a brief review of managing ACS in medical emergency

2. ACUTE CORONARY
SYNDROME
(EMERGENCY MANAGEMENT)
BY
DR. ISTIKHAR ALI SAJJAD

3. DEFINITION
 Acute coronary syndrome (ACS) refers to a
spectrum of clinical presentations attributed to
obstruction of the coronary arteries.
 It encompasses unstable angina, non-ST segment
elevation myocardial infarction (ST segment
elevation generally absent), and ST segment
elevation infarction (persistent ST segment
elevation usually present).
 The definition of acute coronary syndrome depends
on the specific characteristics of each element of
the triad of clinical presentation (including a
history of coronary artery disease),
electrocardiographic changes and biochemical
cardiac markers

4. INVESTIGATIONS
ECG
Transient ST-segment elevations
Dynamic T-wave changes:
Inversions, normalizations, or
hyperacute changes
ST depressions: These may be
junctional, downsloping, or horizontal

5. INVESTIGATIONS
 Laboratory studies
Creatine kinase isoenzyme MB (CK-MB)
levels
Cardiac troponin levels
Myoglobin levels
Complete blood count
Basic metabolic panel

6. INVESTIGATIONS
 Chest radiography
 Echocardiography
 Myocardial perfusion imaging
 Cardiac angiography
 Computed tomography, including CT
coronary angiography and CT coronary
artery calcium scoring

7. TREATMENT STEPS
Following steps should be followed
 Myocardial oxygenation
 35-50% O2 inhalation
 Antiplatlets
 Aspirine p/o 300mg bolus then 75-81mg/day
 Clopidogrel p/o 300mg bolus then 75 mg/day (avoid if
CABG planned)
 Antithrombins (in moderate and high risk patients only)
 Inj. Heparin 5000 units I/V bolus then 0.25 units/Kg/hr
OR
 Inj. Enoxaparin 1mg/Kg S/C twice a day.

8.  Glycoprotein IIb/IIIa inhibitors (indicated in high
risk patients only)
 Eptifibatide 180ug/Kg I/V bolus then
2ug/Kg/min for 72 hrs
OR
 Abciximab 0.25mg/Kg I/V bolus then 0.125
ug/Kg/min (max. 10 ug/min) for 12 hrs
 Analgesics
 Diamorphine/morphine 2.5-5mg I/V
 Decrease myocardial energy consumption
 Bisoprolol 2.5-5 mg P/O
OR
 Atenolol 5mg I/V repeated after 15 mins then
25-50 mg P/O per day.

9.  Coronary vasodilatation
Glyceryl trinitrate 2-10mg/hr I/V,
buccal, sublingual
 Plaque stabilization/ventricular remodeling
HMG CoA reductase inhibitor (
simvastatin 20-40 mg/day or
atorvastatin 80mg/day)
ACE inhibitors/ARBs

10. In case of STEMI
 (Urgent referral to CCU)
 If patient presents within 12 hrs of
symptoms onset then
 Streptokinase OR Retiplase OR
Tenectiplase OR
 PCI within 30 mins

11. Refer Patient for Urgent Angiography if
 Persistent/recurrent angina with ST
elevation >2mm or deep negative T wave
 Clinical signs of heart failure
 Haemodynamic instability
 Life threatning arrhythmias