Acute coronary syndrome

Acute coronary syndrome (ACS) is a medical emergency and requires IMMEDIATE HOSPITAL ADMISSION!


Definition

• Classified based on changes on the ECG and serial cardiac troponin levels
• Refers to a range of acute myocardial ischaemic states
• ST elevation
• Non-ST elevation
• Unstable angina (no rise in troponin levels)
• Non-ST elevation MI (rise in troponin levels)
• Troponin I is more SPECIFIC (less false positives)
• Troponin T is more SENSITIVE (less false negatives)

Epidemiology

• 3 in 1000 every year for Non-STEMI
• 114000 in total every year

Risk factors (for atherosclerosis)

Modifiable

• Age
• Male
• FH
• Premature menopause
• Racial - Indian, Pakistan, Bangladesh

Non-modifiable

• Smoking
• Diabetes mellitus (impaired glucose tolerance)
• Hypertension
• Dyslipidaemia (Raised LDL and Lowered HDL)
• Obesity
• Physical inactivity

Presentation

Symptoms of ACS

• Pain in the chest and/or other areas including the arms, back or jaw lasting longer than 15 minutes
• Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or haemodynamic instability
• New-onset chest pain, or abrupt deterioration in stable angina, with recurrent pain occuring frequently with little or no exertion and lasting longer than 15 minutes

• Prolonged (more than 20 minutes) anginal pain at rest
• New-onset angina with limitation on daily activities
• Recent destabilisation of previously stable angina, with moderate or severe limitation of daily activites
• Post-myocardial infarction angina
• Associated with:
• Sweating
• Nausea
• Vomiting
• Dyspnoea
• Fatigue
• Shortness of breath
• Palpitations

Differential diagnoses

• Cardiovascular
• Acute pericarditis
• Myocarditis
• Aortic stenosis
• Aortic dissection
• Pulmonary embolism
• Respiratory
• Pneumonia
• Pneumothorax
• Gastrointestinal
• Oesophageal spasm
• Oesophagitis
• GORD
• Acute gastritis
• Cholecystitis
• Pancreatitis
• Musculoskeletal
• Tietze's

Investigations

• 12-lead ECG
• Cardiac enzymes
• FBC
• Blood glucose
• Echocardiography
• CXR
• Cardiac Magnetic Resonance imaging (CMR)
• Coronary angiography (gold standard)

Management

• Urgent hospital admission
• Resuscitation
• Pain relief - Intravenous opioid (with anti-emetic), GTN
• 300mg Aspirin unless patient is allergic
• Resting 12 lead ECG
• Oxygen sats with pulse oximetry

Drugs

• Anticoagulation
• Aspirin
• Clopidogrel
• Prasugrel + Aspirin
• Ticagrelor + Aspirin (long term)
• Glycoprotein IIb/IIIa inhibitors
• Antithrombin therapy
• Revascularisation
• Coronary angiography with follow on PCI
• Other
• Nitrates
• Beta-blockers
• Calcium antagonists (Calcium channel blockers)
• ACE inhibitors

Further

• Assess LV function
• Cardiac rehabilitation
• LIFESTYLE ADVICE

Prognosis

• In hospital death and re-infarction in 5-10%
• Poor prognosis factors:
• Advanced age
• Severe ECG changes
• Big rise in troponin
• LV dysfunction, cardiogenic shock
• Increased heart rate + arrhythmias
• Renal impairment
• Diabetes mellitus
• Anaemia
• Cerebrovascular disease/ peripheral vascular disease

Prevention

LIFESTYLE ADVICE!!!!!