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Acute Coronary Syndromes

Include everything from stable angina to myocardial infarction

Diagnosis of Acute Myocardial Infarction (AMI)


1. Typical clinical picture
• Pressing retrosternal chest pain
• Spread to jaw and/or arm/s
• Associated dyspnoea, sweating and anxiousness
2. Diagnostic ECG signs
3. Diagnostic elevation of enzymes (CK peak at 6 hours ⇒ take blood after 6 hours)
• CK MB fraction > 6 %

Diagnosis of Unstable Angina (UAP)


1. Typical retrosternal chest pain
• Recently developed angina, progressive worsening of angina or angina at rest

2. Normal enzymes

Both UAP and AMI can present with:


1. Typical chest pain
2. Pulmonary oedema
3. Dysrhythmias

Causes of Retrosternal Chestpain


Cardiac
• Acute coronary syndrome
• Acute pericarditis
• Mitral valve prolapse
• Valve lesions
• Dissecting aneurism

Pulmonary
• Pleuritis
• Pulmonary embolism
• Pneumothorax

Musculosceletal
• Costochondritis

Gastro-intestinal
• Oesophagitis
• Hiatus hernia
• Oesophageal spasm
• Peptic ulcer

Goals of Treatment
1. Pain relief
2. Limit size of infarction
3. Prevent complications
4. Treat complications
5. Rehabilitation (Long term)

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Internal Medicine – Paarl
Hospital

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Acute Management
1. Aspirin (Immediately)
2. Heparin
3. Anti-ischaemic drugs
• Nitrates (If pain)
• β-blockers
4. Thrombolytic therapy
5. Morphine
6. ACE-inhibitors
7. Revascularisation
8. Oxygen
9. Bed rest
10. Other:
• Maxalon
• Senekot

1. Aspirin
♦ Antiplatelet drug
• All patients with UAP or AMI
• 300 mg stat
• 150 mg daily thereafter

2. Heparin
♦ Anti-thrombin agent
• All patients who did not receive thrombolytic therapy
• 5000 U IV stat (All patients)
• 25 000 U in 200 ml Normal Saline IV over 24 hours at 8 ml/hour (check PTT daily)
or
• 12 500 U subcutaneously 2 times per day

3. Anti-ischaemic drugs
Nitrates
• Isordil 5 mg sublingual PRN for pain
and/or
• Tridil IV (for sustained pain) – 50 mg in 200 ml fluid, titrate against blood pressure and
pulse rate, start at 10 ml/hour

β-blockers
♦ Improve myocardial oxygen supply to demand ratio
♦ ↓ pain
♦ ↓ infarct size
♦ ↓ incidence of ventricular arrhythmia

• Ensure a good blood pressure before initiation

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4. Thrombolytic therapy (Streptokinase)

Indications
• Within 12 hours of pain if:
1. Typical retrosternal chest pain
2. ≥ 2 mm ST-segment elevation in ≥ 2 consecutive ECG leads
or
NEW left bundle branch block

Contra-indications
• Previous cerebrovascular bleed
• CVA within last year
• Severe hypertension (Systole > 180 or diastole > 110 mmHg)
• Active internal bleeding
• Streptokinase within last year

Relative contra-indications
• Current use of anticoagulant
• Invasive surgery within preceding 2 weeks
• Prolonged CPR within preceding 2 weeks
• Known bleeding tendency
• Pregnancy
• Active peptic ulcer disease

Complications
• Allergic reactions
• Bleeding

Administration
• 1,5 million U in 200 ml Normal Saline over one hour
• Follow-up ECG one hour after administration

5. Morphine
♦ Pain relief
• 2 mg IV as needed

6. ACE-inhibitors
♦ Cardiac remodeling
• Blood pressure allowing, use cautiously within first 24 hours

7. Revascularisation
• PTCA (Percutaneous transluminal coronary angioplasty)
• Coronary bypass
• If ongoing pain on maximal medical therapy
• If candidate for thrombolysis, but Streptokinase contra-indicated

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Right Ventricular Infarction
Clinical presentation
• Hypotension
• ↑ JVP
• Kussmaul’s sign
• Tender hepatomegaly
• Dysrhythmias

Management
• Aspirin
• Heparin / Streptokinase
• IV fluids (LOTS !!!)
• Avoid nitrates! – Not orally either
• Cautious use of β-blockers

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Hospital

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Acute Complications
Pulmonary oedema
• Lasix 80 mg IV stat (If blood pressure allows)
• Morphine 2 mg IV stat (If blood pressure allows)
• Oxygen 100 %
• CPAP or intubation and ventilation
• Nurse in semifowler position
• Rescue myocardium
− Nitrates
− Disprin
− Streptokinase
− Heparin
• IV Tridil
• Dobutamine
• Dopamine
• NB: Find cause

Dysrhythmias
1. Atrial fibrillation
• If blood pressure stable and pulse rate < 100 ⇒ observe
• Electric cardioversion – If haemodynamically unstable

2. Ventricular fibrillation
• Electric cardioversion

3. Ventricular tachycardia
• Electric cardioversion if haemodynamically unstable
• Lignocaine 80 mg IV stat,
followed by 800 mg in 200 ml Normal Saline over 24 hours as maintenance

4. Bradydysrhythmias
• Atropine
• Pacemaker
− Bradycardia < 50
− Mobitz II AV block
− 3o AV block
− Bifascicular block (RBBB and LBBB)

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Internal Medicine – Paarl
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Myocardial Infarction and Unstable Angina


1. Obtain 12 Lead ECG (Do right sided ECG if inferior infarct)

2. Disprin 300mg stat, thereafter 150 mg daily

3. IV line for emergency arrhythmia treatment

4. Thrombolytic therapy
(Streptokinase 1,5 million units in 200 ml 0,9% Saline over one hour)

Indications
• ≤ 6 h pain
• ≥ 2mm ST-segment elevation in 2 contiguous leads and persistent pain
or
new left bundle branch block and persistent pain

Contraindications
• Previous cerebral bleed
• CVA within last year
• Severe hypertension (Systole >180 or diastole > 110)
• Active internal bleeding
• Streptokinase within the last year

5. Pain control
• Morphine 2mg IVI as needed, monitor blood pressure
(Morphine 10mg diluted in 9 ml of water ⇒ give 2 ml boluses)

• Isordil 5 mg S/L stat (Not with right ventricular infarct)

• Nitroglycerine (Tridil) IVI – if persistent pain (Not with right ventricular infarct)
(50 mg in 200 ml fluid , titrate against blood pressure and pulse rate)

6. Maxalon 10 mg IVI – For nausea if indicated

7. Oxygen

8. Beta-adrenergic blockers (Atenolol) – If blood pressure allows


(Exclude other contraindications)

9. Heparin (If not a candidate for thrombolytic therapy)


• 5000 units IVI stat
• If PTT daily available ⇒ PTT 2 x control for 48 pain free hours
(Start with 25 000 units IVI over 24 hours – adjust as needed)
• If PTT not available ⇒ 12 500 units twice a day subcutaneously

10. Obtain cardiac enzymes 6 hours after pain started


11. ACE inhibitors (Enalapril)
• If hemodynamically stable, be careful within first 24 hours

12. Bed rest

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13. Mild sedation, soft diet and stool softeners
14. Revascularisation (Tygerberg Hospital) - If continued pain on maximal therapy

Internal Medicine – Paarl


Hospital

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