ACUTE CORONARY SYNDROME

DIFFERENTIAL DIAGNOSIS
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain

GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GORD • Trauma
• Pancreatitis
ACUTE CORONARY SYNDROME (ACS)

Definition: The spectrum of acute ischemia related syndromes ranging from UA to MI

with or without ST elevation that are secondary to acute plaque rupture or plaque
erosion.

[----UA---------NSTEMI----------STEMI----]
PATHOPHYSIOLOGY OF STABLE ANGINA AND ACS

Pathophysiology ACS

Decreased O2 Supply

Asymptomatic
•Flow- limiting stenosis
•Anemia
•Plaque rupture/clot

Angina
Increased O2 Demand

O2 supply/demand mismatch→Ischemia

Myocardial ischemia→necrosis
WHAT IS ACUTE CORONARY SYNDROME?
Stable Angina Unstable Angina NSTEMI STEMI
DISTINGUISHING FEATURES

SA: UA: NSTEMI: platelet STEMI: complete

plaque platelet aggregation occlusion
formation adhesion

 Precipitated by stress or At rest or minimal exertion

exertion
Lasts >20 minutes
 Lasts <20 minutes
Often accompanied by other s/s
 Relieved by GTN or
resting Poor GTN relief
DEFINITIONS
UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST depression * Can be normal * Hyperacute T waves
* Possible T wave * New LBBB
inversion * T inversion (hours)
* Q waves (days)

* ST elevation is >1mm in limb leads and >2mm in chest leads

IMPORTANT ECG FINDINGS

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
ADJUNCTIVE THERAPY (IF INDICATED)
LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg OD
Clopidogrel 300mg loading dose
Beta blocker - atenolol 5mg (CaCB if contraindicated)
Nitrates – usually IV
STEMI
TIME IS MUSCLE
Percutaneous coronary intervention (Primary PCI)
 ‘Call to balloon time’ of 120 minutes
 Requires clopidogrel 600mg loading dose
 Rescue PCI after failed thrombolysis
Thrombolysis
 Streptokinase / alteplase / tenecteplase…
 Contraindications
 Clopidogrel 600mg loading dose AND LMWH
Beta blocker i.e. Atenolol
ACE inhibitor i.e. Lisinopril
UNSTABLE ANGINA/NSTEMI CARDIAC CARE
Evaluate for conservative vs. invasive strategy based upon:
Likelihood of actual ACS
Risk stratification by TIMI risk score
ACS risk categories per AHA guidelines

Low High
Intermediate
TIMI RISK SCORE
T: Troponin elevation (or CK-MB elevation)
H: History or CAD (>50% Stenosis)
R: Risk Factors: > 3 (HTN, Hyperlipidemia, Family Hx, DM II, Active Smoker)
E: EKG changes: ST elevation or depression 0.5 mm concordant leads
A2:Aspirin use within the past 7 days; Age over 65
T: Two or more episodes of CP within 2 hours
DECIDING BETWEEN EARLY INVASIVE VS A CONSERVATIVE STRATEGIES
Definitive/Possible ACS
Initiate ASA, BB, Nitrates,
Anticoagulants, Telemetry

Early Invasive Strategy

Conservative Strategy
• TIMI Risk Score >3
• New ST segment•Hemodynamic instability •TIMI Risk Score <3 (Esp. Women)
•Elecrical instability
deviation •Refractory angina
•No ST segment deviation
• Positive biomarkers
•PCI in past 6 months •Negative Biomarkers
•CABG
•EF <40%

Remains Stable
Recurrent Signs/Symptoms ↓
Coronary angiography Heart failure Assess EF and/or Stress Testing
(24-48 hours) Arrhythmias ↓
EF<40% OR Positive stress
Go to Angiography
LONGER-TERM MANAGEMENT
 Continuous ECG monitoring as inpatient/ CCU
 Aspirin 75mg OD (lifelong)
 Clopidogrel 75mg (1 year)
 Beta blocker (1 year - lifelong)
 ACE inhibitor
 Statin
 Modification of risk factors