Acute Coronary

Syndromes
N60B
Spring 2015
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Case Scenario
A 55-year-old man presents with a chief complaint
of severe (10 out of 10) substernal chest pain. He
has pain radiating down his left arm and up into his
jaw, nausea, and a profound sense of impending
doom. He is covered with small beads of sweat.
Vital signs: TEMP = 37.2C; HR = 110 bpm;
BP = 150/100 mm Hg; RESP = 12
Describe your immediate assessment.
Describe your immediate general treatment.
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Items of Immediate Assessment (<10 min)

Check vital signs with automatic or standard BP cuff
Determine oxygen saturation
Obtain IV access
Obtain 12-lead ECG
Obtain a brief, targeted history and perform a physical
examination; focus on eligibility for fibrinolytic therapy
Obtain blood sample for initial cardiac marker levels

Cardiac-specific troponins I and T increase 3 or 4 hrs after

injury, stay elevated for 10 to 14 days.
Baseline Cardiac troponin I <0.03 ng/mL and troponin T
<0.20ng/mL

Initiate electrolyte and coagulation studies, BNP

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Immediate General Treatment

Oxygen at 4 L/min
Aspirin 160 to 325 mg
Nitroglycerin SL or spray
Morphine IV (if pain not relieved
with nitroglycerin)

Oxygen Used in
Acute Coronary Syndromes
Why?
Increases supply of oxygen to ischemic tissue
When?
Always when AMI is suspected
How?
Start with nasal cannula at 2-4 L/min
maintain O2 sat greater than 90%
Remember: oxygen-IV-monitor
Watch Out!
Rarely COPD patients with hypoxic
ventilatory drive will hypoventilate
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Nitroglycerin: Actions
Decreases pain of ischemia
Increases venous dilation
Decreases venous blood return to heart
Decreases preload and cardiac
oxygen consumption
Dilates coronary arteries
Increases cardiac collateral flow

Nitroglycerin: Indications
Class I: First 24 to 48 hours in patients with
ST-segment elevation or depression including

LV failure (acute pulmonary edema or CHF)

Elevated BP (especially with signs of LV failure)
Large anterior infarction
Persistent ischemia

Suspected ischemic chest pain

Unstable angina (change in angina pattern)
Acute pulmonary edema (if BP >90 mm Hg systolic)
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Nitroglycerin: Dose
Sublingual: 0.3 to 0.4 mg; repeat every 5 minutes
Spray inhaler: 2 metered doses at 5-minute intervals
IV infusion: 12.5 to 25 g bolus, 10 to 20 g/min
infusion, titrated

Nitroglycerin: Precautions
Use extreme caution if systolic BP <90 mm Hg
Use extreme caution in RV infarction
Suspect RV infarction with inferior ST changes
Limit BP drop to 10% if patient is normotensive
Limit BP drop to 30% if patient is hypertensive
Watch for headache, drop in BP, syncope,
tachycardia
Tell patient to sit or lie down during administration
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Morphine Sulfate:
Actions, Indications
Why? (Actions)
To reduce pain of ischemia
To reduce anxiety
To reduce extension of ischemia by reducing
O2 demands
When? (Indications)
Continuing pain
Evidence of vascular congestion (acute
pulmonary edema)
Systolic blood pressure >90 mm Hg
No hypovolemia
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Morphine Sulfate:
Dose, Precautions
How? (Dose)
2 to 4 mg titrated to effect
Goal: Eliminate pain
Watch out for (Precautions)
Drop in blood pressure, especially in patients with
Volume depletion
RV infarction
Depression of ventilation
Nausea and vomiting (common)
Bradycardia
Itching and bronchospasm (uncommon)
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Aspirin: Actions
Why? (Actions)
Blocks formation of thromboxane A2
(thromboxane A2 causes platelets to aggregate
and arteries to constrict)
These actions will reduce
Overall mortality from AMI
Nonfatal reinfarction
Nonfatal stroke
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Aspirin:
Indications, Dose, Precautions
When? (Indications) As soon as possible!
Standard therapy for all patients with new pain suggestive
of AMI
Give within minutes of arrival
How? (Dose) 160- to 325-mg tablet taken as soon as possible
Watch Out! (Precautions)
Relatively contraindicated in patients with active peptic
ulcer disease or asthma
Contraindicated in patients with known aspirin
hypersensitivity
Bleeding disorders
Severe hepatic disease
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-Blockers
Mechanism of action
Blocks catecholamines from binding to
-adrenergic receptors
Reduces HR, BP, myocardial contractility
Decreases AV nodal conduction
Decreases incidence of primary VF

