AcuteCoronarySyndromes(ACS)

Thisisbasicallyanumbrellatermfor:
STEMISTelevationMI
NSTEMInonSTelevationMI
Unstableangina
Theyaregroupedtogetherbecausetheyall
haveacommonmechanismruptureorerosion
ofthefibrouscapofacoronaryarteryplaque.
Imagineitlikeaspectrumwithunstableangina
atoneend,andSTEMIattheotherNSTEMIis
inthemiddle.
Epidemiology
ItisthemostcommoncauseofdeathintheUK
50%ofdeathsoccurwithin2hoursofonsetof
symptoms
Incidenceof300000casesperyear
Morethan1.4mpeopleintheUKsufferfrom
anginathisalsohasincidenceof
approximately2%
CADaccountsforabout3%ofadmissiontoUK
hospitalseachyear

Etiology
Nonmodifiable
Age
Gender(male)
FHofIHDonlyifsymptomspresentbefore
theageof55
Modifiable
Smoking
Hypertension
Diabetes
Hyperlipidaemia
Obesity
Sedentarylifestyle

Controversial
Stress
TypeApersonality
LVHleftventricularhypertrophy

Cocaineuse
fibrinogen
Symptoms
Pain!Canradiatedowntheinsideofthearm,andinto
theneckandjawandcanlastuptoacoupleofhours.
Mayalsoradiatetotheepigastriumorback
Distress,alsosometimesafeelingofimpending
doom
Breathlessnessindeedinmanycasesthismaybe
theonlysymptommanyMIsactuallypass
unrecognisedparticularlyindiabeticpatients
silentMI
Syncopefaintingifthisoccurs,thenitwillbea
resultofseverearrhythmia,orseverehypotension.
Sweating
Tachycardia
Vomitingandsinusbradycardiathismayoccurasa
resultofexcessivevagalstimulation,whichismost
commonininferiorMI
Nauseaandvomitingmayalsobeaggravatedby
opiatesgivenforpainrelief
Suddendeaththisusuallyoccursfromventricular
fibrillationorasystole.Mostofthesedeathsoccur
withinthefirsthour.
1 Ifthepatientsurvivesthefirsthour,
thentheliabilityofserious
arrhythmiasremains,but
diminisheswitheachsubsequent
hour.So,patientshavetobe
educatedtogethelpassoonas
possible!
2 Cardiacfailureisthemajorcauseof
deathinthosethatsurvivethefirst
fewhours.Whetherornotcardiac
failuredevelopsisdependentonthe
extentofmyocardialdamage.
Remember,infarctioncanoccurintheabsenceofany
physicalsigns
MI(andstroke)isoftenmorecommoninthe
morning.ThisisthoughttobebecauseBPlowers
duringthenight,andthenrisesagainwhentheperson
wakesup.ThishigherBPmaythendislodgeany
thrombusthathasformedovernight.
Signs
Signs of impaired myocardial function
3rd/4thheartsounds
Pansystolicmurmur
Pericardialrub
Pulmonaryoedemacrepitationsinthelungs
Hypotension
Quietfirstheartsound
Narrowpulsepressure(differenceof<40mmHg)

RaisedJVP
Signs of sympathetic activation

Pallor(basicallylookingpasty.Itcanbegeneralised
orlocalised,butisonlyreallyclinicallysignificantif
generalised.Mostevidentinthepalmsandonthe
face)
Sweating
Tachycardia

Presentation of a silent MI
(nocardiacpain/chesttightness)usuallyin
diabeticand/orelderlypatients
Syncope
Pulmonaryoedema
Epigastricpain
Vomiting
Acuteconfusionalstate
Stroke
Diabetichyperglycaemia
Pathology
MIisalmostalwaysduetoocclusivethrombus
formationatthesiteofruptureorerosionofan
atheromatousplaque.Thepainexperiencedisusually
thesameasangina,butlastslongerandmaybemore
severe.
Patientsshouldcallanambulanceiftheyexperience
anginatypepain,which,afterusingGTNspray
doesnotsubsidewithin15minutes.
Thepainisoftenexcruciatinglookatthepatients
face/expression/pallortodeterminetheseriousness
ofthepain

Therearetwodifferentmechanisms.Either:
thefibrouscapoftheplaqueitselfgetsasuperficial
injury,andathrombusformsonit,or,
inmoreadvanced,unstableplaques,thefibrouscap
completelyruptures,andnotonlycansomeofthe
contentsescape,butbloodcanalsoentertheplaques,
formingathrombuswithintheremainingcapofthe
plaque.

Theplateletsthenreleaseserotoninandthromboxane
A2andthiscausesvasoconstrictioninthearea
resultinginreducedbloodflowtothemyocardium,
andischaemicinjury.

