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Acute Coronary Syndromes

© Resuscitation Council (UK)

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Objectives

• To discuss the clinical spectrum of ischaemic heart disease

• To recognise different presentations of the disease process

• To discuss treatment of the different clinical presentations encountered

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Fissuring Plaque

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Acute Coronary Syndromes

Clinical syndromes form spectrum of the same disease process:

Unstable angina

Non-Q wave myocardial infarction

Q wave myocardial infarction

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Stable angina• Pain from myocardial ischaemia

–tightness/ache across chest

–radiating to throat/arms/back/epigastrium

–provoked by exercise

–settles when exercise ceases

• NOT an acute coronary syndrome

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Unstable angina

• Angina of effort with increasing frequency and provoked by less exertion

• Angina occurring recurrently and unpredictably - not specific to exercise

• Unprovoked and prolonged episode of chest pain - no ECG or laboratory evidence of MI

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Non-Q wave myocardial infarction• Symptoms suggesting MI

• Non-specific ECG abnormalities initially

– ST segment depression

– T wave inversion

• Elevated cardiac enzymes

• Unstable coronary artery disease

– unstable angina

– non-Q wave MI

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Non-Q wave myocardial infarction

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Q wave myocardial infarction

• Prolonged chest pain

• Acute ST segment elevation

• Q waves

• Elevated cardiac enzymes

- creatine kinase

• Troponins

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Anterolateral myocardial infarction

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New terminology• Q waves (or a lack of them) take time to

develop clinically• Treatment is based on the admission

and subsequent 12 lead ECGs• Is ST segment elevation present or not ?• STEMI or NSTEMI

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STEMI

• ST Elevation MI

• Usually develops into Q wave MI

• Troponin positive

• However, early effective treatment may prevent full thickness infarct

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NSTEMI

• Non ST Elevation MI• Usually do not develop Q waves

(but may do)• May or may not be troponin positive• Treatment may depend on other

clinical factors and history

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Immediate management and treatment in all

acute coronary syndromes• A,B,C,D,E approach• “MONA”

–Morphine (or diamorphine)–Oxygen–Nitroglycerine (GTN spray or tablet)–Aspirin 300 mg orally (crush/chew)

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Patients with ST Elevation MI or MI with LBBB

Early coronary reperfusion therapy:

• Thrombolytic therapy• Percutaneous transluminal coronary angioplasty (PTCA)• Coronary artery bypass surgery (CABG)

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Left Bundle Branch Block

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Absolute contraindications to thrombolytic therapy

• Previous haemorrhagic stroke

• Other stroke or CVA within 6 months

• Active internal bleeding

• Aortic dissection

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Unstable angina and Non-Q wave MI (NSTEMI)

• ‘MONA’• Heparin

– continuous infusion unfractionated, or– subcutaneous low molecular weight

• Intravenous nitrate • If ‘high risk’

– glycoprotein IIb/IIIa inhibitor• Consider beta-blockers

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Any Questions?

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Summary

• In acute coronary syndromes consider A, B, C, D, E approach and ‘MONA’

• Start reperfusion therapy early if indicated