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3rd Lecture - ACS

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Ghassak Ahmed
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14 views

3rd Lecture - ACS

Uploaded by

Ghassak Ahmed
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Hassan Ala Farid

M.B.Ch.B. – Resident

Internal Medicine Department


College of medicine / University of Basra
Acute Coronary
Syndrome

Objective : Able to diagnose ACS ( acute coronary
syndrome ) and start emergency measures to treat and
prevent further complications .
Overview

 Acute coronary syndrome (ACS) includes :

1. unstable angina
2. STEMI
3. NSTEMI
Symptoms

 Acute central chest pain , lasting > 20min , often
associated with nausea , sweatiness , dyspnea ,
palpitations.

 ACS without chest pain is called ‘silent’; mostly seen


in elderly and diabetic patients , Silent MIs may
present with: syncope, pulmonary edema, epigastric
pain and vomiting ( be aware of this ! )
Risk factors
1. Age

2. male gender
3. family history of IHD (MI in 1st degree relative <55yrs).
4. Smoking
5. Hypertension
6. DM
7. hyperlipidemia
8. obesity
9. sedentary lifestyle
Signs

 Distress , anxiety, pallor , sweatiness, pulse decrease
or increase , BP decrease or increase .

 There may be signs of heart failure ( raised JVP,


basal crepitations) or a pansystolic murmur
(papillary muscle dysfunction/rupture , VSD) , leg
odema .
Tests
 ECG :

1. Classically , hyperacute (tall) T waves, ST elevation or
new LBBB occur within hours of transmural infarction . T
wave inversion and development of pathological Q
waves follow over hours to days
2. In other ACS : ST depression, T wave inversion, non-
specific changes, or normal.
3. In 20% of MI, the ECG may be normal initially.
Sequential ECG changes following acute MI.


Inferior & Lateral STEMI

Anterior STEMI

Acute posterolateral STEMIA

LBBB

Tests

 Cardiac troponin levels (T and I) are the most sensitive ( -Ve
after 6 hours from pain can rule out MI ) and specific ( + Ve can
rule in ) markers of myocardial necrosis . Serum levels raise
within 3–12h from the onset of chest pain, peak at 24–48h, and
decline to baseline over 5–14 days.

 CXR: Look for cardiomegaly, pulmonary oedema .

 Blood tests : FBC , U&E , glucose , lipids , base line PTT , PT ,


INR


Thrombolytic therapy

 Early coronary reperfusion saves lives; decisions must be
taken quickly so seek senior advice early.
 Look for typical clinical symptoms of MI plus ECG
criteria:
1. ST elevation >1mm in ≥2 adjacent limb leads or >2mm in
≥2 adjacent chest leads.
2. LBBB (unless known to have LBBB previously).
3. Posterior changes: deep ST depression and tall R waves
in leads V1 to V3.
Thrombolytic therapy

 Benefit reduces steadily from onset of pain, target time is
<30min from admission; use >12h from symptom onset
requires specialist advice ( only if ongoing chest pain )

 Do not thrombolyse ST depression alone, T-wave inversion


alone, or normal ECG.

 Patients with STEMI who do not receive reperfusion (eg


presenting >12h after symptom onset) should be treated with
enoxaparin/unfractionated heparin .
Thrombolytic therapy

 Absolute Contra-indications :

1. Previous intracranial haemorrhage.


2. Ischaemic stroke <6months.
3. Cerebral malignancy or AVM.
4. Recent major trauma/surgery/ head injury (<3wks).
5. GI bleeding (<1 month).
6. Known bleeding disorder.
7. Aortic dissection.
8. Non-compressible punctures <24h, eg liver biopsy, lumbar
puncture.
Thrombolytic therapy

 Relative CI :

1. TIA <6 months.


2. Anticoagulant therapy.
3. Pregnancy/<1wk post partum.
4. Refractory hypertension (>180mmHg/110mmHg).
5. Advanced liver disease.
6. Infective endocarditis.
7. Active peptic ulcer ( not bleeding ulcer ) .
8. Prolonged/traumatic resuscitation

Further treatment

1. B - blocker, eg metoprolol 50 mg or atenolol 5mg or bisoprolol
2.5 mg unless contraindicated, eg asthma , acute LV failure or
heart block .

2. ACE-inhibitor: Consider starting ACE-i (eg lisinopril 2.5mg)


in all normotensive patients (systolic ≥120mm/Hg) within 24h
of acute MI, especially if there is clinical evidence of heart
failure or echo evidence of LV dysfunction.

3. clopidogrel 300mg loading followed by 75mg/day for 30 days


Further treatment

1. Statin ( atorvastatin 40 – 80 mg )

2. GTN: routine use now not recommended in the acute setting


unless patient is hypertensive or in acute LVF

3. Oxygen is recommended if patients have SaO2 <95%, are


breathless or in acute LVF .

4. Anticoagulation: An injectable anticoagulant must be used in


primary PCI. use enoxaparin ± a GP IIb/IIIa blocker or heparin
Right ventricular infarction

 Confirm by demonstrating ST elevation in rV3/4 and/ or echo.
• NB : rV4 means that V4 is placed in the right 5th intercostal
space in the midclavicular line.

 Treat hypotension and oliguria with fluids (avoid nitrates and


diuretics).
 Monitor BP carefully, and assess early signs of pulmonary
oedema.
 Intensive monitoring and inotropes may be useful in some
patients.
Acute management of ACS without ST-segment elevation




 High-risk patients (persistent or recurrent ischaemia, ST


depression , diabetes, +Ve troponin)

 Low-risk (no further pain, flat or inverted T-waves, or normal


ECG, and negative troponin):
Non - STEMI

Skills stations

1. Discover the ischemic changes in ECGs

2. Give thrombolytic therapy as indicated

3. Use infusion pump for heparin infusion


Any question ?

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