DifferentiatingtypesofMI

TransmuralMIthisisaninfarctthatcauses
necrosisoftissuethroughthefullthicknessofthe
myocardium
NontransmuralthisisanMIthatdoesnotcause
necrosisthroughthefullthicknessofthemyocardium
Diagnosis
Essentially2outofthefollowing3:
Suggestivehistory
o Sign/symptoms
o Riskfactors
ECGchangesPositivecardiacenzymestests
TroponinT
TroponinI

Differentials
Cardiac
Angina
Pericarditis
Myocarditis
Aorticdissection

Pulmonary
PE
Pneumothorax
Anythingthatcausespleuriticchestpain

Oesophageal
Oesophagealreflux/spasm
Tumour
Oesophagitis
AcuteManagement
Prehospital
Callambulance
Aspirin300mgorallyunlessanobvious
contraindication
Painrelief,e.g.510mgmorphine+metoclopramide

(antiemetic)10mgIVavoidIMinjectionsasthereis
ariskofbleedingandyoujustgaveloadsofaspirin!
SublingualGTN(unlesshypotensive)
1 Youcangiveupto3spraysof
GTNbutdontgiveanyiftheHR
<50,orthesystolicBP<90.

Hospital
AttachECGmakearecordingitisalso
reasonablylikelythatthiswillhavebeendoneinthe
ambulance.YouhavetodifferentiateraisedST
segmentMifromnonraisedSTsegmentMI.
Assessoxygensaturationifsatsareabove94%
youdonotneedtogiveoxygen(inpractice,people
areoftengivenoxygenregardlessbutthisisnotbest
practice)
Ifsatsarebelow94%thengivehighflowoxygenvia
anonrebreathermask(i.e.withaninflatedbagon)
InpatientswithknownCOPD,aimforsatsbetween
8892%giveoxygenviaa24%or28%Venturi
mask(colourcoded)andgetanABG.
GetIVaccesstakebloodsfor

FBC,U+E,glucose,lipids,cardiacenzymes,ABG
Takehistory/makebriefassessment

HistoryofCHD?
Riskfactors?
Contraindicationstothrombolysis
Doacardiacexamination

Pulse
BP
JVP
Murmurs
Signsofheartfailure
Peripheralpulses
Signsofprevioussurgery
ECGdothisbeforeyougivethrombolysisto
differentiateraisedSTsegmentornotMI
Give300mgaspirinifnotalreadyadministeredGive
510mgmorphineandmetoclopramide10mgIVif
notalreadyadministered

Becareful!givingpainreliefcanmaskwhether
thereisstillongoingpain,andthusyouarentableto
tellifyoureGTNisworking!
GiveGTNsublingually,2spraysoronetabletifnot
alreadygivenBUTdontgivewithsystolicBP<90,
orwithaHR<50InSTEMIGIVETHOMBOLYSIS
thesooneryougiveitthebetterthegreatest
benefitisseenwithinthefirst12hoursofchestpain,
butmaystillbebeneficialupto12hours.TheBritish
HeartFoundationadvisesthatitshouldbegivenno

greaterthan90minutesafterinitialonsetofchest
pain,andideallynogreaterthan60minutesif
possible
ThepainexperiencedduringanMIisrelatedto
myocardialischaemiaifthepaingoesawayits
probablytoolatetosavetheheartmuscle.
Streptokinaseistheusualdrugused.
BUTDONTGIVETHROMBOLYSISTOTHOSE
WITHOUTSTELEVATION!
Giveablockerusuallyatenolol5mgIV.Donot
giveifasthmaorrightventricularfailure!GiveCXR
youshouldalwaysgivetheanticoagulantfirst,unless
yoususpectaneurysm!Patientswithdiabetes,
consider:
Glucose
Insulin
Potassium
ConsiderDVTprophylaxisContinueallmedications
further(unlesscontraindicated),exceptcalcium
channelagonists,untilreviewedforlongterm
treatment

Notethatmorphineisalsoavasodilator
Investigations
ECG
Mostcommonly,aSTEMI
Earlywithinhours
PeakedTwave(verytallTwave)
RaisedSTsegment
Within24h
InvertedTwavesthismayormaynotpersist
STsegmentreturnstonormal.RaisedSTsegments
maypersistifaleftventricularaneurysmdevelops
Withindays
PathologicalQwavesformthesemayresolvein
10%ofcases
1 WesaytheQwaveispathological
ifitis>25%oftheheightoftheR
wave,and/oritisgreaterthan0.04s
width(1smallsquares)and/or
greaterthan2mmheight(2small
squares)
2 Qwavesarealsoasignofa
previousMIthechangesinQ

wavesaregenerallypermanent.The
changesinTwavesmayormaynot
revert.TheSTsegmentcanreturn
tonormalwithinhours.
Nonqwaveinfarctsareinfarcts
thatoccurwithoutthechangesseen
intheQwaves,butstillwiththeST
andTchanges.

