3 acute coronary syndromes 2010v1

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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