Acute Coronary syndromes

REPORT PREPERD BY MASTER

MOHAMMED ABD AL-KAREEM MUSTAFASUPERVISERED BY

PROF.DR.KHALEDA ALWAN

Blood Supply To The Heart

•The left and right coronary arteries and their branches supply arterial blood to the heart. These arteries originate from the aorta just above the aortic valve leaflets. The heart has large metabolic requirements, extracting approximately 70% to 80% of the oxygen delivered (other organs consume, on average, 25%). Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and decrease myocardial perfusion. Patients, particularly those with coronary artery disease (CAD), can develop myocardial ischemia (inadequate oxygen supply) when the heart rate accelerates.

• The left coronary artery has three branches. The artery from the point of origin to the first major branch is called the left main coronary artery. Two bifurcations arise off the left main coronary artery. These are the left anterior descending artery, which courses down the anterior wall of the heart, and the circumflex artery, which circles around to the lateral left wall of the heart. The right side of the heart is supplied by the right coronary artery, which progresses around to the bottom or inferior wall of the heart. The posterior wall of the heart receives its blood supply by an additional branch from the right coronary artery called the posterior descending artery. Superficial to the coronary arteries are the coronary veins. Venous blood from these veins returns to the heart primarily through the coronary sinus, which is located posteriorly in the right atrium.

Coronary arteries (red vessels) arise from the aorta and encircle the heart. Coronary veins are shown in blue.

What is Heart Disease?

•Called Coronary Heart Disease or Coronary Artery Disease

•Diagnosed when arteries that supply blood to heart muscle becomes hardened and narrowed

•Caused by plaque on inner walls and called atherosclerosis

•Eventually Heart suffers from lack of oxygen and causes

• Chest pain• Angina• Heart Attack (Myocardial infarction)

Acute Coronary Syndrome: Definitions

• The term acute coronary syndromes is used to collectively describe acute myocardial infarction (heart attack) and unstable angina (chest pain occurring at rest, new onset of pain with exertion, or angina that is more frequent, longer in duration or lower in threshold than before).

• Chest pain:•Angina: Severe constricting pain w/the sensation

of choking/suffocating•Heart attack: Blockage of a coronary artery

causing tissue damage/death.

• Acute: Sudden onset w/severe, sharp pain (compare to chronic)

• Syndrome: Group of symptoms characteristic of disease/disorder

• Myocardial: Referring to the heart muscle• Ischemia: Decrease of blood supply

Transient Myocardial ischemia

Severe Chest pain

Myocardial Blood Flow

Myocardial O2 Demands

= ACS

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Clogged arteries

The underlying cause is

• Atheroscelerotic changes

Fissuring of atheroscelerotic plaques

Platelet aggregation

Thrombosis

Coronary artery spasm

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Who can developing Coronary Artery Disease? (Risk Factors )

• Nonmodifiable Risk Factors• Family history of coronary

heart disease• Increasing age• Gender (heart disease occurs

three times more often in men than in premenopausal women)

• Race (higher incidence of heart disease in African Americans than in Caucasians)

•Modifiable Risk Factors•High blood cholesterol

level•Cigarette smoking,

tobacco use•Hypertension•Diabetes mellitus•Lack of estrogen in

women•Physical inactivity•Obesity

Signs and Symptoms• None: This is referred to as silent ischemia.

Blood to your heart may be restricted due to CAD, but you don’t feel any effects.

• Chest pain: If your coronary arteries can’t supply enough blood to meet the oxygen demands of your heart, the result may be chest pain.

• Shortness of breath: Some people may not be aware they have CAD until they develop symptoms of congestive heart failure- extreme fatigue with exertion, shortness of breath and swelling in their feet and ankles.

• Heart attack: Results when an artery to your heart muscle becomes completely blocked and the party of your heart muscles fed by that artery dies.

