ACS pathophysio & treatment

1. IHD and Angina
Pectoris:
Acute coronary
syndrome
Name: Nur A’isyah Binti Idris
Matric no.: 08201210068

2. Definition
• A term encompasses
both unstable angina
and MI
• Characterised by
• New-onset/rapidly
worsening angina
• Angina on minimal
exertion
• Angina at rest
• caused by dynamic
obstruction usually
due to complex
ulcerated with
adherent platelet rich
thrombus
• Along with coronary
artery spasm

5. Acute Myocardial Infarction
(MI)
Criteria for MI:
Detection of a rise/fall of cardiac biomarkers with
at least 1 value above 99th centile upper reference
limit with at least 1 of following:
1. Signs of ischemia
2. New or presumed new significant ST segment –
T wave or bundle branch block
3. Pathological Q wave in ECG
4. Imaging evidence of new loss of viable
myocardium

6. • Criteria for previous MI:
1. Pathological Q waves with or without
symptoms in the absence of non-ischemic
causes
2. Imaging evidence of a region of loss of viable
that is thinned and fails to contract, in absence
of non ischemic causes

7. Clinical feature
Symptoms
• Prolonged cardiac pain
• Anxiety and fear of impending death
• Nausea and vomiting
• Breathlessness
• Collapse/syncope

8. Physical sign
• Sign of sympathetic activation: pallor, sweating,
tachycardia.
• Sign of vagal activation: vomiting, bradycardia
• Sign of impaired myocardial function: Hypotension,
oliguria, cold peripheries, narrow pulse pressure,
raised JVP, S3 heart sound, diffuse apical impulse,
lung crepitations
• Sign of complication: mitral regurgitation,
pericarditis

9. Diagnosis
• Precise history taking and examination
• ECG changes
• Serum biomarkers

11. Investigation
Electrocardiography –changes STEMI
• Proximal occlusion of major CA
• ST elevation
• Diminution size of R wave
• Development Q wave
• T wave become inverted
A – normal
B – within minutes
C – within hours
D – within days
E – after several weeks or months

12. Electrocardiography –changes NSTEMI
• Partial occlusion of major vessel / complete occlusion
of minor vessel unstable angina / partial thickness
MI
• ST depression
• T wave become inverted

13. Difference ECG changes in STEMI &
NSTEMI

14. Plasma cardiac biomakers
• In unstable angina, there is no detectable rise in
cardiac biomakers
• In MI, the cardiac biomakers are :
1. Creatine kinase (CK-MB)(12H)
2. Troponin I and T
3. Lactate dehydrogenase(LDH)
4. Aspartate aminotransferase

16. • Other blood test : leucocytosis, ESR & CRP
• Chest x-ray : pulmonary edema, cardiomegaly
• Echocardiography: assessing ventricular function
& detect other complication.

17. Management
• Immediate management: 12 hours
• Analgesia
• Antithrombotic therapy
• Antiplatelets
• Anticoagulants
• Anti-anginal therapy
• Reperfusion therapy
• Late management

18. Immediate management:
• should be admitted to hospital
• Patients are manage in cardiac unit & if there is no
complications, patient can be mobilise from 2nd day
& discharged after 3-5 days.
• Analgesiato relieves distress and to lower
adrenergic drive
iv opiates(morphine sulphate 5-10mg)/diamorphine
2.5-5mg)
 Antiemetics ( metoclopramide 10mg)

19. Anticoagulant therapy
1. Antiplatelet therapy
• Within 12 hours , 300 mg aspirin PO + 600 mg
clopidogrel
• Followed by 75 mg aspirin daily + 150 mg (first 1
week) 75 mg clopidogrel
• Alternative drug is ticagrelor 180 mg, followed
by 90 mg twice daily

20. 2. Anticoagulants
• To reduce risk of re-infarction and
thromboembolic complications
• Heparin, low molecular weight heparin or
pentasaccharide
• E.g : Fondaparinux ( sc 2.5mg/day)
• Enoxaparin (sc 1mg/kg twice daily)
• Should be continue for 8 days/ until discharge

21. Anti-anginal therapy
• Sublingual glyceral trinitrate 300-500mcg
• i.v GTN 0.6 – 1.2 mg/hr
• Isosorbide dinitrate 1-2 mg/hr
• i.v B-blockers to reduce arrhythmias and improve
short term mortality
• Atenolol 5-10mg
• Metoprolol 5-15 mg over5 min

22. Reperfusion therapy
Non-ST segment elevation ACS
1. Coronary angiography
2. Coronary revascularisation
ST segment elevation ACS
Percutaneous coronary intervention (PCI)
• Treatment of choice of STEMI
• Used in combination with GpIIb/IIIa receptor antagonist and
stent implantation
• Results in reduced risk of recurrent stroke or MI
• It is ideally done within 2 hours

23. Thrombolysis therapy
• Due to availability and resource, thrombolytic
therapy remains as the treatment of choice
• Reduce mortality rate by 25 – 50%
• Alteplase 15 mg i.v bolus given over 90 minutes
followed by
• 0.75 mg/kg over 30 min followed by
• 0.5 mg/kg over 60 min

24. Complication of ACS
Arrhythmias
• Ventricular /
atrial
fibrillations
• Ventricular /
Atrial
tachycardia
• Bradycardia
Ischaemia
Acute circulatory
failure
PericarditisEmbolism
Mechanical
complication
Impaired
ventricular
function,
remodelling,
aneurysm

25. Late management of ACS
• Lifestyle modification
 Diet
 Cessation of smoking
 Regular exercise
• Secondary prevention
drug therapy
 Antiplatelet therapy
 Beta-blocker
 ACEI/ARB
 Statin
 Additional therapy
for control of
diabetes and
hypertension
 Mineralocorticoid
receptor antagonist
• Device therapy
 Implantable cardiac
defibrillator

26. THANK YOU 