DISCUSSION

ACS: DEFINITION
A spectrum of clinical diagnoses comprising unstable angina, Non-STEMI, and STEMI that
share similar pathological features involving intracoronary thrombosis.

PATHOPHYSIOLOGY
atherosclerosis with superimposed coronary thrombosis
Slowly growing high-grade stenoses can progress to complete occlusion but do not usually
precipitate acute STEMI d/t collateral circulation
During development of plaques, abrupt transition can occur, resulting in
Platelet activation
Thrombin generation
Thrombus formation
Blood flow occlusion leads to imbalance between supply and demand and could lead
to myocardial necrosis
Pts with non-transmural infarction more likely to have more significan stenosis in IRA
Less severe stenosis with lipid-laden plaques and fragile caps more likely to rupture and
causing thrombsis and STEMI

Stable Angina
Progressive narrowing of coronary lumen
Stable fibrous cap
Unstable Angina
Progressive narrowing
Acute worsening of coronary lumen due to thrombus formation

NSTEMI
Acute worsening of coronary lumen due to
thrombus formation
Sub-occlusive/transient coronary thrombus with
myocardial necrosis
STEMI
Minimal prior narrowing of coronary lumen
Acute rupture of thin fibrous cap
Occlusive thrombus formation
Acute injury pattern
Myocardial necrosis

TYPE OF ACS

Angina
Definition: Discomfort in the chest/ choking, that
characteristically comes on with exertion,
relieved by rest and/or NTG

Favors Ischemic Origin

Against Ischemic Origin

Character

Constricting
Squeezing
Burning
Heaviness

Dull ache
Knife-like, sharp
Jabs
Pleuritic

Location

Substernal
Anterior thorax
Arms, shoulders
Neck, teeth,
Interscapular

Left submammary area

Left hemithorax

Provoking
Factors

Exertion
Excitement
Cold, meals, stress

Pain after completion

of exercise
Pain with movement

Acute coronary syndrome

Based on ECG and cardiac enzymes, ACS is classified into:
STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion, elevated cardiac enzymes
Unstable Angina: Non specific EKG changes, normal cardiac enzymes
Unstable Angina
Occurs at rest and prolonged, usually lasting >20 minutes
New onset angina that limits activity
Increasing angina: Pain that occurs more frequently, lasts longer periods or is increasingly
limiting the patients activity

EKG
STEMI:
Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
Clinically significant ST segment elevations:
o than 1 mm (0.1 mV) in at least two anatomical contiguous leads
or 2 mm (0.2 mV) in two contiguous precordial leads
(V2 and V3)
Note: LBBB and pacemakers can interfere with diagnosis of MI on EKG

EKG
NSTEMI:
ST depressions (0.5 mm at least) or T wave inversions ( 1.0 mm at least) without
Q waves in 2 contiguous leads with prominent R wave or R/S ratio >1.
o Isolated T wave inversions:
can correlate with increased risk for MI
o may represent Wellens syndrome:
critical LAD stenosis
>2mm inversions in anterior precordial leads
Unstable Angina:
May present with nonspecific or transient ST segment depressions or elevations
Cardiac Enzymes
Troponin is primarily used for diagnosing MI because it has good sensitivity and specificity.
o CK-MB is more useful in certain situations such as post reperfusion MI or if
troponin test is not available

Other conditions can cause elevation in troponin such as renal failure or heart failure
The increasing troponin trend is the important thing to look for in diagnosing MI.
Order Troponin together with ECG when doing serial testing to rule out ACS.

Risk Stratification: TIMI score

NSTEMI or unstable angina are risk stratified:
o Age>=65
o >= 3 CAD risk factors:
o HTN, hyperlipidemia, diabetes, smoker, family hx of early MI
o Documented CAD with >=50% stenosis
o ST segment deviation
o 2 aginal episodes in past 24 hours
o Aspirin use in the past week (marker for more severe case)
o Elevation of cardiac enzymes
Stratify risk based on number of variables
Risk:
0-2: Low 3-4: Intermediate 5-7: High risk

Manifestations
Chest Pain Classification
Substernal
Exertional
Relieved with rest
Interpretation
Typical Angina: 3 criteria from above

Atypical Angina: 2 criteria from above

Non-Anginal Chest Pain: 1 or less criteria from above
Symptoms
prolonged pain > 30 min usually
constricting, crushing, or compressing; heaviness or squeezing
can be choking, burning, knife-like
retrosternal, radiating to L>R side of chest, ulnar sides of arms L>R, shoulder, upper extremity,
jaw, neck, interscapular region sometimes epigastric
pain usually implies ischemia
other sx
o nausea/vomiting more common in inferior MI
o weakness
o dizziness
o palpitation
o cold perspiration
o sense of impending doom
US/NSTEMI Rx
DIAGNOSTICS
Troponin
cTnT (33 kDa) binds to tropomyosin to complex molecule to thin filament
cTnI (24kDa) inhibits actin-myosin interactions
cTnC binds Ca2+
Generally not detectable in plasma of normal persons

TnT and TnI have different amino acid sequence in cardiac vs. skeletal muscle
Permits development of cardiac specific antibodies
More sensitive and specific than CKMB
Detects minimal amounts of cardiac necrosis (neg. CKMB)
o minor myocardial damage/microinfarction
Elevated in MI (pos. CKMB)
New guidelines suggest troponin is sufficient to dx MI
Other situations assoc. with increased troponin:
o CHF
o ICU
o Renal failure
o CVA
o Myocarditis/other myocardial injury

Exercise Stress Testing

Positive response: horizontal 1mm ST depression and symptoms
High risk response:
o Deep ST depression
o Poor exercise tolerance: unable to exercise past stage 2 (<6 mins)
o Exercise induced hypotension and dysrhythmias
Uninterpretable:
o LBBB
o Digoxin
o LVH
Contra-indications:
o Severe Aortic stenosis
o Aortic dissection
o MI/ACS within 24 h
o PE
Angiography
Gold standard
Defines anatomy: 1VD, 2VD, 3VD, LM

Assesses LV function
Guides treatment: PCI, CABG or medical therapy
Indications
UA/post MI with ongoing pain, ST depresssion
Hemodynamic instability
CHF, ventricular arrhythmias
Previous PCI, CABG
High risk non-invasive test
Emerging as the strategy of choice for initial evaluation of most ACS with elevated
troponins or EKG changes
o Based on FRISC II, TACTICS trials