The document discusses acute coronary syndrome (ACS), which includes unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). It focuses on angina pectoris, describing the three main types as stable angina, unstable angina, and Prinzmetal angina. Risk factors for angina are discussed, including modifiable factors like hypertension, smoking, and high cholesterol. The pathophysiology of angina and differences between NSTEMI, STEMI, and unstable angina are summarized.

1. Acute Coronary Syndrome(ACS)
/Coronary Artery Disease (CAD)
/Coronary Heart Disease (CHD)
By:
Manjeet Singh Jangra
PharmD

2. • Acute coronary syndrome (ACS) is the umbrella
term for the clinical signs and symptoms of
myocardial Ischemia: unstable angina, non–ST-
segment elevation myocardial infarction (Non-
STEMI), and ST-segment elevation myocardial
infarction (STEMI).
• Here we will discuss the following chapters in
details:
Angina Pectoris
Myocardial Infarction

3. Angina Pectoris

4. Introduction
• Angina pectoris is a clinical syndrome that occurs
when low blood flow to the heart (myocardial
ischemia) limits delivery of oxygen to the heart
muscle during exertion.
• It is felt as discomfort and tightening in the chest that
is sometimes accompanied by pain in the left arm,
shoulders, or jaw.
• Usually, blood flow is decreased because of blockage
within one or more of the coronary arteries supplying
the heart muscle (coronary artery disease).
• Its risk increase with age , smoking, hypertension,
hypercholesterolemia, diabetes.

5. Types of Angina
The various forms are divided into three basic types:
1. Stable angina: in which pain is present only during
exertion or extreme emotional distress and disappears
with rest;
2. Unstable angina: in which symptoms occur with
increasing frequency and pain occurs more easily at
rest, feels more severe, or lasts longer; and
3. Prinzmetal angina, in which angina occurs at rest,
when sleeping, or when exposed to cold temperatures.
In the latter type of angina, symptoms are generally
caused by transient spasms of the coronary artery rather
than by actual blockage of the artery by plaque or clots.

7. Risk Factors
Non-modifiable Risk factors include age, sex, family
history, and ethnicity or race.
Men have a higher risk than women.
Men older than age 45, women older than age 55, and
anyone with a first-degree male or female relative who
developed coronary artery disease before age 55 or 65,
respectively, are also at increased risk.
Modifiable risk factors include elevated levels of serum
cholesterol, low-density lipoprotein cholesterol, and
triglycerides; lower levels of high-density lipoprotein
cholesterol; and the presence of type 2 diabetes, cigarette
smoking, obesity, a sedentary lifestyle, hypertension, and
stress

9. Pathophysiology
• Usually, blood flow is decreased because of blockage within one or
more of the coronary arteries supplying the heart muscle (coronary
artery disease).
• This blockage is typically the result of a buildup of fatty deposits
(plaque) that gradually block the flow of blood and oxygen in the
artery (atherosclerosis).

10. • Atherosclerotic narrowing of the coronary artery is the
most frequent source of cardiac ischemia and angina;
however, endothelial damage or dysfunction in the heart,
a sudden tightening or narrowing of the coronary artery
(vasospasm), or severe narrowing of the aortic valve
(aortic stenosis) may also interfere with coronary blood
flow, reduce delivery of oxygen to heart tissue, and cause
angina.
• Angina can also be caused by other mechanisms that
reduce oxygen delivery, such as anemia (low red blood
cell count and/or low hemoglobin), low blood pressure
(hypotension), bradycardia, exposure to carbon
monoxide, and inflammation.

15. Unstable Angina
Cause
• Thrombus partially or intermittently occludes the coronary artery
Signs and Symptoms
• Pain with or without radiation to arm, neck, back, or epigastric
region
• SOB, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea,
hypotension or hypertension, decreased arterial oxygen saturation
(SaO2) rhythm abnormalities ; Occurs at rest or with exertion; limits
activity
Diagnostic Findings: ST-segment depression or T-wave inversion on
electrocardiography (ECG); Cardiac biomarkers not elevated.
Treatment (MONA-BAH)
• Oxygen to maintain oxygen saturation level at > 90%
• Nitroglycerin or morphine to control pain
• b-blockers, ACE inhibitors, statins (started on admission and
continued long term), clopidogrel, unfractionated heparin or LMWH,
and glycoprotein IIb/IIIa inhibitors

16. Non–ST-Segment Elevation Myocardial Infarction (NSTEMI)
Cause: Thrombus partially or intermittently occludes the coronary artery
Signs and Symptoms: Pain with or without radiation to arm, neck, back, or
epigastric region, SOB, diaphoresis, nausea, lightheadedness, tachycardia,
tachypnea, hypotension or HTN, ↓ed arterial oxygen saturation (SaO2) and
rhythm abnormalities.
• Occurs at rest or with exertion; limits activity; Longer in duration and more
severe than in unstable angina
Diagnostic Findings: ST-segment depression or T-wave inversion on
electrocardiography; Cardiac biomarkers are elevated
Treatment (MONA-BAH, PCI):
• Oxygen to maintain SaO2 level at > 90%
• Nitroglycerin or morphine to control pain
• b-blockers, ACEI, statins (started on admission and continued long term),
clopidogrel, unfractionated heparin or LMWH, and glycoprotein IIb/IIIa
inhibitors
• Cardiac catheterization and possible PCI for patients with ongoing chest
pain, hemodynamic instability, or increased risk of worsening clinical
condition

17. ST-Segment Elevation Myocardial Infarction (STEMI)
Cause: Thrombus fully occludes the coronary artery
Signs and Symptoms: Pain with or without radiation to arm, neck, back, or
epigastric region, SOB, diaphoresis, nausea, lightheadedness, tachycardia,
tachypnea, hypotension or hypertension, decreased arterial O2
saturation (SaO2), and rhythm abnormalities; Occurs at rest or with exertion;
limits activity, Longer in duration and more severe than in unstable angina
(irreversible tissue damage [infarction] occurs if perfusion is not restored)
Diagnostic Findings: ST-segment elevation or new left bundle branch block
on ECG. Cardiac biomarkers are elevated
Treatment: (TPA, MONA-BAH, PCI): Fibrinolytic therapy within 30
minutes of medical evaluation, Oxygen to maintain SaO2 level at > 90%
• Nitroglycerin or Morphine to control pain
• BB, ACEI, statins (started on admission & continued long term),
clopidogrel,
unfractionated heparin or LMWH
• PCI within 90 minutes of medical evaluation

18. Some common ECG changes in AMI

21. Commonly Available Fibrinolytics