Acute Coronary Syndrome

1. ACUTE CORONARY SYNDROME
DR YE HTOOK MG
M.B.,B.S M.MED.SC (INTERNAL MED)
MRCP(UK), MRCPE

3. CHEST PAIN
ECG
(1872-1924)
BIOCHEMICAL
MARKERS
(1963)

4. CHEST PAIN
• GREATER IN SEVERITY
• LONGER IN DURATION (>15 MIN)
• NOT RELIEF BY S/L GTN
• ASSOCIATED WITH ANS (NAUSEA,
VOMITING,SWEATING, BREATHLSSNESS)

5. DDx of Acute chest pain
• Acute coronary syndrome
• Pericarditis / other cardiac
• Acute aortic syndrome
• Acute pulmonary emboli / pulmonary
disease
• Musculoskeletal pain
• GI pain
• Neuritis pain / psychiatric

6. ECG

7. Dx CRITERIA
• ST ELEVATION OF ≥ 2 mm in adjacent chest leads
• ST ELEVATION OF ≥ 1 mm in adjacent limb leads
• New onset LBBB

8. ST elevation ≥ 2mm in adjecent chest leads

9. ST elevation of ≥ 1mm in adjacent limb leads

10. BIOCHEMICAL MARKERS
• CK MB
• Cardiac troponins
• HS troponins

11. • On admission + 3 Hours after
< 20 ng < 20 ng negative
>20 ng ↑ 10 ng Likely MI
>20 ng >20 ng but change < 10
alternative Dx

13. OTHER CAUSES OF INCREASE TROPONIN
• Acute pulmonary embolism
• Severe heart failure
• Myocarditis
• Acute pericarditis
• Renal failure
• Hypovolaemia
• CVA

14. ACS
CHEST PAIN
ECG CHANGES STEMI
BIOCHEMICAL MARKERS
NSTEMI UA
+
-
+ -

15. MANAGEMENT
• REPERFUSION
• ANTIPLATELETS
• ANTICOAGULANTS
• OTHER MEDICAL TREATMENTS
• CARDOLOGIST REFERRAL

16. STEMI

18. TREATMENT
• ASPRIN 300 mg stat followed by 75 mg OD
• S/L GTN
• IV DIAMORPHINE 2.5 – 5 mg
• IV METOCLOPRAMIDE 10 mg
• TIGAGRELOR 180 stat and followed by 90 mg BD
• BISOPROLOL 2.5 – 5 mg OD
• ATOVARSTATIN 80 mg OD
• RAMIPRIL 1.25 mg BD

19. REPERFUSION
• PCI OR THROMBOLYSIS

22. < 12 HOURS FROM ONSET OF SYMPTOMS
• PCI possible within 90 mins _ PCI
• Otherwise _ Thrombolysis

23. >12 Hrs and < 24 hours if pain persist or recurs
• Reperfusion can be done

24. Thrombolysis
• Streptokinase 1.5 million units in 100 ml
of N/S for 1 hour
• Alteplase
• Tenecteplase

25. CONTRAINDICATIONS TO THROMBOLYSIS
• Haemorrhagic stroke
• Ischaemic stroke < 6 months
• CNS damage of neoplasm
• Recent major trauma/ surgery/ head injury < 3
mths
• GI bleeding within last month
• Known bleeding disorder
• Aortic dissection

26. • Recheck ECG 90 mins after thombolysis
• Resolusion of > 50% in single lead - success

29. Normal left coronary artery

30. Normal right coronary artery

33. ANTI COAGULANTS

35. CARDIOLOGIST REFER
• WHEN ?

36. NSTEMI / UA

37. Normal left coronary artery

38. NSTEMI

39. REPERFUSION
• Immediate emergency reperfusion therapy
has no demonstrable benefit

40. TREATMENT
• ASPRIN 300 mg stat. followed by 75 mg Od
• CLOPIDOGREL 300 mg stat. followed by 75 mg OD
• BISOPROLOL 2.5 – 5 mg OD if notcontraindicated
• FOUNDAPARINUX 2.5 mg S/C
• GTN 2 – 10 mg/hr infusion PRN
• ATOVASTATIN 80 mg OD
• RAMIPRIL 1.25 mg BD

41. TIMI SCORES
• RISK FACTORS POINTS
Age > 65 1
≥ CAD risk factors 1
(↑Cho, FHx, HTN,DM,PVD,
smoking)
Known CAD 1
Asprin use in the past 7 days 1
Severe Angina (≥ 2 episodes 1
in last 24 Hrs)
increase cardiac markers 1
ST deviation ≥ 0.5mm 1

42. • MEDICAL Asprin
Nitrate
ᵝ blockers
antithrombotics
• INVASIVE PCI
CABG
There is no accurate method predicting which
patient will stabilize on medical treatment alone
and which will progress to MI

43. TIMI SCORE
• TOTAL 0 – 7
• 5 – 7 High risk
• 3 – 4 intermediate risk
• 0 – 2 low risk

44. TIMI 3 – 7 ( intermediate to high risk)
• Tn T positive – early invasive stragtegy (< 72 Hrs)
• Tn T negative – early out patient IVX

46. • 47 years old, gentleman, previously healthy.
• C/O palpitation for 5 hours
• ECG – HR 140/min , fast AF ? SVT

47. • Carotid sinus massage
• 5 hours after that – weakness on Rt UL & LL
(4/5)
• Tn T markedly elevated (529.4)

48. • Daignosed as NSTEMI -
• CT SCAN (head) - NAD
• Give LMWH
• TIMI score 4
• Refer to cardiac center

49. At cardiac center,
• Coronary angiogram was done

50. Tripple vessels disease

51. • PCI was done

52. LCX
Total occlusion at proximal LCX
Reperfusion after stent

53. LAD
Subtotal occlusion at mid
LAD
Reperfusion after stent

54. • He was discharged
• Took regular medicines
• He returned to his Unit and serving his duties

55. 2 months later,
• He suffered from CHEST PAIN
• Serial ECG were done

57. • CK MB 1.28 ng/ml (1.39 – 6.22)
• Troponin T 18.06 pg/ml (0.00 – 14 )
• After 3 hours – troponin level become (2221.0)

58. • Gave LMWH
• Transfer to cardiac center

59. ECG on next day

60. • Dx STEMI
• Thrombolysis
• Failed
• Recuse PCI

61. RCA
Total occlusion at distal
RCA
Reperfusion after stent

62. • NOW HE IS IN GOOD HEALTH AND LIVE
HAPPILY WITH HIS FAMILY

63. ACS
CHEST PAIN
ECG CHANGES STEMI
BIOCHEMICAL MARKERS
NSTEMI UA
+
-
+ -
PCI
THROMBOLYSIS
ANTICOAGULANT CARDIOLOGIST
REFER