Acute Coronary Syndromes

Introduction

Acute coronary syndromes (ACSs) include all syndromes compatible with acute myocardial ischemia resulting from imbalance between myocardial oxygen demand and supply.

ACSs are classified according to electrocardiographic (ECG) changes into (1) ST-segment-elevation (STE) myocardial infarction (MI) or (2) non–ST-segment elevation (NSTE) ACS, which includes NSTE MI and unstable angina (UA).

Clinical Presentation

• Predominant symptom is midline anterior chest discomfort (usually at rest), severe new-onset angina, or increasing angina that lasts at least 20 minutes. Discomfort may radiate to the shoulder, down the left arm, to the back, or to the jaw. Accompanying symptoms may include nausea, vomiting, diaphoresis, and shortness of breath.
• No specific features indicate ACS on physical examination. However, patients with ACS may present with signs of acute HF or arrhythmias.

Diagnosis

• Obtain 12-lead ECG within 10 minutes of presentation. Key findings indicating myocardial ischemia or MI are STE, ST-segment depression, and T-wave inversion. Appearance of a new left bundle-branch block with chest discomfort is highly specific for acute MI. Some patients with myocardial ischemia have no ECG changes, so biochemical markers and other risk factors for coronary artery disease (CAD) should be assessed.
• Biochemical markers of myocardial cell death are important for confirming diagnosis of acute MI. Diagnosis is confirmed with detection of rise and/or fall of cardiac biomarkers (cardiac troponin preferred) with at least one value above the 99th percentile of the upper reference limit and at least one of the following:

(1) symptoms of ischemia;

(2) new significant ST-segment–T-wave changes or new left bundle branch block;

(3) pathological Q waves; or

(4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Typically, a blood sample is obtained once in the emergency department, then 6 to 9 hours later.

• Patient symptoms, past medical history, ECG, and biomarkers are used to stratify patients into low, medium, or high risk of death, MI, or likelihood of failing pharmacotherapy and needing urgent coronary angiography and percutaneous coronary intervention (PCI).

Treatment

Goals of Treatment: Short-term goals include:

(1) early restoration of blood flow to the infarct-related artery to prevent infarct expansion (in the case of MI) or prevent complete occlusion and MI (in UA),

(2) prevention of death and other complications,

(3) prevention of coronary artery reocclusion,

(4) relief of ischemic chest discomfort, and

(5) resolution of ST-segment and T-wave changes on ECG. Long-term goals include control of cardiovascular (CV) risk factors, prevention of additional CV events, and improvement in quality of life.

PHARMACOLOGIC THERAPY

• Admit the patient in ICU or CCU for monitoring and pass IV line
• Bed rest and reassurance
• Oxygen inhalation if SPO2 is less than 92% then SOS
• ECG monitor and rhythm strip
• Inj Morphine (dilute 10mg in to 1o ml N/S 0.9%) 1-2 mg/minute IV Stat OR Inj Nalbin+Gravinate IV stat
• Tab Angised (Glyceryl trinitrate) 0.5mg 1 Tab S/L stat repeat every 10 to 15 minutes
• Tab Disprin 300mg 1 tab PO stat
• Tab Noclot-LD (Clopidogrel) 300mg 1 tab PO stat
• Inj Arixtra (Fondaparinux) 2.5-5mg S/C OD, Contraindicated in renal diseases Or
• Inj Clexane (Enoxaparin) 60 mg S/C for 3 days BD, OD dose in renal impairment
• Tab Carveda ( Carvideolol) 6.25-25mg 1 tab PO BD OR
• Tab Merol (Metoprolol) 12.5-50 mg 1ta PO OD
• Tab Ramipace (Ramipril) 1.25-5mg 1 tab PO OD