Assessing Chest Pain for Angina Pectoris

Assessing Chest Pain for myocardial infarction

Assessment of Angina and mi chest pain

Treatment of an acute attack of ACSSublingual nitroglycerin (0.5 mg ) or isosorbide

dinitrate (5 mg ) or Oral spray nitroglycerin (0.4 mg/metered dose),

isosorbide dinitrate(1.25 mg/metered dose)

Relief within 1-3 min. Persistence of pain

Repeat nitroglycerin at 5 min. interval (3 tab. max.)

Relief not relieved

InfarctionHOSPITALIZATION18

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Detection Methods

• Electrocardiogram –non-invasive (85% accurate)• Stress Tests • Angiograms –invasive (used in other 15% of cases)• Blood tests: used to evaluate kidney and thyroid function as

well as to check cholesterol levels and the presence of anemia.

• Chest X-ray: shows the size of your heart and whether there is fluid build up around the heart and lungs.

• Echocardiogram: shows a graphic outline of the heart’s movement

• Ejection fraction (EF): determines how well your heart pumps with each beat.

Stop smoking Reduce weight

Treat Hypertension , Hypercholestrolimia

and Diabetes

AVOID Severe exertion

Heavy meal Emotions Cold Weather

General measures

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• Graduated exercise may open new collaterals

a. For an acute attack

b. For immediate pre-exertional

prophylaxis

c. For long-term prophylaxis

d. Antiplatelet therapy.

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Immediate pre-exertional prophylaxis of AnginaSublingual nitroglycerin (0.5 mg) or isorbide dinitrate (5 mg) should be taken 5 min. before effort.

For Long term prophylaxis:Long acting nitrates, Ca++ channel blockers,

b-blockers or combinations of these drugs.

Antiplatelet therapy:Aspirin in small dose (75-150 mg daily orally)or Dipyridamole (75 mg t.d.s orally)

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Coronary artery bypass grafting (CABG)

Percutaneous Transluminal coronary Angioplasty (PTCA)

For patients not responding to adequate medical therapy

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Management of Unstable AnginaNitrate

+b-blocker

+Aspirin (low dose) and/or

Heparin orThrombolytic (stryptokinase)to minimize risk of infarction

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Unstable Angina• Cause • Thrombus partially or intermittently occludes the coronary

artery• Signs and Symptoms • Pain with or without radiation to arm, neck, back, or epigastric

region • Shortness of breath, diaphoresis, nausea, lightheadedness,

tachycardia, tachypnea, hypotension or hypertension, decreased arterial oxygen saturation (SaO2) and rhythm abnormalities

• Occurs at rest or with exertion; limits activity• Diagnostic Findings • ST-segment depression or T-wave inversion on

electrocardiography • Cardiac biomarkers not elevated

CONT…

• Treatment • Oxygen to maintain oxygen saturation level at >

90% • Nitroglycerin or morphine to control pain • b-blockers, angiotensin-converting enzyme

inhibitors,), clopidogrel (Plavix), unfractionated heparin or lowmolecular- weight heparin, and glycoprotein IIb/IIIa inhibitors

Non–ST-Segment Elevation MyocardialInfarction (NSTEMI)• Signs and Symptoms Longer in duration and more severe than in unstable

angina• Diagnostic Findings: Cardiac biomarkers are elevated.• Treatment: Cardiac catheterization and possible

percutaneous coronary intervention for patients with ongoing chest pain, hemodynamic instability, or increased risk of worsening clinical condition

ST-Segment Elevation MyocardialInfarction (STEMI)

• Cause: Thrombus fully occludes the coronary artery.• Diagnostic Findings: • ST-segment elevation or new left bundle branch block on

electrocardiography. • Cardiac biomarkers are elevated.• Treatment • b-blockers, angiotensin-converting enzyme inhibitors, statins

(started on admission and continued long term), clopidogrel (Plavix), unfractionated heparin or low-molecularweight heparin

• Percutaneous coronary intervention within 90 minutes of medical evaluation

• Fibrinolytic therapy within 30 minutes of medical evaluation