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    Acute Coronary Syndromes

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    horosu
    Acute coronary syndromes are caused by a reduction of blood supply to the heart muscle and are a leading cause of death. They include unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI). The main risk factors are diabetes, hypertension, smoking, and dyslipidemia. Diagnosis involves symptoms like chest pain, ECG changes like ST elevation or depression, and elevated cardiac biomarkers. Treatment depends on the type of acute coronary syndrome and involves reperfusion therapies like fibrinolysis, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) to restore blood flow.

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    Acute Coronary Syndromes

    Uploaded by

    horosu
    32 views47 pages
    Acute coronary syndromes are caused by a reduction of blood supply to the heart muscle and are a leading cause of death. They include unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI). The main risk factors are diabetes, hypertension, smoking, and dyslipidemia. Diagnosis involves symptoms like chest pain, ECG changes like ST elevation or depression, and elevated cardiac biomarkers. Treatment depends on the type of acute coronary syndrome and involves reperfusion therapies like fibrinolysis, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) to restore blood flow.

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    Acute Coronary Syndrome

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    Acute coronary syndromes are caused by a reduction of blood supply to the heart muscle and are a leading cause of death. They include unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI). The main risk factors are diabetes, hypertension, smoking, and dyslipidemia. Diagnosis involves symptoms like chest pain, ECG changes like ST elevation or depression, and elevated cardiac biomarkers. Treatment depends on the type of acute coronary syndrome and involves reperfusion therapies like fibrinolysis, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) to restore blood flow.

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    32 views47 pages

    Acute Coronary Syndromes

    Uploaded by

    horosu
    Acute coronary syndromes are caused by a reduction of blood supply to the heart muscle and are a leading cause of death. They include unstable angina, ST-elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction (NSTEMI). The main risk factors are diabetes, hypertension, smoking, and dyslipidemia. Diagnosis involves symptoms like chest pain, ECG changes like ST elevation or depression, and elevated cardiac biomarkers. Treatment depends on the type of acute coronary syndrome and involves reperfusion therapies like fibrinolysis, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) to restore blood flow.

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    of 47

    Acute Coronary

    Syndromes
    Dr. Horea Feier
    Definition

    • = an acute reduction of blood supply to the heart muscle

    • Cardiovascular diseases are the leading cause of death in


    industrialized countries

    •
    EPIDEMIOLOGY
    CLINICAL PRESENTATIONS
    OF CAD
    • The clinical presentations of CAD include:

    • silent ischaemia

    • stable angina pectoris

    • heart failure

    • unstable angina

    • myocardial infarction (MI)

    • sudden death Acute Coronary Syndromes


    Acute coronary syndromes
    Acute coronary syndromes
    • ST-elevation ACS

    •     (STE-ACS):

    • typical acute chest pain and


    persistent (>20 min)

    • ST-segment elevation

    • generally reflects an acute


    total coronary occlusion

    • most will ultimately develop an


    ST-elevation MI (STEMI).
    STEMI
    Acute coronary syndromes
    • non-STE-ACS

    •     (NSTE-ACS):

    • acute chest pain

    • without persistent

    •     ST-segment elevation

    • persistent or transient ST segment


    depression or

    •     T-wave inversion

    • further qualified into non-ST elevation


    MI (NSTEMI) or unstable angina.
    NSTEMI
    Physiopathology

    • Atherothrombosis

    • Atherosclerosis - a fixed and barely reversible process of


    gradual luminal narrowing (slowly over decades)

    • Thrombosis - a dynamic and potentially reversible


    process causing rapid complete or partial occlusion of the
    coronary artery
    Risk Factors for
    Atherosclerosis

    • Major risk factors:

    • Diabetes, HTA, Smoking, Dyslipidemia (LDL>100 mg/dl,


    HDL< 60 mg/dl), Age (Men>45, Women>55), Family
    history, Homocysteinemia, Sex

    • Minor risk factors

    • Obesity, Physical inactivity, Estrogen deficiency


    Diagnosis of AMI
    2 from 3 criteria must be fulfilled :

    •Clinical symtoms

    –Chest pain

    •ECG changes

    –ST elevation or depression

    –negative T wave

    •Elevated cardiac biomarkers

    –Troponin I or T

    –CK-MB

    –myoglobin
    Hospital vs. 1-year Mortality
    Prognosis of STEMI vs.
    NSTEMI
    • The causes of the higher death rates of NSTE-ACS
    than of STE-ACS pts. during long-term follow-up are:

    • older pts.

    • more co-morbidities (diabetes and renal failure).

