Post on 15-Apr-2017
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ACUTE CORONARY SYNDROME(EMERGENCY MANAGEMENT)
BYDR. ISTIKHAR ALI SAJJAD
DEFINITION Acute coronary syndrome (ACS) refers to a
spectrum of clinical presentations attributed to obstruction of the coronary arteries.
It encompasses unstable angina, non-ST segment elevation myocardial infarction (ST segment elevation generally absent), and ST segment elevation infarction (persistent ST segment elevation usually present).
The definition of acute coronary syndrome depends on the specific characteristics of each element of the triad of clinical presentation (including a history of coronary artery disease), electrocardiographic changes and biochemical cardiac markers
INVESTIGATIONS
ECGTransient ST-segment elevationsDynamic T-wave changes: Inversions,
normalizations, or hyperacute changes
ST depressions: These may be junctional, downsloping, or horizontal
INVESTIGATIONS
Laboratory studies Creatine kinase isoenzyme MB (CK-MB)
levelsCardiac troponin levelsMyoglobin levelsComplete blood countBasic metabolic panel
INVESTIGATIONS
Chest radiography Echocardiography Myocardial perfusion imaging Cardiac angiography Computed tomography, including CT
coronary angiography and CT coronary artery calcium scoring
TREATMENT STEPSFollowing steps should be followed Myocardial oxygenation
35-50% O2 inhalation Antiplatlets
Aspirine p/o 300mg bolus then 75-81mg/day Clopidogrel p/o 300mg bolus then 75 mg/day (avoid if
CABG planned) Antithrombins (in moderate and high risk patients only)
Inj. Heparin 5000 units I/V bolus then 0.25 units/Kg/hrOR
Inj. Enoxaparin 1mg/Kg S/C twice a day.
Glycoprotein IIb/IIIa inhibitors (indicated in high risk patients only) Eptifibatide 180ug/Kg I/V bolus then 2ug/Kg/min
for 72 hrsOR
Abciximab 0.25mg/Kg I/V bolus then 0.125 ug/Kg/min (max. 10 ug/min) for 12 hrs
Analgesics Diamorphine/morphine 2.5-5mg I/V
Decrease myocardial energy consumption Bisoprolol 2.5-5 mg P/O
OR Atenolol 5mg I/V repeated after 15 mins then
25-50 mg P/O per day.
Coronary vasodilatationGlyceryl trinitrate 2-10mg/hr I/V, buccal,
sublingual Plaque stabilization/ventricular remodeling
HMG CoA reductase inhibitor ( simvastatin 20-40 mg/day or atorvastatin 80mg/day)
ACE inhibitors/ARBs
In case of STEMI (Urgent referral to CCU) If patient presents within 12 hrs of
symptoms onset then Streptokinase OR Retiplase OR
Tenectiplase OR PCI within 30 mins
Refer Patient for Urgent Angiography if Persistent/recurrent angina with ST
elevation >2mm or deep negative T wave Clinical signs of heart failure Haemodynamic instability Life threatning arrhythmias