Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations caused by obstruction of the coronary arteries, including unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction. Investigations for ACS involve ECGs, cardiac enzyme levels, imaging tests, and angiography. Treatment steps include oxygen supplementation, antiplatelet medications, antithrombins, glycoprotein IIb/IIIa inhibitors, analgesics, beta blockers, nitrates, statins, ACE inhibitors, and referral for percutaneous coronary intervention or thrombolysis depending on the severity and timing of symptoms.

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