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ACUTE CORONARY

SYNDROME
By: Dr. Muhammad Alauddin Sarwar
Medical officer,
Sindh Government Qatar Hospital,
Karachi.
ACS
Any constellation of clinical symptoms that are
compatible with myocardial ischemia. It encompasses
Acute ST elevated myocardial infarction (STEMI)
Non ST elevated myocardial infarction ( NSTEMI)
Unstable Angina

Worldwide Statistics
Each year:
• > 4 million patients are admitted with unstable
angina and acute MI
• > 900,000 patients undergo PTCA with or without
stent

ACC/AHA and National Guidelines for USA & NSTEMI 2003


PATHOPHYSIOLOGY OF ACS

Video clip explaining Atheromatous pathology of ACS


ACS

ACC/AHA and National Guidelines for USA & NSTEMI 2003


DIAGNOSIS OF ACS
It can be made on the basis of

History
ECG
Cardiac (Bio Markers)
DIAGNOSIS OF ACS
1) HISTORY
Likelihood of ACS Unlikelihood of ACS
Chest or left arm pain as chief Pleuritic pain
symptom. Localized middle or lower
K/C of CAD, including MI abdominal pain.
Age >70 yrs Pain that may be localized by
Male sex the tip of 1 finger.
D/M Pain with movement or
Recent cocaine use palpation of chest wall.
Transient MR, hypotension, Constant chest pain for many
diaphoresis, pulmonary edema. hours
Very brief episodes of pain that
last a few seconds or less.
Pain that radiates into the lower
extremities.
ACC/AHA and National Guidelines for USA & NSTEMI 2003
DIAGNOSIS OF ACS
ECG:
High likelihood of Intermediate Low Likelihood of
ACS Likelihood of ACS ACS
New, transient Fixed Q waves T waves
ST-segment Abnormal ST flattening or
deviation (0.05 segment or T inversion in leads
mV), or waves with dominant R
T wave waves
inversion (0.2 Normal ECG
mV)

ACC/AHA and National Guidelines for USA & NSTEMI 2003


DIAGNOSIS OF ACS
3) Cardiac ( Bio Markers)
High likelihood of Intermediate Low Likelihood of
ACS Likelihood of ACS ACS
Elevated Normal Normal
cardiac TnI, TNT,
or CKMB

ACC/AHA and National Guidelines for USA & NSTEMI 2003


EVALUATION OF ACS
ACC/AHA & National Definite ACS
Guidelines 2003.
No ST elevation ST elevation

Non diagnostic ECG normal ST & T wave changes on Evaluate for


initial serum cardiac marker going pain positive cardiac reperfusion
markers hemodynamic therapy
abnormalities
Observe, follow up 4-8 hrs:
ECG, Cardiac markers
See AHA
guidelines for
Ac. MI
No recurrent pain, negative Recurrent ischemic pain or
follow up studies positive follow up studies
diagnosis of ACS confirmed

Stress study to provoke ischemia


Consider evaluation of LV function if ischemia is present

Negative: Non-ischemic Positive: diagnosis of


discomfort, Low risk ACS ACS confirmed

OPD follow up Admission, manage via acute ischemic pathway


EVALUATION OF ACS

STRATEGIES
In the early conservative strategy, coronary
angiography is reserved for patients with evidence of
recurrent ischemia (angina or ST-segment changes at
rest or with minimal activity) or a strongly positive
stress test despite vigorous medical therapy.

In the early invasive strategy, patients without


clinically obvious contraindications to coronary
revascularization are routinely recommended for early
coronary angiography and angiographically directed
revascularization, if possible.
ACC/AHA Guidelines 2003
EVALUATION OF ACS
SAARC Guidelines: Adopted from ACC/AHA

ACC/AHA and National Guidelines for USA & NSTEMI 2003


EARLY INVASIVE STRSTEGY FOR ACS

NST-AMI ACS Task Force. C 2003 European Society of Cardiology


ACS (STEMI)
STEMI is the most important component of
ACS.
It needs to be dealt urgently & efficiently.
Time is muscle (Thrombolysis is preferred
if onset of pain to presentation is under 3
hours)
Every GP should be able to pick ST
elevation in the ECG & to provide proper
emergency medication & referral.

ACC/AHA and National Guidelines for STEMI 2006


The ECG
Recognition of AMI

• Know what to look for—


– ST elevation >1 mm
J point
– 2 contiguous leads
• Know where to look
– I, AVL, V5, V6 = Lateral
– V1 V2 V3 V4 = Anterior
– II, III & AVF = Inferior
PR baseline

ST-segment Elevation
= 4.5 mm
12-Lead ECG Variations
in AMI and Angina
Baseline

Ischemia—tall or inverted T wave (infarct),


ST segment may be depressed (angina)

Injury—elevated ST segment, T wave may invert

Infarction (Acute)—abnormal Q wave,


ST segment may be elevated and T wave
may be inverted

Infarction (Age Unknown)—abnormal Q wave,


ST segment and T wave returned to normal
A 45 years old male patient on Bed -5 in Cardiac Ward

ECG at
11/2/08
5 days before
admission

NSR, ST elevation
II, III and avF.
ST depression in I,
avL and V2 – V6

Acute Inferior wall


MI
ECG at admission
5 days after MI

NSR,Poor R waves
and T inversion II,
III and avF.
Upper} NSR, ST elevation in I, avL, V2 – V5, ST depression in II,III and avF
ANTERIOR WALL MI
NSR,ST elevation in I, avL
and V1 to V6
ST depression in II, III & avF.
Anterior Wall MI
NSR, ST depression V1 to V3 with R wave and upright T
waves, ST elevation in V5 & V6.
Postero Lateral wall MI.
ER Management of STEMI
Reassurance
Targeted history
ECG to be interpreted within 10 min
Oxygen @ 2-4 L/min
I/V access with two wide bore cannulae
ASA (Disprin) 300mg chewable
Clopidogrel (Loclog 75mg) 4 stat+LMWH S/C if
Thrombolytic therapy is not near.

ACC/AHA and National Guidelines for STEMI 2006


STEMI Management
 Sublingual nitroglycerin (Angised) 500mcg sos
 Streptokinase to be given stat after ECG confirms
ST elevation
 Morphine I/V to relieve pain and anxiety.
 Oral beta blocker, if no sign of heart failure
DRUGS to be used in first 24 hrs
• Clopidogrel 75 mg OD
• ACE inhibitor / ARBs if ACEI intolerance
• Atorvastatin 20 mg at night.

ACC/AHA and National Guidelines for STEMI 2006