapy Other medical therapy: ACE inhibitors ? Nitrates Anticoagulants Persistent symptoms ? No Yes Consider Reperfusion Therapy
  35. 35. 10/ 51 ST depression/T-wave inversion: Suspected AMI Heparin + Aspirin Nitrates for recurrent angina Assess Clinical Status Continued observation in hospital Consideration of stress testing PCI CABG No Yes Antithrombins: LMWH - high-risk patients Anti-Platelets: GpIIb/IIIa inhibitor Patients without prior beta-blocker therapy or who are inadequately treated on current dose of beta-blocker Persistnet symptoms in patients with prior beta-blocker therapy or who cannot tolerate beta-blockers Establish adequate beta-blockade Add calcium antagonist High-risk patient: 1. Recurrent ischemia 2. Depressed LV function 3. Widespread ECG changes 4. Prior MI Clinical stability Catheterization: Anatomy suitable for revascularization Medical Therapy Modified from Antman EM. Atlas of Heart Disease, VIII; 1996 ST depression/T-wave inversion: Suspected AMI Antithrombins: LMWH - high-risk patients Anti-Platelets: GpIIb/IIIa inhibitorPatients without prior beta-blocker therapy or who are inadequately treated on current dose of beta-blocker Establish adequate beta-blockade Add calcium antagonist Persistnet symptoms in patients with prior beta-blocker therapy or who cannot tolerate beta-blockers Assess Clinical Status High-risk patient: 1. Recurrent ischemia 2. Depressed LV function 3. Widespread ECG changes 4. Prior MI Catheterization: Anatomy suitable for revascularization Yes PCI CABG Medical Therapy Clinical stability Continued observation in hospital Consideration of stress testing Heparin + Aspirin Nitrates for recurrent angina No
  36. 36.  IV CANULA  OXYGEN INHALATION  MORPHINE DERIVATIVES  NITROGLYCERINE SUBLINGUALLY  ORAL Asprin 300mg chew and swallow THEN 75mgd  Clopidogril. 300 bolus then 75mg/day  Anti-coagulation  UFH: initial bolus 60u/kg, maximum 5000u followed by infusion of 12u/kg /hr. maximum 1000u/hr to keep APTT of 1.5-2 times of control.  LWMH: (enoxaparin): 1mg/kg bid.
  37. 37.  should be avoided in patients of hypotension.  Right ventricular MI, bradycardia < 50/ min. Sublingual preparation used ,If pain still continues then IV nitroglycerine 10microgram/ min should be initiated.  Dose adjustment may be performed every 5 min at 10 microgram/min until chest pain resolves or heart rate increases or BP decreases more than 10 %.
  38. 38. Cellular Mechanism of Vasodilatation Nitrates Formation of Nitric oxide (NO) Activation of Guanylate cyclase Synthesis of cyclic GMP Relaxation of Vascular smooth muscles
  39. 39. Effect of Nitrates : Venodilatation Arteriolar dilatation Preload Afterload Myocardial Oxygen demand 2- Redistribution of coronary flow towards subendocardium 3- Dilatation of coronary collateral vessels 1-
  40. 40. Adverse Reactions : 1- Postural Hypotension & Syncope 2- Tachycardia 5- Throbbing Headache 4- Facial Flushing 3- Drug Rash 6- Prolonged high dose Methaemoglobinaemia
  41. 41.  They reduce myocardial ischemia and infarct size and myocardial rupture.  IV metoprolol 5 mg can be repeated every 5 min for 3 doses. If tolerated then can be shifted to oral medication 25-50 mg/ 6 -12 hrly.
  42. 42. Fatigue & weakness Hyperglycemia Nightmares , Hallucinations , Depression. Plasma Triglycerides & HDL Cholesterol Discontinuation after long ttt exacerbates Angina Adverse Reactions :
  43. 43. CHF A-V block Peripheral Vascular disease Hypotension Contraindications : Bronchial asthma
  44. 44.  Only indicated in highest risk UA/NSTEMI patients (dynamic changes on EKG, elevated biomarkers, electrical instability) and/or in whom early PCI is planned  Abciximab is the choice if early angiography and PCI is planned  Tirofiban indicated when no PCI planned
  45. 45.  Handle patient carefully while providing initial care, starting I.V. infusion, obtaining baseline vital signs, and attaching electrodes for continuous ECG monitoring.  Maintain oxygen saturation greater than 92%.  Administer oxygen by nasal cannula if prescribed
  46. 46. Following agents are used as fibrinolytic agents.  TPA  Streptokinase.  Tenecteplase.  Reteplase.
