Acute coronary syndrome

Dr E Appleton and Dr E McGimpsey

Definition

Risk factors

Common presentations
Symptoms

Pain, which is usually described as pressure, squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm Palpitations Exertional dyspnea that resolves with pain or rest Diaphoresis (sweating) from sympathetic discharge Nausea from vagal stimulation

Physical findings
Hypotension: Indicates ventricular dysfunction due to myocardial ischemia, myocardial infarction (MI), or acute valvular dysfunction Hypertension: May precipitate angina or reflect elevated catecholamine levels due to anxiety or to exogenous sympathomimetic stimulation Pulmonary edema and other signs of left heart failure Jugular venous distention Cool, clammy skin and diaphoresis in patients with cardiogenic shock Change in heart sounds - third heart sound (S3) and, frequently, a fourth heart sound (S4) A systolic murmur related to dynamic obstruction of the left ventricular outflow tract

Beware the silent MI elderly/diabetic patients

Diagnosis
In the emergency setting, electrocardiography (ECG) is the most important diagnostic test for angina. ECG changes that may be seen during anginal episodes include the following: Transient ST-segment elevations Dynamic T-wave changes: Inversions, normalizations, or hyperacute changes ST depressions: These may be junctional, downsloping, or horizontal New LBBB

Diagnosis cont
Laboratory studies that may be helpful include the following: Cardiac troponin levels - marker of cardiac damage most importantly 12 hours post worst pain > 50 = +ve Creatine kinase isoenzyme MB (CK-MB) levels Complete blood count check for anaemia Basic metabolic panel deranged electrolytes can ppt MI Diagnostic imaging modalities that may be useful include the following: CXR check for pulmonary oedema, cardiomegaly Echocardiography to confirm if LVF after STEMI Myocardial perfusion imaging determine level of ischaemic tissue Cardiac angiography to view coronary vessels and determine level of plaque formation

Acute Managment

Longterm Management

TIMI score Unstable Angina/NSTEMI score used to risk assess patients

Pneumonic AMERICA: Age > 65 Markers (increased serum cardiac markers) EKG (ST depression) Risk factors (3 or more CAD risk factors: patient age, family history, hypercholesterolemia, hypertension, smoking, diabetes, obesity, sedentary lifestyle, metabolic syndrome) Ischemia (2 or more anginal events over past 24 hours) CAD (prior coronary stenosis of 50% or more) Aspirin use within past 7 days Score Interpretation: Score of 0-1 = 4.7% risk Score of 2 = 8.3% risk Score of 3 = 13.2% risk

Score of 4 = 19.9% risk Score of 5 = 26.2% risk Score of 6-7 = at least 49%

Timi score - STEMI

Age 65 years? < 65 +0 65-74 +2 75 +3 Yes+1 Yes+3 Yes+2 Yes+2 Yes+1 Yes+1 Yes + 1 DM or HTN or Angina? SBP < 100 mmHg? HR > 100 bpm? Killip Class II-IV? Weight < 67 kg (147.7 lbs)? Anterior ST Elevation or LBBB? Time to Treatment > 4 hrs?