Includes: Introduction, Quick Diagnosis, Differential Diagnosis, Symptoms, Management(Invasive and Non-Invasive) of STEMI and NSTEMI in this brief presentation on Acute Coronary Syndrome.

1. Acute Coronary Syndrome

2. Introduction
Acute Coronary Syndrome is the spectrum of clinical
presentations ranging from those for :
1. Unstable Angina
2. Non- ST segment Elevation Myocardial Infarction
3. ST segment Elevation Myocardial Infarction

3. Symptoms
• Prolonged cardiac pain(>20 min): chest, throat,
arms, epigastrium or back
• Anxiety and fear of impending death
• Nausea and vomiting
• Breathlessness
• Collapse/syncope

4. Physical Signs
• Signs of sympathetic activation: pallor, sweating, tachycardia
• Signs of vagal activation: vomiting, bradycardia
• Signs of impaired myocardial function
Hypotension, oliguria, cold peripheries
Narrow pulse pressure
Raised JVP
Third heart sound
Quiet first heart sound
Diffuse apical impulse
Lung crepitations
• Signs of tissue damage: fever
• Signs of complications: e.g. mitral regurgitation, pericarditis

5. Conditions mimicking pain in ACS
Pericarditis
Dissecting aortic aneurysm
Pulmonary embolism
Esophageal reflux, spasm, or rupture
Biliary tract disease
Perforated peptic ulcer
Pancreatitis

6. Rapid Diagnosis
ST segment elevation
Cardiac Biomarkers(6-
24 hrs of onset)
Symptoms
ST segment
Elevation
Myocardial
Infarction
Non-ST segment
Elevation Myocardial
Infarction
Unstable Angina

7. Unstable Angina and NSTEMI
Management
1. Antiplatelet therapy: aspirin 75-300 mg + clopidogrel 600 mg
unless contraindications exist
2. Antithrombin therapy: unfractionated heparin or
subcutaneous enoxaparin for 48-72 hrs or until angiography is
performed.
3. Glycoprotein Iib/IIIa inhibitors (tirofiban or eptifibatide):
especially in high risk patients

8. 4. β-blockers unless contraindicated: Atenolol 5-10 mg IV
Metoprolol 5-15 mg IV
5. Intravenous nitroglycerine 5–10 µg/min for refractory pain.
Dosage can be increased by 10 µg/min every 3–5 min.
6. Thrombolytic therapy is NOT effective!! Infarcted artery is NOT
occluded in 60-85% of cases

9. Invasive management
1. Early coronary angiography(within 48 hrs) and
revascularization is recommended in patients with severe
comorbidity.

10. STEMI / Q wave MI
Initial Management:
1. Place patient on continuous cardiac monitoring
2. Oxygen, aspirin, β-blockers
3. Nitroglycerin and morphine
4. Patients presenting within 12 hours of the onset of
symptoms should have reperfusion strategy started.

11. Reperfusion Therapy
PCI vs thrombolysis
1. PCI is the best if provided promptly, improving short
and long term outcomes compared to thrombolysis
in patient presenting within 12 hours
2. A time delay of 2 hours from patient presentation to
PCI is maximum desirable

12. 3. When PCI is delayed or not available, reperfusion with
thrombolysis is best.
4. Greatest benefit when used for symptoms <12 hours
5. Streptokinase and alteplase: rapid IV infusion
6. Reteplase and Tenecteplase: rapid bolus injection

13. Adjuvant Therapy Used with Reperfusion
Antiplatelet therapy
1. Aspirin
2. Clopidogrel
Glycoprotein IIb/IIIa Inhibitors
Emergency CABG: Failed PCI

14. Late presentation: 12 Hours After Onset of
Symptoms
Reperfusion and PCI not indicated in stable patients
CABG may be considered
CABG is also considered in those with cardiogenic
shock or in association with mechanical repair

15. Discharge Medications
Aspirin: 75-300 mg/day
Clopidogrel: intolerance to aspirin or as alternative for 9-12
months
β-blockers: indefinitely
ACE inhibitors: For CHF or left ventricular dysfunction (EF<40%)
is present
Statins
Nitrates: Short acting nitrates as a rule. Long acting if
persistant chest pain in present
Control risk factors(diet, alcohol, exercise)

16. References
Oxford American Handbook of Cardiology
Harrison’s Cardiovascular Medicine
Davidson's Principles and Practice of Medicine 21st
edition (2010)
Essentials of Medical Pharmacology, 7th edition

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