Presentation 3

ACUTE CORONARY
SYNDROME
BY DR ANNETTE AMA COURNOOH
EMERGENCY PHYSICIAN SPECIALIST
MBCHB, MGCS
OUTLINE
 DEFINITION
 EPIDEMIOLOGY
 RISK FACTORS
 PATHOPHYSIOLOGY
 CLINICAL PRESENTATION
 DIAGNOSIS
 MANAGEMENT
 PREVENTION
DEFINITION
 Acute coronary syndrome refers to a spectrum of clinical presentations

ranging from those with
 STEMI
 NSTEMI and
 Unstable angina
EPIDEMIOLOGY
 About 7 million patients with chest pain present to a U.S. ED each year.
 Of these, more than 50% are placed into an observation unit or admitted
to the hospital and yet only about 10% are eventually diagnosed with an
acute coronary syndrome (ACS).
 Approximately 2% of patients with acute myocardial infarctions (AMIs) are not diagnosed on initial
presentation to the ED.
 Of all patients who present to emergency departments with symptoms

of ACS, only 20-25% will have ACS confirmed as their discharge
diagnosis.
AETIOLOGY
 The most common cause by far is atherosclerotic plaque rupture in coronary

artery disease. Other less common causes include:
1. Aortic or coronary artery dissection

2. Vasculitis
3. Connective tissue disorders
4. Drugs: cocaine
5. Coronary artery spasm
Risk Factors
 Smoking
 Hypertension
 Diabetes Mellitus
 Dyslipidaemia
 Elevated triglycerides
 Family History event in first degree relative
 Age-- 45 for male/55 for female
 Chronic Kidney Disease
 Lack of regular physical activity
 Obesity
 Lack of diet rich in fruit, veggies, fiber
Acute coronary syndromes
 Unstable Angina
 Non-ST-Segment Elevation MI (NSTEMI)
 ST-Segment Elevation MI (STEMI)
 Similar pathophysiology
 Similar presentation and early management rules
 STEMI requires evaluation for acute reperfusion
intervention
Diagnosis of Acute MI STEMI / NSTEMI
 At least 2 of the following

•Ischemic symptoms
•Diagnostic ECG changes
•Serum cardiac marker elevations
Diagnosis of Angina
• Typical angina
All three of the following:
• Substernal chest discomfort
• Onset with exertion or emotional stress
• Relief with rest or nitroglycerin
• Atypical angina
• 2 of the above criteria
• Noncardiac chest pain
• 1 of the above
ANATOMY OF CORONARY VESSELS
Anatomy cont’d
PATHOPHYSIOLOGY
DEFINITIONS
Unstable angina
 An unprovoked or prolonged episode of chest pain raising a suspicion of acute
myocardial infarction
 Without a definite ECG or laboratory evidence
Cont’d
NSTEMI
Chest pain suggestive of AMI(Acute myocardial infarction)
Non-specific ECG changes(ST segment elevation or depression)
Laboratory test showing release of troponins
Cont’d
STEMI
Sustained chest pain suggestive of AMI
Acute ST segment elevation or
New Left bundle branch block(LBBB)
EVALUATION
The first step of evaluation:

1. ECG, helps differentiate between STEMI and NSTEMI, unstable angina.
 American Heart Association guidelines maintain that any patient with
complaints suspicious of ACS should get an ECG within 10 minutes of arrival.
contd
 Cath lab should be activated as soon as STEMI is confirmed in a percutaneous

coronary intervention (PCI) center.
 Cardiac enzymes especially troponin, CK-MB/CK ratio is important in assessing
the NSTEMI versus myocardial ischemia without tissue destruction.
 A chest x-ray is useful in diagnosing causes other than MI presenting with
chest pain like pneumonia and pneumothorax. The same applies for blood
work like complete blood count (CBC), chemistry, liver function test, and
lipase which can help differentiate intraabdominal pathology presenting with
chest pain.[4]
DIFFERENTIAL DIAGNOSIS OF CHEST PAIN
MANAGEMENT
Reperfusion therapy
 Diagnosis of STEMI requires emergent reperfusion therapy to restore normal blood flow through
coronary arteries and limit infarct size.
 PCI is associated with reduced mortality of approx. 30% and decreased risk of intracranial
haemorrhage and stroke which makes it the best choice for elderly and those at risk for
bleeding.
 In optimal circumstances, the usage of PCI is able to achieve restored coronary artery flow in
>90% of subjects. Fibrinolytic's restores normal coronary artery flow in 50–60% of subjects.
Oxygen
 Supplemental oxygen should be given to patients with signs of

breathlessness, heart failure, shock, or an arterial oxyhemoglobin
saturation <94%.[6]
Nitroglycerin
 Nitroglycerin has beneficial effects during suspected cases of ACS. It dilates the
coronary arteries, peripheral arterial bed, and venous capacitance vessels.
 The administration of nitroglycerin should be carefully considered in cases when
administration would exclude the use of other helpful medications.
 Patients with ischemic discomfort receive up to 3 doses (0.4 mg) over 3–5 min
intervals, until chest discomfort is relieved or low blood pressure limits its use.
 Nitroglycerin may be administered intravenously, orally, or topically. Clinicians
should be cautious in cases of known inferior wall STEMI and suspected right
ventricular involvement because patients require adequate right ventricle preload.
A right-sided ECG should be performed to rule out right ventricular ischemia.[6]
Anti-Platelet therapy
 This is common management provided by other healthcare professionals.

 This generally involves the utilisation of medications, predominately in tablet
form. These drugs can be aspirin, adenosine diphosphate ADP)-receptor
blockers and glycoprotein IIb/IIIa inhibitors, among others.[3]
Beta blockers
 β-Adrenergic receptor blockers have shown to reduce mortality and decrease

infarct size with early intravenous usage and can prevent arrhythmias.
 β-Blockers reduce myocardial workload and oxygen demand by reducing
contractility, heart rate, and arterial blood pressure.[6]
Anticoagulation
Anticoagulant medications such as

 unfractionated heparin (UFH)
 low-molecular-weight heparin (LMWH)
 or less commonly bivalirudin have been shown to decrease reinfarction
following reperfusion therapy.
PREVENTION
There are a number of known risk factors for ACS including:
 High blood pressure

 High cholesterol
 Being overweight
 Smoking
 Diabetes
 A family history of heart disease and stroke
 Older age
Prevention of ACS starts with healthy living and sometimes medication to lower
risk factors. Some of the things you can do include:
 Eating a healthy, balanced diet

 Maintaining a healthy weight
 Moderate physical exercise
 Controlling diabetes
 Taking medication as prescribed by a doctor to treat risks like high blood
pressure, high cholesterol and diabetes
THANK YOU

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ACUTE CORONARY

 Acute coronary syndrome refers to a spectrum of clinical presentations

 Of all patients who present to emergency departments with symptoms

 The most common cause by far is atherosclerotic plaque rupture in coronary

1. Aortic or coronary artery dissection

 At least 2 of the following

The first step of evaluation:

 Cath lab should be activated as soon as STEMI is confirmed in a percutaneous

 Supplemental oxygen should be given to patients with signs of

 This is common management provided by other healthcare professionals.

 β-Adrenergic receptor blockers have shown to reduce mortality and decrease

Anticoagulant medications such as

There are a number of known risk factors for ACS including:

 High blood pressure

 Eating a healthy, balanced diet

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