  47. 47.  Thrombolytic therapy should be considered in patients with ST- elevation MI in 2 or more leads.  Effective if given within 12 hours but not beyond 24 hours.  It is not indicated if symptoms have resolved or the patient with ST- depression.
  48. 48. Absolute. • Intracranial hemorrhage • Ischemic strokes within past year • Head trauma • Suspected Aortic dissection. • Active internal bleed • BP> 180/110
  49. 49.  Allergy or previous use of streptokinase------ 5 days to 2 years  Active peptic ulcer disease  Internal bleed 2-4 weeks  Prolonged CPR > 10 min.  Major surgery < 2 weeks  Known bleeding diathesis  hemorrhagic ophthalmic condition (e.g., hemorrhagic diabetic retinopathy),  Severe menstrual bleeding.  Pregnancy
  50. 50. • Streptokinase. • 1.5 million units IV over 60 min. • Retiplase. • IV bolus of 10 mg over 2 min followed by another IV bolus of 10 mg over 30 min. • Alteplase. • IV bolus of 15 mg followed by a 0.75mg/kg by IV infusion over 30 min. then 0.5 mg/kg over 60 min. maximum dose of 100mg over 90 min.
  51. 51.  Grade O: indicates complete occlusion.  Grade I: some penetration beyond the part of obstruction but without penetration distal part.  Grade II: perfusion of entire infarct vessel into distal bed but flow is delayed.  Grade III: full perfusion of infarct vessel.  Fibrinolytic therapy reduces mortality in 50 %.
  52. 52.  It is alternative to thrombolytic therapy.  Used in patients in whom diagnosis is in doubt.  Cardiogenic shock, increased bleeding risk.  It should be considered when door to baloon time is < 90 min.
  53. 53. • Primary PCI is preferred over thrombolysis in patients < 75 years age and present with cardiogenci shock within 36 hrs of MI. and PCI can be performed within 18 hours of shock. • Contraindications to fibrinolytic therapy. • Increased risk of death or CHF. • Underwent resent PCI. • NOTE: emergency CABG is a high risk precedure that should be considered if a patient has cardiogenic shock and coronary vasculature is not compatible for PCI or the procedure has failed.
  54. 54.  (PTCA) is an effective alternative to reestablish blood flow to ischemic myocardium.  Primary PTCA is an invasive procedure in which the infarct-related coronary artery is dilated during the acute phase of an MI without prior administration of thrombolytic agents  These complications can include retroperitoneal or vascular hemorrhage, other evidence of bleeding, early acute reocclusion, and late restenosis.
  55. 55.  Bed rest for 12 hrs.  Under supervision to upright position sitting in a chair in 24 hours.  In absence of shock, hypotension, 2rd day, can go to washroom on wheel chair, can take shower or stand on the sink.  End of 3rd day, activity is increased.
  56. 56.  For 1st 4-12 hrs:  Clear fluids or NPO.  30% less of total calories , complex carbohydrates should take 50% of total calories.  Bowels:  Bed side comod should be used .  Diet rich in bulk, stool softners and lexatives.
  57. 57.  After medical therapy including thrombolysis:  Stress test: Is done to determine the prognosis or functional capacity.  Stress test: Can be performed 4-6 days after the MI. Can also be performed after hospital discharge 2-3 weeks or late after discharge 3-6 weeks if the initial post infartction stress test was sub maximal.
  58. 58. • The goal of secondary prevnetion is to produce a favourable impact on the morbidity and mortality . • Antiplatelet agents: Asprin 75- 325 mg/ day should be used indefinitly. • Clopidogril : 75 mg/day for a maximum of 9 months. • Ace Inhibitors: reduce mortality and incidence of CHF. • Treatment should be given indefinitely. • Benefit is seen in patients with LV dysfunction, ejection fraction less than 40 and all patients of MI. • Beta blocker: Reduce cardiac events after MI, and should be use indefinitly.
