Date post: | 18-Dec-2014 |
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Health & Medicine |
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Acute Coronary Syndrome
Presented by:Dr. Asim Siddig AbdelrahmanHO Medicine Department
Contents
• Definition of ACS.• Classifications.•Management.• Complications.
Definition
a constellation of symptoms related to obstruction of coronary arteries with chest pain being the most common symptom in addition to nausea, vomiting, diaphoresis
etc.often radiating to the left arm or angle of
the jaw, pressure-like in character
ACS is classified into:
Unstable AnginaSTEMI
NSTEMI
UNSTABLE ANGINA• Pain occurring at rest –
duration > 20min. • Worsening of chest pain,
increases in frequency, duration.
• Angina becoming resistance to drugs that previously gave good control.
• NB! ECG – normal, ST depression(>0.5mm), T wave changes
MI• Leading cause of death in US• Thrombosis in atherosclerotic artery causes 90%
of MIs.• A region of the myocardium is abruptly deprived
of blood supply due to restricted coronary blood flow.• Ischemia results and may lead to necrosis within
6 hours.
Risk Factors
• Age• Sex• FH : MI in 1st degree relatives <55 yrs.• Smoking.• Obesity, sedentary lifestyle.• HTN, DM.• Hyperlipidemia.
Females, when compared to males:
-present with MI later in life.-have poorer prognosis and high morbidity.-are 2x as likely to die in the first weeks.-are more likely to die from the first MI.-have higher rates of unrecognized MI.
Study in US
Features suggesting MI • The pains are usually more
severe .• There are more associated
symptoms such as sweating, palpitation, nausea, or vomiting.
• Duration is > 20 minutes.• Usual relieving factors such as
rest or GTN spray do not help.• May be silent in elderly or
diabetics.• Patients often tells you they
think they are going to die (EXTREME distress, sweatiness, anxiety, pulse, BP or ).
DiagnosisBrief History and physical Examination………
Generally DO:
• CBC.• U&E.• Random BG.• Lipid profile.• CXR: but do not delay treatment waiting
for it.
ECGCardiac Enzymes
STEMI:• ST elevation, Q waves , hyper
acute T waves; followed by T wave inversions.
• Clinically significant ST segment elevations:
• > than 1 mm (0.1 mV) in at least two limb contiguous leads
• or 2 mm (0.2 mV) in two contiguous chest leads (V2 and V3)
• Note: LBBB and pacemakers can interfere with diagnosis of MI on ECG.
The ECG changes
ST elevationInferior MI
NSTEM: ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) or normal ECG.
• Troponin:• The most sensitive and specific marker of myocardial
necrosis.• Serum level increases within 3-12 hrs from the onset of
Chest pain.• +ve in both STEMI and NSTEMI, but –ve in U. angina.
• CK-MB.• Myoglobin.
Management of ACS
Management of ACS• Good IV access• Supplemental O2• Aspirin 300mg ; consider Clopidogrel 300mg too.• Nitrates 1-2 tabs SL.• Morphine 5-10mg IV.• Beta blocker, eg Atenolol 5mg IV (unless Asthma
or LVF).• Restore coronary perfusion : PCI or thrombolysis
in STEMI .• Heparin (LMW) in NSTEMI and U.angina.• Call cardiology fellow! …….. CCU.
Subsequent management• Bed rest 48hrs, continuous ECG monitoring.• Daily Ex.• Prophylaxis againest thromboembolism until fully
mobile (consider warfarin for 3 mo if large Ant.MI).• Aspirin eg 75mg to decrease vascular events.• Long term B blockers.• Starts statin. • ACE inhibitors in all pts ...stop if EF normal.• Address modifiable risk factors eg smoking. • If uncomplicated discharge after 5-7 days.
thrombolysis
Criteria:• ST elevation; >1mm in 2 or more limb leads or
>2mm in 2 or more chest leads.• Newly developed LBBB.• Posterior changes deep ST depression and tall R
waves in V1 toV3.Contraindications;• Internal bleeding, recent surgery and severe
HTN.eg Streptokinase.
Complications:
• Cardiac arrest….. vent. Arrhythmias.• Bradycardias or heart block.• Tachyarrhythmias.• CHF.• Pericarditis.• DVT and PE.
Attention…..SUMMARY
Unstable Angina STEMI
NSTEMI
Non occlusive thrombus
Non specific ECG
Normal cardiac Enzymes.Ttt: +heparin
Non-occlusive thrombus sufficient to cause tissue damage & mild myocardial necrosis
ST depression +/- T wave inversion on ECG, non significant.
Elevated cardiac Enzymes.Ttt: +heparin
Complete thrombus occlusion
ST elevations on ECG or new LBBB
Elevated cardiac enzymesMore severe Symptoms.Ttt: +thromolytics.
Thanks