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-Blockers
Absolute
Contraindications
Severe CHF/PE
SBP <100 mm Hg
Acute asthma
(bronchospasm)
2nd- or 3rd-degree
AV block

Cautions

Mild/moderate CHF
HR <60 bpm
History of asthma
Type 1 Diabetes

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Heparin
Mechanism of action
Indirect thrombin inhibitor
Indications
PTCA or CABG
With fibrin-specific lytics
High risk for systemic emboli
Conditions with high risk for systemic
emboli, such as large anterior MI, atrial
fibrillation, or LV thrombus
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ACE Inhibitors
Mechanism of action
Reduces BP by inhibiting angiotensin-converting
enzyme (ACE)
Alters post-AMI LV remodeling by inhibiting
tissue ACE
Lowers peripheral vascular resistance
by vasodilatation
Reduces mortality and CHF from AMI
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Fibrinolytic Therapy
Breaks up the fibrin network that binds clots together
Indications: ST elevation >1 mm in 2 or more
contiguous leads or new LBBB or new BBB that
obscures ST
Time of symptom onset must be <6 hours
Caution: fibrinolytics can cause death from brain
hemorrhage
Agents differ in their mechanism of action, ease of
preparation and cost
1 agent currently available: alteplase (tPA, Activase)
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Antiplatelet Agents
Blocks glycoprotein IIb/IIIa receptors on platelets
Blocked receptors cannot attach to fibrinogen
Fibrinogen cannot aggregate platelets to platelets
Indications: ACS with NO ST-segment elevation:
NonQ-wave MI
Unstable angina managed medically
UA undergoing PCI
Examples: abciximab (ReoPro), eptifibitide (Integrilin),
tirofiban (Aggrastat)
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Three Percutaneous Coronary

Interventions (PCIs)

2. PTCA + stent
placement

1. PTCA:
Percutaneous
Transluminal
Coronary Angioplasty

3. Atherectomy:
grinds away
the plaque

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Heart Disease in Women

Heart disease is the leading
killer of women in the United
States and the second
leading cause of death in
most developed nations.
--American Heart Association (2007)
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Prognosis After MI
38% of women die within first year
Compared to 25% of men
35% of women will have second MI within 6
years
Compared to 18% of men

Source: Wenger 2004

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Stress

Puts a woman at greater risk for CVD and

poorer outcomes
Depression also may increase risk or deter her
from seeking medical help
Consider screening women with CAD for
depression and refer for treatment as needed
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Signs and Symptoms in Women

Number one symptom is SOB!
Other symptoms include: fatigue, GI symptoms, changes in
sleep patterns
Older women or those with diabetes may not have chest pain
May also have:
Heaviness, squeezing, or pain in left chest, abdomen,
midback, or shoulder
Arm pain
Palpitations or pain thats sharp or fleeting

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And the Answer is.

Differences in physiological vascular
function. The coronary endothelial and
microvascular reactivity are the believed key
players.

WISE Study
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Websites on Sex-Based Differences in

Health and Disease
Society for Womens Health Research:
Overview of sex-based differences
http://www.womenshealthresearch.org/hs/links.htm
http://www.womenshealthresearch.org/hs/healthfacts.htm
Centre for Research in Womens Health
http://www.crwh.org/
National Center for Gender Physiology at the University of
Missouri
http://www.genderphysiology.org
Partnership for Gender-Specific Medicine
http://cpmcnet.columbia.edu/dept/partnership/
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