  59. 59. • B1 selective blokeres e.g Metoprolol 100mg BID, atenolol 100mg daily, propranolol 80mg TID. • Cholestrol treatment: • With ACS and ST-elevation MI, it should be less than 100mg/dl. • Tobacco cessation • Diet: • A body mass index of < 25kg/m2 is desireable. • Diabetes: • Target HbA1C <7. • Exercise: • The goal is a minimum of 3-4 days per week of 30-60 min of activity in those who are physically capable.
  60. 60.  Routine office visits:  Every 4-12 months are suggested for the 1st year.
  61. 61. Pericardial Complications  Pericarditis  Dressler’s syndrome  Pericardial effusion Thromboembolic Complications  Thromboembolism  Deep venous thrombosis  Pulmonary embolism
  62. 62. Electrical Complications  Ventricular tachycardia  Ventricular fibrillation  Supraventricular tachydysrhythmias  Bradydysrhythmias  Atrioventricular block (first, second, or third degree)
  63. 63. Vascular Complications  Recurrent ischemia  Recurrent infarction Mechanical Complications  Left ventricular free wall rupture  Ventricular septal rupture  Papillary muscle rupture with acute mitral regurgitation
  64. 64. Myocardial Complications  Congestive heart failure  Hypotension/cardiogenic shock  Right ventricular infarction  Aneurysm formation
  65. 65. • Post infarction ischemia: • Nitrates. Beta blockers. Clopidogril. Asprin. • Arrythmias: • Sinus bradycardia: Atropine 0.5-1 mg IV.
  66. 66.  Supraventricular tachyarrthmia:  IV beta blockers such as metoprolol 2.5- 5mg/hr.  IV diltiazim 5-15mg/hr if beta blockers are contraindicated.  Digoxin 0.5mg as initial dose then 0.25mg every 90 to 120 min.  amiodarone 150mg IV bolus.  Ventricular arrythmias:  1mg/kg bolus of lidocaine if the patient is stable.  If not, then DC cardioversion at 100-200 jouls. IV amiodarone can be used.
  67. 67.  Ventricular fibrillation  Ventricular tachycardia
  68. 68. Conduction disturbances: • Ist degree heart block is the most common and requires no treatment. • 2nd degree block is usually of Mobitz type I and requires treatment only if symptomatic. • Complete AV block occurs in 5% of patiets and generally resolves but it may persist for hours to several weeks. And TPM is indicated in such cases.
  69. 69. • Hypotension and shock: • Patients with hypotension should be treated with successive boluses of 100ml of normal saline until PCWP reaches 15mm of Hg. • Dopamine is the most appropriate for the cardiogenic hypotension initiated at the dose of 2-4mcg/kg/min. • At low doses, < 5mcg it improves renal blood flow. • At intermediate dosages 2.5-10mcg, it stimulates myocardial contractility and above 10mcg it is a potent alpha 1 adrenergic agonist.
  70. 70. • It is associated with inferior wall MI. • Diagnosis is suggested by ST- elevation in right sided anterior chest leads particulary R wave in V4 . • Confirmed by echocardiography.
  71. 71.  Rupture of papillary muscles or interventricular septa usually occurs 3-7 days.  Detected by new systolic murmurs.  Confirmed by doppler echocardiography  surgical intervention is mandatory.
  72. 72. • Complete rupture occurs in 1 % of patients and results in immediate death. • It occurs 2-7 days post infarction. • Involves anterior wall. • Incomplete rupture recognized by echocardiography, radioneucleotide angiography. • Early surgical repair is indicated.
  73. 73. • 10-20% of patients. • Usually follows anterior wall infarction. Recognized by persistent ST- elevation beyond 4-8 weeks. • They rarely rupture but associated with arterial emboli, ventricular arrythmias and CHF. • Surgical resection may be performed.
  74. 74.  Pericardium is involved in 50 % of infarction.  But pericarditis is often not clinically significant.  Pericardial pain occurs 2-7 days, recognized by its variation with position and respiration.  Improved by sitting.  Often no treatment is required but Asprin 650mg 4-6hrly will usually relieve the pain.
  75. 75.  1-12 weeks after infarction.  Autoimmune phenomenom.  Presents as pericarditis associated with ◦ Fever ◦ Leucocytosis ◦ pericardial or pleural effusion.