Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations caused by acute myocardial ischemia and/or necrosis. The document discusses the definition, risk factors, presentation, diagnosis, and management of ACS, with a focus on STEMI, NSTEMI, and unstable angina. Key recommendations include rapid ECG to identify ST elevation, dual antiplatelet therapy, anticoagulation, beta blockers, ACE inhibitors, high-dose statins, reperfusion therapy for STEMI, and comprehensive discharge planning and counseling.
Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations caused by acute myocardial ischemia and/or necrosis. The document discusses the definition, risk factors, presentation, diagnosis, and management of ACS, with a focus on STEMI, NSTEMI, and unstable angina. Key recommendations include rapid ECG to identify ST elevation, dual antiplatelet therapy, anticoagulation, beta blockers, ACE inhibitors, high-dose statins, reperfusion therapy for STEMI, and comprehensive discharge planning and counseling.
Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations caused by acute myocardial ischemia and/or necrosis. The document discusses the definition, risk factors, presentation, diagnosis, and management of ACS, with a focus on STEMI, NSTEMI, and unstable angina. Key recommendations include rapid ECG to identify ST elevation, dual antiplatelet therapy, anticoagulation, beta blockers, ACE inhibitors, high-dose statins, reperfusion therapy for STEMI, and comprehensive discharge planning and counseling.
Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations caused by acute myocardial ischemia and/or necrosis. The document discusses the definition, risk factors, presentation, diagnosis, and management of ACS, with a focus on STEMI, NSTEMI, and unstable angina. Key recommendations include rapid ECG to identify ST elevation, dual antiplatelet therapy, anticoagulation, beta blockers, ACE inhibitors, high-dose statins, reperfusion therapy for STEMI, and comprehensive discharge planning and counseling.
in Resource Limited Areas Registrar education series Definition Management
Presentation STEMI management
STEMI Discharge Planning
NSTE-ACS Summary Acute Coronary Syndrome
What is acute coronary syndrome (ACS)?
What usually causes ACS?
What are classic risk factors for ACS?
What are examples of validated clinical
decision-making tools that can be used with ACS? Presentation What are presenting: Symptoms?
Physical exam abnormalities?
ECG changes?
POCUS findings? STEMI How is a STEMI diagnosed? NSTE-ACS
How is NSTE-ACS diagnosed?
What are the two
categories of NSTE-ACS? ACS Management
What is the management of
ACS? STEMI Management What is the management of a STEMI? Discharge planning What should be included on your discharge planning checklist? ACS Acute coronary syndrome is a spectrum of presentations due to acute myocardial ischemia and/or necrosis • ST elevation myocardial infarction • Non STI elevation MI (NSTEMI) and Unstable angina (UA)
Most commonly caused by platelet aggregation after a
plaque ruptures
Risk factors:
• Non-modifiable: increasing age, male sex, chronic renal insufficiency,
known atherosclerotic disease, family history 55M, 65F • Modifiable: tobacco use, hypertension, hyperlipidemia, diabetes, physical inactivity, obesity • ASCVD calculator
GRACE, TIMI, AMIS, CRUSADE bleeding risk
Presentation
Symptoms Physical findings
• Retrosternal chest pain • Transient MR murmur, hypotension, • With/without radiation to 1 or 2 diaphoresis, pulmonary edema, or rales arms • Oppressive chest pressure EKG • Abdominal pain • Dyspnea • New transient ST segment deviation • Nausea/vomiting • T wave inversion in multiple precordial leads • Diaphoresis • Fixed Q waves ST depression 0.5 to 1 mm • Syncope • Absence of chest wall tenderness • T wave inversion greater than 1 mm
Atypical POCUS • Regional wall motion abnormalities Less likelihood STEMI
Symptoms characteristic of myocardial ischemia • Perform ECG within 10 minutes of presentation
Persistent ST elevation in the
