By DR.MD.

MOSHARRAF HOSSAIN ASSOCIATE PROFESSOR OF MEDICINE

Unstabe angina STEMI NSTEMI

Also known as crescendo angina It is angina of increasing frequency or severity It occurs on minimal exertion or at rest It is associated with increased risk of MI RAPIDLY WORSENING ANGINA Without myocardial damage Usually no cardiac markers elevation ECGST depression, T inversion at rest

Pain SOB Chest tightness/heavyness VOMITING Sweating Collapes

Tachycardia, Sweating, anxious Dyspnoea Arrythmia Heart failure Co-morbidities Peripheral vascular disease

Sudden death Reduce MI Arrythmia Hypotension Heart failureALVFAcute pulmonary edema

Initial 12 lead ECG is mandatory---look for hyper acute T, ST elevation, ST depression Biochemical markersCKMB, troponin I,T (structural cardiac proteins release during cardiac muscle damage & necrosis, corner stone of dx of MI), CKMB Echocardiography Leukocytosis-CBC Also ask BG, thyroid function, renal function CXR

CKMB starts at 4-6 hrs & normal 48-72 hr Troponin I,T srart to rise at 2-4 hr, nomal after 2 weeks Troponin high + s/s of iscaemia/ ST elevation >1mmin limb lead/>2mm IN CHEST LEAD or new LBBB or new Q wave In echocardigraphynew regional motion abnormality New loss of viable myocardial imaging

Anteroseptal-v1-v4 Anterolateral V4-V6 ,aVL,L1 SeptalV3-V4 Inferior11,111,aVF Posterior---tall R in v1v4 with st depression

Immediate clinical assessment PTR BP pulse oximetry Do urgent 12 lead ECG, Troponin Arrange admission to ICU/CCU Start high flow O2, Aspirin 300 mg PO,clopdogrel 300-600 mg po, GTNSL, Spray,or IV .6-1.2mg/hr sp for LVF or prsistant pain inj. Morphine 2.5 -5 mg iv, plus metoclopramide 10 mg IV (MONA)

Cardiac monitoring Metoprolol 5-15mg IV/50-100mg PO Or atenolol IV 5-10mg for pain relief/arrythmia and reduce mortality Continue monitoring with O2

RX AS ALL ACS plus Reperfusion therapy- if available Emergency primary PCI (percutaneous coronary intervention) + GP iib/iiib receptor antagonist antiplatelet IVI(Tirofiban or Abciximab) PCI NA and eligible for Thrombolysis(best in 2hr)do use IV streptokinase 1.5 million in 100ml NS over one hour or rTPA-- Alteplase IV bolus 15 mg, then .75 mg/kg in 30 min,then .5mg/kg to complete in 90 min. NB Tenecteplase or reteplase can be used.+LMWH

Rx as All ACS Plus LMWH-Enoxaparin img/kg 12 hourlySC or fondaparinux 2.5 mg SC daily for 12 days or till discharge Medium to high risk ACSConsidercoronary angiography+ GP Iib/IIIb RA IVI

Aspirin 75mg po /D Clopidogrel 75mg po/D BB Statin ACEI Heparin

Indicationsleft main coronary artery stem stenosis, 3 vessel disease (LAD,CX,RCA) By IMA/LIMA or reverse own saphenus vein

MI 1st hour is more risky ACS-12% death in I month, 1/5th in 6 months

Recurrent ischaemia Extensive ecg changes High biomarkers Arrythmia Shock MR HF Comorbidities

May be in I week Join work after I month Advice follow up Life style change Quit smoking Reduce weight treat co-morbidities

PVC, VT, VF, AF Atrial tachycardia Bradycardia (Inf MI) Heat block Acute circulatory failure Shock pericarditis

Papillary necrosis and rupture VSD Pericardial temponade MR, ventricular aneurism Dressler syndromes (pyrexia,pericarditis,pleurisy,prednisolone) Embolismstroke, TIA,Ischarmic limb, pulmonary embolism

THANKS