What is acute coronary syndrome? презентация

WHAT IS ACUTE CORONARY SYNDROME?
Stable Angina
Unstable Angina
NSTEMI
STEMI

DEFINITIONS
Unstable angina:
An unprovoked or prolonged episode of chest pain raising suspicion of acute myocardial infarction (AMI)
Without definite ECG or laboratory evidence
NSTEMI:
Chest pain suggestive of AMI
Non-specific ECG changes (ST depression/T inversion/normal)
Laboratory tests showing release of troponins
STEMI:
Sustained chest pain suggestive of AMI
Acute ST elevation or new LBBB

Atherosclerosis
Epithelial injury
Migration of monocytes/macrophages
LDL lipids consumed ? foam cells
Growth factors ? smooth muscle, collagen, proteoglycans
Atheromatous plaque forms
PATHOPHYS

RISK FACTORS
Increasing age
Gender (male)
Family History
Hypertension
Diabetes
Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol

CLINICAL FEATURES
Dyspnoea
Heart murmurs
Palpitations
Chest pain
Nausea
Acute confusion
Pallor
Hypotension or hypertension
Sweaty
Vomiting
Syncope
Indigestion
Tachycardia or bradycardia
Fever
Asymptomatic/silent

UA:
platelet
adhesion
NSTEMI: platelet aggregation
DISTINGUISHING FEATURES
STEMI: complete occlusion
SA:
plaque
formation
At rest or minimal exertion
Lasts >20 minutes
Often accompanied by other s/s
Poor GTN relief
Precipitated by stress or exertion
Lasts <20 minutes
Relieved by GTN or resting

RISK FACTORS
MODIFIABLE
Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol
Hypertension
Diabetes
NON-MODIFIABLE
Increasing age
Gender (male)
Ethnicity
Family History
?Diabetes

DIFFERENTIAL DIAGNOSIS

WHAT DO YOU WANT TO ASK HIM/HER?
30minute history of central ‘crushing’ chest pain radiating to his jaw and left arm, 10/10
He is SOB, looks very pale, clammy and sweaty, and has vomited twice
PMHx of hypertension and hypercholesterolaemia
Takes metformin, salbutamol inhalers and citalopram
FHx includes father dying of MI aged 50
Smoked 40 cigarettes a day for the past 35 years and drinks a bottle of whiskey a week
Cant exercise “because of my asthma”

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

IMPORTANT ECG FINDINGS

WHERE IS THE PROBLEM?

COMMON ACS MANAGEMENT
Morphine (5-10mg slow IV injection)
Oxygen (titrate sats to need)
Nitrates - GTN spray (400mcg = 1 spray) or tablet (1mg)
Aspirin (300mg chewed)
Plus an antiemetic i.e.
Metoclopramide 10mg IV

LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg OD
Clopidogrel 300mg loading dose
Beta blocker - atenolol 5mg
Nitrates – usually IV
Consider coronary angiography within 72 hr
UNSTABLE ANGINA & NSTEMI

SCORING SYSTEMS
GRACE SCORING
Predicts 6/12 mortality in NSTEMI patients
Age
HR and systolic BP
Killip class (CCF, pulmonary oedema, shock)
Cardiac arrest on admission
Elevated cardiac markers
ST segment change
TIMI
Risk of cardiac events in next 30 days
Age >65
Known coronary artery disease
Aspirin in last 7/7
Severe angina (>2 in 24hr)
ST deviation >1mm
Elevated troponins
> CAD risk factors

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
Reperfuse urgently if <12hr from onset to get blood back to myocardium that isn’t yet irreversibly damaged
CI include: known bleeding disorder, ischemic stroke in last 6/12, hemorrhagic stroke ever, active bleeding, suspected aortic dissection
STEMI

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