    • a greater extent of coronary artery and vascular diseases

    • persistent triggering factors such as inflammation


    Clinical diagnosis
    • STE/NSTE-ACS:

    • Intense prolonged (20 min) pain at rest - retrosternal  pressure or heaviness (‘angina’)
    radiating up to the neck, shoulder and jaw and down to the ulnar aspect of the left arm

    • May be accompanied by other symptoms such as

    •    diaphoresis, nausea, abdominal pain, dyspnoea

    • Unstable angina:

    • New onset severe angina (class III of CCS)

    • Recent destabilization of previously stable angina with

    •    at least CCS III angina characteristics (crescendo angina)

    • Post-MI angina.
    Clinical diagnosis

    • Typical chest pain

    • Nausea

    • Sweating
    Clinical diagnosis

    • Atypical presentations are not uncommon

    • epigastric pain

    • recent-onset indigestion

    • stabbing chest pain

    • chest pain with some pleuritic features

    • increasing dyspnoea

    • often can be observed in younger (25-40y.), older (75y.


    in women, in pts. with diabetes, chronic renal failure,
    or dementia.
    Physical examination
    • Frequently normal

    • Signs of heart failure or haemodynamic instability

    • Diff. dg.:

    •    - nonischaemic cardiac disorders: pulmonary


    embolism, aortic dissection, pericarditis, valvular
    heart disease

    •     - extra-cardiac causes: pneumothorax,


    pneumonia, pleural effusion
    Physical examination
    • Heart failure
    • Tachycardia, tachypnoe

    • Pulmonary rales (pulmonary congestion)

    • RV failure - ↑ jugular congestion, hepatomegaly

    • Hypotension ↓ 100/60 mmhg

    • cardiac shock (tachycardia)

    • ↑ vagal nerve activity (bradycardia - inferior IM)

    • Bradycardia

    • AV block

    • Inferior IM - non-serious, frequent

    • Anterior IM - serious, rare


    ECG

    • The first-line diagnostic tool

    • ST segment elevation =>


    STEMI

    • no ST-segment elevation/
    ECG normal => NSTEMI/
    Unstable angina

    A normal ECG doesn’t rule out AMI


    Location of AMI
    • ST elevation only:

    • Anteroseptal - V1-V3

    • Anterolateral - V1-V6

    • Inferior wall - II, III, aVF

    • Lateral wall -  I, aVL, V4-V6

    • Right ventricular - RV4,


    RV5

    • Posterior- R/S ratio >1 in


    V1 and T wave inversion
    Markers
    • Markers of myocardial injury:

    • cardiac troponins (I and T)


    • creatinine kinase (CK)

    • CK isoenzyme MB (CK-MB)

    • Myoglobin

    • repeated blood sampling and measurements are required 6–12 h


    after admission and after any further episodes of severe chest pain
    Markers
    • Non-coronary condition  with Troponin elevation

    • Severe congestive heart failure

    • Aortic dissection, valve disease

    • Myocarditis

    • Hypertrophic CMP, Stress CMP

    • Hypertensive crisis

    • Acute and chronic renal failure

    • Cerebrovascular accident
    Evolution of biochemical markers over time
    Non-invasive exams
    • Transthoracic ECHO

    • Regional and global systolic


    function

    • Valve assessment (ischemic


    MI)

    • Presence of complications
    (Free wall rupture,
    Ventricular septal defect,
    Papillary muscle rupture)
    Invasive coronary imaging

    • Coronary angiography= gold


    standard!!!

    • Visualization of coronary
    anatomy

    • Direct PCI/
    Thrombusaspiration
    Initial decision-making
    Treatment of ACS
    • Rationale:

    • To provide as early a reperfusion as possible (“Time


    is muscle”)

    • Fibrinolysis (no PCI on-site)/PCI/Surgery (PCI


    unsuitable, complications)

    • Treatment: high-dose antiplatelet therapy to limit


    extension of AMI, lowering O2 demand, vasodilators,
    treatment of arrythmias, treatment of heart failure
    Reperfusion strategies
    Reperfusion according to time
    (STEMI)
    PCI
    Aspiration thrombectomy

    = the aspiration (suction) of thrombotic material from the occlusion site


    CABG?

    • CABG

    • No role in uncomplicated
    STEMI

    • Preferred over PCI in


    multivessel/left-main
    NSTEMI

    • Treatment of choice in
    complicated STEMI
    CABG?

    • On-Pump or Off-Pump
    CABG (OPCAB)?

    • On-Pump- for most patients

    • OPCAB- special subsets


    (renal failure, low EF)

    • Graft patency better On-


    Pump
    Mechanical complications
    of AMI

    1. LV Free Wall Rupture

    2. Septum Rupture (Post MI VSD-Ventricular Septal Defect)

    3. Papillary Muscle Rupture

    4. Acute Aneurysm formation

    Emergent Surgery!!!
    LV Free Wall Rupture

    • Rupture of the LV Wall into the


    pericardium

    • D3 after extensive AMI in


    unprotected circulation

    • Hemopericadium,
    Tamponade=> Emergent
    surgery!!

    => Emergent Surgery (Sutureless Patch Closure ± CABG)


    Post AMI VSD

    • Rupture of the ventricular


    septum => VSD

    • D3 after extensive AMI in


    unprotected circulation

    • Left-to-right shunt=> Acute


    RV volume overload => RV
    Failure => Hepatic, Renal,
    Mesenteric injury
    => Emergent Surgery (VSD Patch Closure ± CABG)
    Papillary Muscle Rupture

    • Rupture of the postero-medial


    Papillary Muscle => MR

    • D3 after extensive, inferior


    AMI in unprotected circulation

    • Severe, Acute MR (mitral


    regurgitation)=> Pulmonary
    Edema => Acute Heart Failure

    => Emergent Surgery (Mitral replacement± CABG)


    Acute LV Aneurysm

    • Acute Aneurysm Formation

    • Rare

    • Muscle replaced by FIbrotic


    Tissue => Dyskinesia =>
    Acute Heart Failure

    => Surgery (LV Repair ± CABG)


    Thank you!

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