absence of a LBBB or LVH • ≥ 2 mm in men or ≥ 1.5 mm (0.15 mV) in women in leads V2-V3 • ≥ 1 mm (0.1 mV) in 2 other contiguous chest leads or limb leads NSTEMI NSTE-ACS • Symptoms characteristic of myocardial ischemia • Perform ECG within 10 minutes of presentation • No ST elevation on EKG • Increased cardiac biomarkers Severe UA • Symptoms characteristic of myocardial ischemia • Perform ECG within 10 minutes of presentation • No ST elevation on EKG or • No increase in cardiac biomarkers ACS Management Aspirin (indefinitely) • Loading dose 162 – 325mg • Maintenance dose 75-162 Clopidogrel (12 months) • Loading dose 300mg • Maintenance dose 75mg Enoxaparin (2-8 days) • <75yo 30mg IV bolus • Followed in 15 minutes by 1mg/kg SQ x12 hours (max 100mg for first two doses) • >75yo 0.75mg/kg SQ q12 hours Carvedilol 6.25mg bid titrated to 25mg bid as tolerated • Contraindications: signs of heart failure, low output state, risk of cardiogenic shock ACE-I/ARB (if LVEF <40%, HTN, DM, CKD)
Atorvastatin 40-80mg
Nitroglycerin 0.4mg sublingual q5 minutes for pain
Oxygen 2 - 4L ONLY if O2 sat < 90%
Morphine • 4-8mg IV q5-15 minutes for pain if pain persists despite all other therapy STEMI Management All ACS measures (with dose differences) plus reperfusion therapy as early as possible • Ideally within 90 minutes of presentation • Can be implemented within 12-24 hours of symptoms • Clopidogrel loading dose is 600mg
Transfer to a facility that can perform
percutaneous coronary intervention (PCI) • If > 120 minutes to PCI give fibrinolytics
Fibrinolytics decrease mortality by 50% if
administered within 1 hour • Streptokinase 1.5MU infusion over 30 - 60 minutes • Alteplase 15mg bolus + 0.75mg/kg for 30 min + 0.5mg/kg for 60 minutes • Reteplase 10-U + 10-U IV boluses given 30 minutes apart • Tenecteplase 30mg (<60mg), 35mg (60-69kg), 40mg (70- 70kg)
Contraindications to fibrinolysis Discharge planning Perform echocardiography to assess LV function
Dual antiplatelet therapy for 12 months
Beta blocker
ACE-I
Spironolactone if LVEF<40% (DM or HF)
High dose statin
Nitroglycerin as needed
Cardiac rehab
Dietary counseling
Physical activity prescription
Tobacco cessation Cardiac biomarkers •cTnI, CTnT (recommended) High-sensitivity •Sensitivity 79-83%, Specificity 93-95% •Measured at presentation and 3-6 hours after symptom Troponin onset •May take up to 6 hours to become positive
Causes of non- •CHF, infiltrates, malignancy, myocarditis, pericarditis,
trauma, viral cardiomyopathy, drug toxicity, pulmonary ischemic rise in embolism, renal failure, sepsis, stroke, subarachnoid troponin hemorrhage
Creatinine Kinase •Peaks more rapidly than troponin and decreases faster Myocardial Band •Not recommended (CK-MB)
•Earliest peak and decrease
Myoglobin •Not recommended Atypical Older age Epigastric pain Dementia
Diabetes Indigestion Women Less likely Right Sharp sided Pleuritic Tearing Shifting Ripping Positional Burning Fleeting Contraindications to fibrinolysis Contraindications to fibrinolysis • Prior ICH, known cerebral vascular lesion, known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding/diathesis, significant closed head or facial trauma within 3 months, intracranial or spinal surgery within 2 months, severe uncontrolled hypertension unresponsive to emergency therapy, risk for cardiogenic shock
Relative contraindications • History of poorly controlled hypertension, SBP>180, DBP>110, ischemic stroke > 3months, dementia, known intracranial pathology, major surgery < 3weeks, internal bleeding <2-4 weeks, noncompressible vascular punctures, pregnancy, active peptic ulcer, oral anticoagulant therapy STEMI Doses Aspirin (indefinitely) •Loading dose 162 – 325mg •Maintenance dose 75-162 Clopidogrel (12 months) •Loading dose 600mg •Maintenance dose 75mg Enoxaparin (2-8 days) •<75yo 30mg IV bolus •Followed in 15 minutes by 1mg/kg SQ x12 hours (max 100mg for first two doses) •>75yo 0.75mg/kg SQ q12 hours Streptokinase 1.5MU infusion over 30 - 60 minutes
Carvedilol 6.25mg bid titrated to 25mg bid as tolerated
•Contraindications: signs of heart failure, low output state, risk of cardiogenic shock
ACE-I/ARB (if LVEF <40%, HTN, DM, CKD)
Atorvastatin 40-80mg
Nitroglycerin 0.4mg sublingual q5 minutes for pain
Oxygen 2 - 4L ONLY if O2 sat < 90%
Morphine •4-8mg IV q5-15 minutes for pain if pain persists despite all other therapy Assess risk factors
A1c
Lipid
Renal function
Urine protein Perform ECG within 10 minutes of suspected ACS
Summary Give aspirin, clopidogrel and enoxaparin
Start betablocker if no contraindication
Start ACE-I and high dose statin
If pain persists after nitroglycerin and the above, give
morphine
If O2 saturations are < 90% give oxygen
Perform echocardiography prior to discharge to assess
