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ACUTE CORONARY
SYNDROMES
CAUSES
Angina & MI
Muskuloskeletal pain
Esophagitis & Esophagial spasm
Pleurisy
Pneumothorax
Costochondritis
Aortic dissection
Pancreatititis & Cholecystitis
Root pain
Pericarditis
Fibromyalgia
Mediastinitis
APPROAC
H
Suspect Cardiac
Pain in
>40yrs,male
Post menopausal
C/C smoker
DM/HTN
Obese
Sedentary
PHYSICAL
FINDINGS
Apprehensive look, Angor
amini
Sweating, cold
skin,Hypotension,
Tachy/Bradycardia,Arrythmi
as
Wide/Narrow pulse pressure
Dyskinetic Apex
S3,S4,Apical sys murmur
Pericardial rub
Basal creps
IHD
ACS
UA
NSTEMI STEMI
ACS
60% UA
40%MI
2/3NSTEMI
1/3STEMI
PATHOPHYSIOL
OGY
1. A/C plaque change
2. Dynamic obstruction (vasospastic)
3. Progressive mechanical obstruction
4. INCREASED myocardial O2 demand
5. Decreased supply of O2
UA & NSTEMI
UA Presents as
Rest angina >10 minutes
Severe & new onset angina
Crescendo angina
NSTEMI
Above features + evidence
of myocardial necrosis
ECG
1. Labile ST Segment
depression
2. T Inversion
3. Transient ST Elevation
Cardiac Specific
markers
1. Myoglobin- first to rise (with in 2 hrs) less
value
2. Troponin I- has got prognostic
value,PREFFERED MARKER
3. CPK-MB4. LDH 1
NOT elevated in Pts with UA
Rx of UA /
NSTEMI
GOALS
1. Prevention of Thrombus
2. Restoration of coronary
blood flow
3. Reduction in myocardial o2
demand
Supplemental o2
Morphine SO4
1. Reduces pain
2. Causes venodialatation
3. Arteriolar dialatation
4. Vagotonic effect
5. Useful in pul edema
Dosage 2 -4 mg Iv Rpted every 5 mts or until S/E ensue
S/E Hypotension,Nausea, vomitting,Apnea,Urinary retention
Antiplatelet
therapy
1. Aspirin-325 mg non enteric chew stat if no
c/I . Later 150 mg /day
2. Clopidogrel- 300mg stat & 75 mg / d
3. Combination ecospirin + clopidogrel
4. Gp 2 b 3a antagonists
1. Absciximab
2. Epifibatide
3. tirofiban
Anticoagulant
therapy
1. UFH 50 60 IU/kg Max (5000IU) IV
bolus----->12IU/kg/hr (Max 1000) aPTT
Titrated to 1.5 to 2.5
2. LMWH1. Dalteparin(Fragmin)
2. Enoxaparin
Anti ischemic Rx
Nitrates NTG 0.5 mg s/l,Sorbitrate 5
mg s/l
C/I
Hypotension,
1. RVMI
2. Tachycardia >100bpm
BETA Blockers
Metoprolol 12.5 1 BD,Atenolol 25 1 OD,Carvedilol 3.125 1
BD,Betaxolol
Decreases myocardial o2 demand
C/I Hypotension,
HR <60 bpm
Marked 1 AV Block
BR Asthma
Complete HB
STEMI
MC Cause of death is VF
DIAGNOSIS ( 2 or > of the following)
1. H/o Prolonged chest discomfort / Angina equivalent >30 mts
2. 2mm or < STE in precordial leads OR 1mm or > STE in Inferior leads
3. Elevated biomarkers
History
1. Typical cardiac pain / Angina equivalent
2. Silent MI- present with confusion,dyspnoea,unexplained
hypotension
1.
2.
3.
4.
Elderly
Diabetics
Hypertensives
Post op Pts
O/E
1. PSM Mitral area
2. RVMI Cardiogenic shock,hypotension,^JVP No
features of pul edema
ECG
1. Hyperacute T Waves
2. ST Segment changes
1.
2.
3.
4.
5.
2, 3 aVF - IWMI
V1 V2 V3 AWMI
1 aVL V5 V6- Lateral
PWMI- reciprocal changes in anterior leads
RVMI STE in V4R Q Waves
Investigations
FLP/ FBS
Trop I,CPK MB
CXR
ECG
PT
ECHO
Rx
1. General measures
1. Continuous ECG, BP, SpO2 measurement
2. O2
3. Two IV Lines
4. RVMI Start IV Fluids. C/I in Pul Edema
5. CCU
Medications
Aspirin-325 mg non enteric chew stat if no
c/I . Later 150 mg /day
Clopidogrel- 300mg stat & 75 mg / d
No role for Gp 2 b 3a antagonists
Nitrates
Beta Blockers
Atropine 0.6mg iv (Max 2mg) For
bradycardia
Morphine+ Phenergan
Contd
THROMBOLYTIC THERAPY
IND-
THROMBOLYTIC THERAPY
C/I
1. H/O ICH
2. AVM, Aneurysms
3. Intracranial tumours
4. Ischemic stroke <3 months
5. Aortic dissection
6. Major Trauma with in 3 months
7. High BP , SBP>180 mm DBP >110mm
8. Bleeding diathesis
9. Previous STK use > 5days & <2 yr
10. >12 hrs after onset of pain
Administration
1.5 million IU STK in 100 ml NS over 1HR
Inj Avil + Efcorlin given prior
ECG & BP monitoring
Adverse reactions
Symptomatic improvement
ECG Change
1.
2.
3.
Contd
Statins - HMG Co A Reductase inhibitors
S/E
Hepatotoxicity
Myopathy
Rhabdomyolysis
ICATIONS
A/C pericarditis
Dresslers syndrome
A I process
^ ESR,Pericardial effusion,fever
MIAS
WITH HEMODYNAMIC COMPROMISE
REQUIRE PROMPT Rx
Left antr fascicle block
Bradycardia - in MI involving R coro A
Observation
Atropine
pacing
Sinus Tachycardia
PSVT
AF & AFl
Accelerated junctional rytham
Ventricular arrythmias
VPCs
AIVR- Ventricular rate>60 125 bpm
NSVT
VT
Stable Inj xylocard 50 mg IV
Inj Amiodarone75 stat & 500 mg in 500 ml NS Iv infusion
Avoid IV Fluids
Morphine is helpful
Diuretics , ACEI,Nitrates
in IWMI & PWMI
Cardiogenic shock
Give IVF,support with Dopamine ,
Dobutamine
Intra aortic balloon pump
RVMI
Mechanical complications
Aneurysm due to wall motion abnormality
A/W Mural Thrombi
Persistent STE > 1 monthsEmpirical anticoagulation (Warf) INR
2-3
Pappillary M Rupture
Postr medial lip is mostly affected
Echo, Doppler diagnostic
FOLLOW UP CARE
Continue drugs & Dose Adjustment
Every 4- 6 months in 1st year
Thereafter yrly & SOS
THANK YOU