Acute

Coronary
Syndrome
Carrie Hurst FY1
What we’ll cover in next 30 mins…

 Definitions

 Clinical features and differentiating ACS

 ECGs

 Management

 Complications

 Some tips from a 2013 Warwick grad

 Case study
What is Acute Coronary Syndrome?

Stable Angina Unstable Angina NSTEMI STEMI

 Definitions
 Unstable angina:
 An unprovoked or prolonged episode of chest pain
raising suspicion of acute myocardial infarction (AMI)
 Without definite ECG or laboratory evidence

 NSTEMI:
 Chest pain suggestive of AMI
 Non-specific ECG changes (ST depression/T
inversion/normal)
 Laboratory tests showing release of troponins

 STEMI:
 Sustained chest pain suggestive of AMI
 Acute ST elevation or new LBBB

* ALS handbook 6th Edn

 Pathophys (enough to get by..)
Atherosclerosis

 Epithelial injury

 Migration of
monocytes/macro
phages

 LDL lipids
consumed  foam
cells

 Growth factors 
smooth muscle,
collagen,
proteoglycans

 Atheromatous
plaque forms
 Clinical features
 Tachycardia or
 Chest pain bradycardia
 Nausea

 Dyspnoea  Heart murmurs

 Palpitations
 Sweaty

 Hypotension or  Vomiting
hypertension
 Pallor
 Syncope
 Asymptomatic/silent

 Indigestion
 Acute confusion  Fever
 Distinguishing features

 SA:  UA:  NSTEMI:  STEMI:

platelet
plaque adhesion platelet complete
formation aggregation occlusion

 Precipitated by  At rest or minimal exertion

stress or exertion
 Lasts >20 minutes
 Lasts <20 minutes
 Often accompanied by other s/s
 Relieved by GTN or
resting  Poor GTN relief
 Risk Factors
Modifiable Non-Modifiable
 Smoking  Increasing age

 Obesity  Gender (male)

 Diet  Ethnicity

 Lack of exercise  Family History

 High serum cholesterol  ?Diabetes

 Hypertension

 ? Diabetes
 Differential Diagnosis
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain

GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GORD • Trauma
• Pancreatitis
 Investigations
Bedside Obs, ECG, BM
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase,
CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T
depression * Possible T wave waves
inversion * New LBBB
* T inversion (hours)
* Q waves (days)

* ST elevation is >1mm in limb leads and >2mm in chest leads

Important ECG findings
 Where is the problem?

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
 Management

A Patent?
B Oxygen (aim for sats 94-98%), auscultate, RR
C IV access (+/-fluids), HR, BP
D GCS, pupils, cap blood glucose
E Expose
 Common ACS management
 Morphine (5-10mg slow IV injection)

 Oxygen (titrate sats to need)

 Nitrates - GTN spray (400mcg = 1 spray) or tablet (1mg)

 Aspirin (300mg chewed)

 Plus an antiemetic i.e.

Metoclopramide 10mg IV

* BNF 64
 Unstable angina & NSTEMI
 LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux
2.5mg OD

 Clopidogrel 300mg loading dose

 Beta blocker - atenolol 5mg

 Nitrates – usually IV

 Consider coronary angiography within 72 hr

 Scoring systems
GRACE scoring
 Predicts 6/12 mortality in  Risk of cardiac events in
NSTEMI patients
 Age
 HR and systolic BP
 Killip class (CCF,
pulmonary oedema,
shock)
 Cardiac arrest on
admission
 Elevated cardiac
markers
 ST segment change
TIMI
next 30 days
 Age >65
 Known coronary artery
disease
 Aspirin in last 7/7
 Severe angina (>2 in
24hr)
 ST deviation >1mm
 Elevated troponins
 > CAD risk factors
 STEMI
 TIME IS MUSCLE

 Percutaneous coronary intervention (Primary PCI)

 ‘Call to balloon time’ of 120 minutes
 Requires clopidogrel 600mg loading dose
 Rescue PCI after failed thrombolysis

 Thrombolysis
 Streptokinase / alteplase / tenecteplase…
 Contraindications
 Clopidogrel 600mg loading dose AND LMWH

 Beta blocker i.e. Atenolol

 ACE inhibitor i.e. Lisinopril

Longer-term management

 Continuous ECG monitoring as inpatient/ CCU

 Aspirin 75mg OD (lifelong)

 Clopidogrel 75mg (1 year)

 Beta blocker (1 year - lifelong)

 ACE inhibitor

 Statin

 Modification of risk factors

 Complications
Early <72hr Late
 Death  Ventricular wall rupture

 Cardiogenic shock  Valvular regurgitation

 Heart failure  Ventricular aneurysms

 Ventricular arrhythmia  Cardiac tamponade

 Myocardial rupture  Dresslers syndrome

 Thromboembolism  Thromboembolism
 How to say the right thing in
clinicals….
 Have a system!!
 “I would order bedside, blood, imaging and
special test….”
 “ I would check that the patient is
haemodynamically stable using an A-E approach”
 “My management strategy would take into
account conservative, medical and surgical…”

 NEVER GUESS
 You get more marks for knowing your limitations
than for knowing an obscure fact.
 They want to know you’ll be a safe F1
 Case study – Mr FB

A 54 year old gentleman presents to A&E with chest pain…

 What do you want to ask him?
 30minute history of central ‘crushing’ chest pain radiating
to his jaw and left arm, 10/10

 He is SOB, looks very pale, clammy and sweaty, and has

vomited twice

 PMHx of hypertension and hypercholesterolaemia

 Takes metformin, salbutamol inhalers and citalopram

 FHx includes father dying of MI aged 50

 Smoked 40 cigarettes a day for the past 35 years and

drinks a bottle of whiskey a week

 Cant exercise “because of my asthma”

 What are his risk factors?
 Smoking  Increasing age

 Obesity  Gender (male)

 Diet  Family History

 Lack of exercise

 High serum cholesterol

 ? Hypertension

 ?Diabetes
How would you Ix him?
 Case study – Mr FB
 Initial management in acute setting?
 MONA
 Reperfusion
 BB and ACEi

 Long-term management?
 Aspirin, Clopidogrel, Statin, modification of
lifestyle…..
 Summary

 Don’t forget to learn what you think you already

know!

 ECG often

 Structured approach

 Know your acute management – MONA

 Senior review is always the right answer

 References

 BNF 64

 Advance Life Support emodule handbook 6th

Edition

 OHCS 7th Edition

 Great ECG example website:

www.meds.queensu.ca/central/assets/modules/
ECG/ecg_index.html