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