Acute Coronary Syndrome (ACS) refers to a range of conditions caused by reduced blood flow in the coronary arteries, with chest pain being the most common symptom. ACS is classified into unstable angina, NSTEMI (non-ST elevation myocardial infarction), and STEMI (ST elevation myocardial infarction) based on ECG findings and cardiac enzyme levels. Unstable angina involves a non-occlusive thrombus and normal ECG/enzymes, while NSTEMI involves a non-occlusive thrombus causing some tissue damage and mild enzyme elevation. STEMI is the most severe form, with complete thrombus occlusion, ST elevations on ECG, and elevated enzymes. Management involves aspirin, nitrates

1. Acute Coronary
Syndrome
Presented by:
Dr. Asim Siddig Abdelrahman
HO Medicine Department

2. Contents
• Definition of ACS.
• Classifications.
• Management.
• Complications.

3. Definition
a constellation of symptoms related to
obstruction of coronary arteries with chest
pain being the most common symptom in
addition to nausea, vomiting, diaphoresis
etc.
often radiating to the left arm or angle of
the jaw, pressure-like in character

4. ACS is classified into:
Unstable Angina
STEMI
NSTEMI

5. UNSTABLE ANGINA
• Pain occurring at rest –
duration > 20min.
• Worsening of chest pain,
increases in frequency,
duration.
• Angina becoming
resistance to drugs that
previously gave good
control.
• NB! ECG – normal, ST
depression(>0.5mm), T
wave changes

6. MI
• Leading cause of death in US
• Thrombosis in atherosclerotic artery causes 90%
of MIs.
• A region of the myocardium is abruptly deprived
of blood supply due to restricted coronary blood
flow.
• Ischemia results and may lead to necrosis within
6 hours.

7. Risk Factors
• Age
• Sex
• FH : MI in 1st degree relatives <55 yrs.
• Smoking.
• Obesity, sedentary lifestyle.
• HTN, DM.
• Hyperlipidemia.

8. Females, when compared to males:
-present
with MI later in life.
-have poorer prognosis and high morbidity.
-are 2x as likely to die in the first weeks.
-are more likely to die from the first MI.
-have higher rates of unrecognized MI.
Study in US

9. Features suggesting
• The pains are usually more
MI
•
•
•
•
•
severe .
There are more associated
symptoms such as sweating,
palpitation, nausea, or
vomiting.
Duration is > 20 minutes.
Usual relieving factors such as
rest or GTN spray do not help.
May be silent in elderly or
diabetics.
Patients often tells you they
think they are going to die
(EXTREME distress, sweatiness,
anxiety, pulse, BP or ).

10. Diagnosis
Brief History and physical Examination………

11. Generally DO:
• CBC.
• U&E.
• Random BG.
• Lipid profile.
• CXR: but do not delay treatment waiting
for it.

12. Cardiac Enzymes

13. STEMI:
• ST elevation, Q waves , hyper
acute T waves; followed by T
wave inversions.
• Clinically significant ST segment
elevations:
• > than 1 mm (0.1 mV) in at
least two limb contiguous leads
• or 2 mm (0.2 mV) in two
contiguous chest leads (V2 and
V3)
• Note: LBBB and pacemakers
can interfere with diagnosis of
MI on ECG.

14. The ECG changes

15. ST elevation
Inferior MI

16. NSTEM: ST depressions (0.5 mm at least) or T wave
inversions ( 1.0 mm at least) or normal ECG.
• Troponin:
• The most sensitive and specific marker of myocardial
necrosis.
• Serum level increases within 3-12 hrs from the onset of
Chest pain.
• +ve in both STEMI and NSTEMI, but –ve in U. angina.
• CK-MB.
• Myoglobin.

18. Management of ACS

20. Management of ACS
• Good IV access
• Supplemental O2
• Aspirin 300mg ; consider Clopidogrel 300mg too.
• Nitrates 1-2 tabs SL.
• Morphine 5-10mg IV.
• Beta blocker, eg Atenolol 5mg IV (unless Asthma
or LVF).
• Restore coronary perfusion : PCI or thrombolysis
in STEMI .
• Heparin (LMW) in NSTEMI and U.angina.
• Call cardiology fellow! …….. CCU.

21. Subsequent management
• Bed rest 48hrs, continuous ECG monitoring.
• Daily Ex.
• Prophylaxis againest thromboembolism until fully
mobile (consider warfarin for 3 mo if large Ant.MI).
• Aspirin eg 75mg to decrease vascular events.
• Long term B blockers.
• Starts statin.
• ACE inhibitors in all pts ...stop if EF normal.
• Address modifiable risk factors eg smoking.
• If uncomplicated discharge after 5-7 days.

22. thrombolysis
Criteria:
• ST elevation; >1mm in 2 or more limb leads or
>2mm in 2 or more chest leads.
• Newly developed LBBB.
• Posterior changes deep ST depression and tall R
waves in V1 toV3.
Contraindications;
• Internal bleeding, recent surgery and severe
HTN.
eg Streptokinase.

23. Complications:
• Cardiac arrest….. vent. Arrhythmias.
• Bradycardias or heart block.
• Tachyarrhythmias.
• CHF.
• Pericarditis.
• DVT and PE.

24. Attention…..SUMMARY

25. Unstable
Angina
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
Enzymes.
Ttt: +heparin
NSTEMI
Non-occlusive
thrombus
sufficient to cause
tissue damage & mild
myocardial necrosis
ST depression +/T wave inversion on
ECG, non significant.
Elevated cardiac
Enzymes.
Ttt: +heparin
STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
Symptoms.
Ttt: +thromolytics.

26. Thanks