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An acute coronary syndrome (ACS) is a set of signs and symptoms usually a

combination of chest pain and other features like sweating vomiting, interpreted as
being the result of abruptly decreased blood flow to the heart muscles(cardiac
ischemia); the most common cause for ACS is of atherosclerotic plaque in any of
coronary arteries.

Types of Acute Coronary Syndromes - or heart attacks

Acute Coronary Syndrome is a name given to three types of coronary artery diseases
that are associated with sudden rupture of plaque inside the coronary artery:
Unstable angina, Non-ST segment elevation myocardial infarction or heart attack
(NSTEMI), or ST segment elevation myocardial infarction or heart attack (STEMI).

The location of the blockage, the length of time that blood flow is blocked and the
amount of damage that occurs determines the type of acute coronary syndrome.
These life-threatening conditions most often require emergency medical care.

Unstable angina is a new symptom or a change from stable angina. The angina may
occur more frequently, occur more easily at rest, feel more severe, or last longer.
Although this angina can often be relieved with oral medications, it is unstable and if
not treated timely may progress to a heart attack. Usually more intense medical
treatment or a procedure is required. Unstable angina is an acute coronary syndrome
and should be treated as a medical emergency.

Heart attack: Non-ST segment elevation myocardial infarction (NSTEMI): This heart
attack, or MI, does not cause changes on an electrocardiogram (ECG). However,
chemical markers like Cardiac Troponin in the blood indicate that damage has
occurred to the heart muscle. In NSTEMI, the blockage may be partial or temporary,
and so the extent of the damage relatively minimal.

Heart attack: ST segment elevation myocardial infarction (STEMI): This heart attack,
or MI, is caused by a prolonged period of blocked blood supply. It affects a large
area of the heart muscle, and so causes changes on the ECG as well as in blood
levels of key chemical markers. ST segment will elevate in chest leads or arm leads
of ECG depending upon location of heart muscle damage.

Other terms associated with a heart attack:

Pathophysiology of Acute Coronary Syndrome

* in most of ACS cases syndrome occurs when an atherosclerotic plaque ruptures,

fissures or ulcerates and precipitates thrombus formation. This results in sudden
total or near-total arterial occlusion. Alternatively thrombus may break off from a
ruptured plaque and occlude smaller vessels like coronary arteries.
* systemic factors and inflammation also play role in changing haemostatic and
coagulation pathways and may play a part in the initiation of the intermittent
thrombosis that is a characteristic of unstable angina. Inflammatory acute phase
proteins, cytokines, chronic infections and catecholamine surges may enhance
production of tissue factor, procoagulant activity or platelet hyperaggregability.
* in the case of Q wave Mycardial infarction results in a spreading area of necrosis
that reaches epicardium in 4-6 hours – full thickness infarction
* in rare cases may be due to coronary artery occlusion by embolism, congenital
abnormalities, coronary artery spasm and a wide variety of systemic (particularly
inflammatory) diseases
* initially infarcted muscle is softened leading to an increase in ventricular
compliance but, as fibrosis takes place, compliance of heart muscles decreases
* poor correlation between angiographic severity of coronary stenosis and chance
of acute occlusion
* Other causes of reduced myocardial blood flow include mechanical obstruction
(e.g. air embolus), dynamic obstruction (e.g. vessel spasm), and infection or
Electrocardiogram (ECG)
The electrocardiogram is commonly used to detect abnormal heart rhythms and to
investigate the cause of chest pains.

What is an electrocardiogram?

An electrocardiogram or 'ECG' records the electrical activity of the heart. The heart produces tiny
electrical impulses which spread through the heart muscle to make the heart contract. These
impulses can be detected by the ECG machine. You may have an ECG to help find the cause of
symptoms such as palpitations or chest pain. Sometimes it is done as part of routine tests, for
example, before you have an operation.

The ECG test is painless and harmless. (The ECG machine records electrical impulses coming
from your body - it does not put any electricity into your body.)

How is it done?

Small metal electrodes are stuck onto your arms, legs and chest. Wires from the electrodes are
connected to the ECG machine. The machine detects and amplifies the electrical impulses that
occur each heartbeat and records them onto a paper or computer. A few heartbeats are recorded
from different sets of electrodes. The test takes about five minutes to do.

What does an ECG show?

The electrodes on the different parts of the body detect electrical impulses coming from different
directions within the heart. There are normal patterns for each electrode. Various heart disorders
produce abnormal patterns. The heart disorders that can be detected include:

• Abnormal heart rhythms. If the heart rate is very fast, very slow, or irregular. There are
various types of irregular heart rhythm with characteristic ECG patterns.
• A heart attack, and if it was recent or some time ago. A heart attack causes damage to
heart muscle, and heals with scar tissue. These can be detected by abnormal ECG patterns.
• An enlarged heart. Basically this causes bigger impulses than normal.

Limitations of the ECG

An ECG is a simple and valuable test. Sometimes it can definitely diagnose a heart problem.
However, a normal ECG does not rule out serious heart disease. For example, you may have an
irregular heart rhythm that 'comes and goes', and the recording can be normal between episodes.
Also, not all heart attacks can be detected by ECG. Angina, a common heart disorder, cannot
usually be detected by a routine ECG. Specialised ECG recordings sometimes help to overcome
some limitations. For example:

• Exercise ECG. This is where the tracing is done when you exercise (on a treadmill or
exercise bike). This helps to assess the severity of the narrowing of the coronary arteries
which causes angina.
• 24 hour ECG monitor. This is where you wear a small monitor for 24 hours which
constantly records your heart rhythm. It aims to detect abnormal heart rhythms that may
'come and go'