Acute Coronary Syndrome

ACUTE CORONARY
SYNDROME
DR ALI HASSAN GORMANI
DR USMAN JAVED
LEARNING OBJECTIVES
• Understand the definition and classification of Acute Coronary Syndrome.

• Recognize the symptoms and risk factors associated with ACS.
• Learn about essential diagnostic investigations for ACS.
• Understand the principles of management and emergency interventions.
INTRODUCTION
• Definition:
Acute coronary syndrome is a term used to describe:
• Unstable Angina
• Non-ST elevation MI(NSTEMI)
• ST elevation MI(STEMI)
All these components are part of ACS because their initial presentation and early
management is similar.
CLASSIFICATION OF ACS
• Unstable Angina: This is chest pain or discomfort that occurs at rest or with exertion and is more
severe, prolonged, or frequent than typical angina. It may signal that a heart attack is imminent.
• NSTEMI (Non-ST-Segment Elevation Myocardial Infarction): In NSTEMI, there is evidence
of heart muscle damage (as indicated by elevated cardiac biomarkers), but there is no persistent
ST-segment elevation on an electrocardiogram (ECG). The degree of damage is usually less
severe compared to STEMI.
• STEMI (ST-Segment Elevation Myocardial Infarction): This is a severe form of heart attack
where there is a complete blockage of a coronary artery, leading to significant damage to the
heart muscle. It is characterized by persistent ST-segment elevation on an ECG.
PATHOPHYSIOLOGY OF ACS
• Atherosclerosis and plaque rupture.

• Formation of blood clots and coronary artery obstruction.
• Ischemia, myocardial infarction, and potential complications.
SYMPTOMS OF ACS
• Chest pain or discomfort(mainly retrosternal radiating to jaw, neck and arms)

• Shortness of breath
• Vomiting
• Sweating
• Nausea
• Lightheadedness
• Highlight the atypical presentations, especially in women and elderly individuals.
Signs of heart failure: Raised JVP,Crackles in lung field, S3 heart sound

Signs of Iscemia: S4 heart sound new murmur
RISK FACTORS FOR ACS
 Modifiable factors
• smoking
• diet
• physical inactivity
• alcohol consumption
• Stress
• Obesity
 Non-modifiable factors
• age
• gender
• family history
• genetics
• race and ethnicity
• previous hx of ACS or stroke
Medical conditions
• Hypertension
• diabetes,
• hyperlipidemia
DIAGNOSTIC INVESTIGATIONS
• Electrocardiogram (ECG) is the initial best investigation and is central to confirming

diagnosis.
A single normal ECG does not exclude ACS so we do serial ECGs. Common ECG changes:
 ST-Segment deviation is the earliest change that is commonly detected.
• ST-segment elevation: Indicate Transmural injury
• ST-Segment depression: Subendocardial injury
• Q waves: Indicate prior infarction
• T-wave inversion
 Cardiac biomarkers
• Troponin(most Sensitive)
• creatinine kinase-MB(1st enzyme to rise and fall)
Unstable Angina doesn’t cause rise in cardiac enzymes
 Imaging Studies
• Coronary angiography: Visualizing coronary arteries.
• Echocardiography: Assessing heart function and possible complications
MANAGEMENT OF ACS
 Immediate priorities:
• ABCs (Airway, Breathing, Circulation).
 Medical management:
o Analgesia
• IV opiates(IV Morphine Sulphate)

• Antiemetic(IV metoclopramide)
o Anti-Thrombolytic Therapy
• Aspirin
• Adenosine-diphosphate receptor antagonist (Clopidogrel, Ticagrelor, Prasugrel)
• Glycoprotein IIb/IIIa inhibitor (Abciximab, tirofiban)
• Anti-Coagulation Therapy (Unfractionated Heparin, Enoxaparin, Fondaparinux
o Anti-Anginal Therapy
• Nitrates(glyceryl trinitrate either sublingual or IV)

• Beta-Blockers also have been shown to decrease mortality and should be a part of long term maintenance therapy
 Reperfusion Therapy
• Percutaneous Coronary Intervention(treatment of choice in STEMI)
• Thrombolysis( administered within 12 hours of hospital presentation) agents include Alteplase, Streptokinase
 Door to Balloon Time i.e PCI is under 90 mins

 Door to Needle Time i.e thrombolysis is under 30 mins
 Long term Post ACS Management:
o Life Style Modification
o Medication:
• Aspirin & Clopidogrel

• Beta Blockers
• Nitrates
• Statins
• ACE Inhibitors
o Implantable Cardiac Defibrillator (ICD)
COMPLICATIONS OF MI
• Arrhythmias
• Bradyacardia
• Right Ventricular Infarction
• Ventricular Free Wall Rupture
• Rupture of Papillary Muscles
• Interventricular Septal Rupture
• Pericarditis

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ACUTE CORONARY

• Understand the definition and classification of Acute Coronary Syndrome.

• Atherosclerosis and plaque rupture.

• Chest pain or discomfort(mainly retrosternal radiating to jaw, neck and arms)

Signs of heart failure: Raised JVP,Crackles in lung field, S3 heart sound

• Electrocardiogram (ECG) is the initial best investigation and is central to confirming

Unstable Angina doesn’t cause rise in cardiac enzymes

• IV opiates(IV Morphine Sulphate)

• Nitrates(glyceryl trinitrate either sublingual or IV)

 Door to Balloon Time i.e PCI is under 90 mins

• Aspirin & Clopidogrel

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