3 acute coronary syndromes 2010v1
TRANSCRIPT
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Lecture
Acute CoronarySyndromes
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Learning outcomes
To understand the clinical spectrum of coronary
disease
To recognise different presentations of the
disease process
To be aware of the different treatment options
for each clinical presentation
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Acute coronary syndromes
Spectrum of clinical presentation caused by:
Atherosclerotic plaque rupture
Smooth muscle constriction
Thrombus formation
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Fissured plaque
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Acute coronary syndromesClinical syndromes caused by the same
disease process:
Unstable angina
Non-ST-elevation myocardial infarction
ST-elevation myocardial infarction
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Stable angina
Pain or discomfort from myocardial ischaemia:
Tightness/ache usually across chestMay radiate to throat/arms/back/epigastrium
Consistently provoked by exercise
Settles when exercise stops
NOT an acute coronary syndrome
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Unstable angina
1. Angina on exertion with increasing frequencyover a few days, provoked by less exertion
OR
2. Angina occurring recurrently and unpredictably- not specific to exercise
OR
3. Unprovoked and prolonged episode of chest
pain ECG may be normal ST segment depression suggests high risk No troponin release Cardiac enzymes usually normal
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Acute ST depression
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Non-ST-elevation myocardial infarction
(NSTEMI)
Symptoms suggesting acute MI
Non-specific ECG abnormalities ST segment depression
T wave inversion
Troponin releaseUsually elevated cardiac enzymes e.g. creatine kinase (CK)
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NSTEMI
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ST-elevation myocardial infarction
(STEMI)
Symptoms suggesting acute MI
Acute ST segment elevation
Q waves likely to develop
Troponin release
Usually elevated cardiac enzymes (e.g. CK)
Early effective treatment may limit myocardialdamage and prevent Q wave development
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Anterolateral STEMI
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Immediate treatment for all acute
coronary syndromes
ABCDE approach
Aspirin 300 mg orally (crush/chew)
Nitrate (GTN spray or tablet)
Oxygen if appropriate
Morphine (or diamorphine)
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Immediate treatment for all
acute coronary syndromes
Anti-thrombotic Aspirin Clopidogrel or prasugrel
LMW heparin or fondaparinux If very high risk: glycoprotein IIb/IIIa inhibitor
Pain relief Nitrate Morphine
Oxygen if appropriate
Myocardial protection Beta blocker Coronary angiography/PCI in most patients
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STEMI (or acute MI with new LBBB)
Emergency reperfusion therapy:
Percutaneous coronary intervention (PCI)
Fibrinolytic therapy
Avoid delayTime is muscle
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Access to
emergency
reperfusion
YES NO
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Left bundle branch block
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Absolute contraindications to
fibrinolytic therapy
Previous haemorrhagic stroke
Other stroke or CVA within 6 months
CNS damage or neoplasm
Active internal bleeding
Aortic dissection
Recent major surgery or trauma
Known bleeding disorder
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Any questions?
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Summary
Recognise the different presentations
Use ABCDE approach
Start appropriate immediate treatment
Arrange emergency reperfusion therapy when
appropriate
Identify other high-risk patients for furtherinvestigation and treatment