ACUTE CORONARY SYNDROME

By: Dr. Muhammad Alauddin Sarwar

Medical officer,Sindh Government Qatar Hospital,Karachi.

ACSACSAny constellation of clinical symptoms that are compatible with myocardial ischemia. It encompasses

Acute ST elevated myocardial infarction (STEMI)Non ST elevated myocardial infarction ( NSTEMI)Unstable Angina

Each year:• > 4 million patients are admitted with unstable

angina and acute MI • > 900,000 patients undergo PTCA with or

without stent

Worldwide StatisticsWorldwide Statistics

ACC/AHA and National Guidelines for USA & NSTEMI 2003

PATHOPHYSIOLOGY OF ACSPATHOPHYSIOLOGY OF ACS

Video clip explaining Atheromatous pathology of ACS

ACSACS

ACC/AHA and National Guidelines for USA & NSTEMI 2003

DIAGNOSIS OF ACS

It can be made on the basis of

HistoryECGCardiac (Bio Markers)

1) HISTORY

DIAGNOSIS OF ACS

Likelihood of ACSLikelihood of ACS Unlikelihood of ACS Unlikelihood of ACS

Chest or left arm pain as chief symptom.K/C of CAD, including MIAge >70 yrsMale sexD/MRecent cocaine useTransient MR, hypotension, diaphoresis, pulmonary edema.

Pleuritic painLocalized middle or lower abdominal pain.Pain that may be localized by the tip of 1 finger.Pain with movement or palpation of chest wall.Constant chest pain for many hoursVery brief episodes of pain that last a few seconds or less.Pain that radiates into the lower extremities.

ACC/AHA and National Guidelines for USA & NSTEMI 2003

DIAGNOSIS OF ACS

ECG:ECG:

High likelihood of High likelihood of ACSACS

Intermediate Intermediate Likelihood of ACSLikelihood of ACS

Low Likelihood of Low Likelihood of ACSACS

New, transient ST-segment deviation (0.05 mV), orT wave inversion (0.2 mV)

Fixed Q wavesAbnormal ST segment or T waves

T waves flattening or inversion in leads with dominant R wavesNormal ECG

ACC/AHA and National Guidelines for USA & NSTEMI 2003

DIAGNOSIS OF ACS

3) Cardiac ( Bio Markers)3) Cardiac ( Bio Markers)

High likelihood of High likelihood of ACSACS

Intermediate Intermediate Likelihood of ACSLikelihood of ACS

Low Likelihood of Low Likelihood of ACSACS

Elevated cardiac TnI, TNT, or CKMB

Normal Normal

ACC/AHA and National Guidelines for USA & NSTEMI 2003

Definite ACS

No ST elevation ST elevation

Non diagnostic ECG normal initial serum cardiac marker

ST & T wave changes on going pain positive cardiac

markers hemodynamic abnormalities

Evaluate for reperfusion

therapy

Observe, follow up 4-8 hrs: ECG, Cardiac markers

No recurrent pain, negative follow up studies

Recurrent ischemic pain or positive follow up studies

diagnosis of ACS confirmed

Stress study to provoke ischemiaConsider evaluation of LV function if ischemia is present

Positive: diagnosis of ACS confirmed

Negative: Non-ischemic discomfort, Low risk ACS

OPD follow up Admission, manage via acute ischemic pathway

See AHA guidelines for

Ac. MI

ACC/AHA & NationalGuidelines 2003.

EVALUATION OF ACS

In the early conservative strategy, coronary angiography is reserved for patients with evidence of recurrent ischemia (angina or ST-segment changes at rest or with minimal activity) or a strongly positive stress test despite vigorous medical therapy.

In the early invasive strategy, patients without clinically obvious contraindications to coronary revascularization are routinely recommended for early coronary angiography and angiographically directed revascularization, if possible.

EVALUATION OF ACS

STRATEGIESSTRATEGIES

ACC/AHA Guidelines 2003

SAARC Guidelines: Adopted from ACC/AHA

EVALUATION OF ACS

ACC/AHA and National Guidelines for USA & NSTEMI 2003

NST-AMI ACS Task Force. C 2003 European Society of Cardiology

EARLY INVASIVE STRSTEGY FOR ACS

ACS (STEMI)ACS (STEMI)

STEMI is the most important component of ACS.

It needs to be dealt urgently & efficiently.Time is muscle (Thrombolysis is preferred if

onset of pain to presentation is under 3 hours)

Every GP should be able to pick ST elevation in the ECG & to provide proper emergency medication & referral.

ACC/AHA and National Guidelines for STEMI 2006

The ECGThe ECG

Recognition of AMI Recognition of AMI

• Know what to look for—– ST elevation >1 mm– 2 contiguous leads

• Know where to look– I, AVL, V5, V6 = Lateral

– V1 V2 V3 V4 = Anterior

– II, III & AVF = InferiorPR baseline

ST-segment Elevation= 4.5 mm

J point

12-Lead ECG Variations in AMI and Angina

12-Lead ECG Variations in AMI and Angina

Baseline

Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina)

Injury—elevated ST segment, T wave may invert

Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted

Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal

NSR, ST elevation II, III and avF.ST depression in I, avL and V2 – V6

Acute Inferior wall MI

A 45 years old male patient on Bed -5 in Cardiac WardA 45 years old male patient on Bed -5 in Cardiac Ward

ECG at 11/2/085 days before admission

NSR,Poor R waves and T inversion II, III and avF.

ECG at admission5 days after MI

Upper} NSR, ST elevation in I, avL, V2 – V5, ST depression in II,III and avFANTERIOR WALL MI

NSR,ST elevation in I, avL and V1 to V6ST depression in II, III & avF.Anterior Wall MI

NSR, ST depression V1 to V3 with R wave and upright T waves, ST elevation in V5 & V6.Postero Lateral wall MI.

ER Management of STEMIER Management of STEMI

ReassuranceTargeted historyECG to be interpreted within 10 minOxygen @ 2-4 L/minI/V access with two wide bore cannulaeASA (Disprin) 300mg chewableClopidogrel (Loclog 75mg) 4 stat+LMWH S/C if Thrombolytic therapy is not near.

ACC/AHA and National Guidelines for STEMI 2006

STEMI Management

Sublingual nitroglycerin (Angised) 500mcg sos Streptokinase to be given stat after ECG confirms

ST elevation Morphine I/V to relieve pain and anxiety. Oral beta blocker, if no sign of heart failure

DRUGS to be used in first 24 hrs• Clopidogrel 75 mg OD• ACE inhibitor / ARBs if ACEI intolerance• Atorvastatin 20 mg at night.

ACC/AHA and National Guidelines for STEMI 2006