Acute Coronary Syndromes

Definitions
Acute coronary syndrome is defined as
myocardial ischemia due to myocardial
infarction (NSTEMI or STEMI) or unstable
angina
Unstable angina is defined as angina at rest,
new onset exertional angina (<2 months),
recent acceleration of angina (<2 months), or
post revascularization angina
Diagnosis
Dx of acute coronary syndrome is based on history,
physical exam, ECG, cardiac enzymes
Patients can then be divided into several groups
Non-cardiac chest pain (i.e., Gastrointestinal,
musculoskeletal, pulmonary embolus)
Stable angina
Unstable angina
Myocardial infarction (STEMI or NSTEMI)
Other cardiac causes of chest pain (i.e., aortic dissection,
pericarditis)



Pathophysiology of ACS
Plaque rupture and subsequent formation of
thrombus this can be either occlusive or non-
occlusive (STEMI, NSTEMI, USA)
Vasospasm such as that seen in Prinzmetals angina,
cocaine use (STEMI, NSTEMI, USA)
Progression of obstructive coronary atherosclerotic
disease (USA)
In-stent thrombosis (early post PCI)
In-stent restenosis (late post PCI
Poor surgical technique (post CABG)

Pathophysiology of ACS
Acute coronary syndromes can also be due to
secondary causes
Thyrotoxicosis
Anemia
Tachycardia
Hypotension
Hypoxemia
Aterial inflammation (infection, arteritis)
Treatment of ACS; Aspirin
Aspirin is an antiplatelet agent that initiates
the irreversible inhibition of cyclooxygenase,
thereby preventing platelet production of
thromboxane A2 and decreasing platelet
aggregation
Administration of ASA in ACS reduces cardiac
endpoints
Aspirin Trials
VA Cooperative Study
Canadian Multicenter Trial
RISC
Antithrombotic Trialists Collaberation
PURSUIT
ACC/AHA Guidelines for Aspirin
Therapy
Aspirin should be given in a dose of 75-325
mg/day to all patients with ACS unless there is
a contraindication (in which case, clopidogrel
should be given)
Treatment of ACS; Nitrates
Nitroglycerin is considered a cornerstone of anti-
anginal therapy, despite little objective evidence for
its benefit
Benefit is thought to occur via reduction in
myocardial O2 demand secondary to venodilation
induced reduction in preload as well as coronary
vasodilation and afterload reduction
Titrate to relief of chest pain; chest pain = death of
myocardial cells
No documented mortality benefit

Treatment of ACS; Beta Blockers
Beta Blockers reduce myocardial oxygen
demand by reducing heart rate, contractility,
and ventricular wall tension
Administration of beta blockers in ACS reduces
cardiac endpoints
Beta Blocker Trials
HINT (metoprolol)
Beta Blocker Heart Attack Trial (propranolol)
Esmolol vs. placebo
Carvedilol vs. placebo
Propranolol vs. placebo
Overall, treatment with beta blockers reduces
primary endpoints when compared to placebo

AHA/ACC Guidelines for Beta Blocker
Therapy
Intravenous beta blockers should be used
initially in all patients (without
contraindication) followed by oral beta
blockers with the goal being decrease in heart
rate to 60 beats per minute
A combination of beta blockers and nitrates
can be viewed as first line therapy in all
patients with ACS
Treatment of ACS; Clopidogrel
Clopidogrel is a potent antiplatelet agent
It should be administered to all patients who
cannot take ASA
The CURE trial suggests a benefit to adding
Clopidogrel to ASA/Heparin in patients going
for PCI
Give 300 mg loading dose followed by 75
mg/day