Typicalpictureofchanges
STelevationthenlater,Tinversion,thenlater,Q
waveappears

OtherpatternsofECGchange:
STdepression
ReciprocalchangesometimesseeninSTEMI.This
referstoaphenomenonwherebythereisST
DEPRESSIONinsomeleads,inthepresenceofST
elevationinothers.thisoccursastheECGleadsare
viewingtheheartfromdifferentangles.theST
depressionwilltypicallyoccurinleadsviewingthe
heartattheoppositeangletothoseshowingST
elevation.Thepresenceofreciprocalchangeis
thoughttoindicateanearlierpresentationofMIbut
isnotparticularlyassociatedwithdifferentoutcomes.
**20%ofpatientswillinitiallyhavenoECG
changes**
PatientswithoutSTelevationaresaidtohavehada
NSTEMI

REMEMBER!
STdepressionIschaemiathedamageisreversible
(withtherighttreatment)
STelevationInfarctiondamageisirreversible
CXR

Dontdelaytreatmentwhilstwaiting
fortheCXR!Changesmayinclude:
Cardiomegaly
Pulmonaryoedema
Widenedmediastinum
Bloodtests

CardiacenzymestroponinTandI
TroponinTmostcommonlyused
test.
1 Levelshouldbe2x
greaterthannormaltobe
diagnostic
2 Peaklevelofelevationis
1224hoursperform
thetest12hafteronset.
Levelsusuallyraisedfor
aboutaweek
3 Specificforheartmuscle
butnotforMIbe
waryofothercausesof
heartmuscledamage
(e.g.severetachycardia,
heartfailure,myocarditis,
myopericarditis)
4 Helpstodifferentiate
betweenunstableangina
andMI
IftroponinTandECGareboth
normalafter6hours,riskofMIis
only0.3%
Creatinekinase(CK)
1 Foundinskeletaland
myocardialmuscle
2 Raisedafteranysortof
muscletrauma
Glucosenotonlydoesthishelpyou
treatanydiabetespresent,but
evidencesuggeststhatpatientswitha
highglucoseonadmissionhavea
worseprognosisthusyoushouldtreat
thesepatientsmoreaggressively.
Lipidscheckingforraised
cholesterolalthoughthisisnt
actuallynecessaryasallMIpatients
aregivenapotentstatin(e.g.
atorvastatin)regardlessofthe

cholesterollevel.FBCgeta
provisionalplateletlevelbefore
anticoagulation.Checkforanaemia
GIVETHROMBOLYSISif
APPROPRIATE!!!
Indicationsforgivingthrombolysis
Thepatientpresentswithin12hours
ofchestpain,and:
ThereisSTelevationof2mmormore
in2ormorechestleads
ThereisSTelevationof1mmormore
in2ormorelimbleads
ThereisnewonsetLBBB
Thereisevidenceofaposterior
infarct:
1 DominantRwavesand
STdepressioninV1V3

OR
Thepatientpresentswithin1224
hoursofonsetofchestpain
andthereiscontinuingchestpain
ORthereisSTelevation
Contraindicationsforthrombolysis
Internalbleeding
ProlongedortraumaticCPR
Heavyvaginalbleeding
Acutepancreatitis
Activelungdiseasewithcavitation
Recentsurgeryortrauma(<2wks)
Cerebralneoplasm
Severehypertension(>200/120)
Suspectedaorticdissection
Previousallergicreaction
Pregnancy
<18weekspostnatal
Severeliverdisease

Oesophagealvarices
Recentheadtrauma
Recenthaemorrhagicstroke
ifANYofthesearepresent,thenyou
shouldconsidergivingurgent
angioplastyinstead
1in200patientswhoreceive
thrombolysiswillhaveastroke!Do
notgivethombolysistothosewithout
STelevation.

TheuseofPCI(percutaneous
coronaryinterventioni.e.
angioplasty)
Angioplastyisthefirstline
recommendedtreatmentforSTEMI
(andalsohighriskNSTEMI)patients.
Evidencesuggestsitismoreeffective
thanthrombolysisHowever,itisnot
availableatallNHShospitalsinthe
UK.Itismainlyavailableattertiary
centres.Thistermbasicallymeansa
hospitalspecialisedtoperformthis
treatment.i.e.primarycareGP,
secondarycarehospital,tertiarycare
specialisthospital.

SOyoushouldonlyuse
thrombolysisif:
Thepatienthasnocontraindications
theyhaveaSTEMI(notNSTEMI)
angioplasty(PCI)isnotavailable
DifferencesbetweenSTEMi,
NSTEMIandunstableangina
STEMIthemostserioustypeof
ACS.Causedmyocardialinfarction
andischaemia.

Management
1 PCI/Thrombolysis.PCI
ifavailable.Ifnot,
thrombolyseifnoCI's
2 Betablockerunless
contraindicated(e.g.
asthma)e.g.lisinopril
5mgIV
3 ACEistartASAP
usuallywithin24hours,
particularlyifthereare
signsofLVdysfunction
e.g.lisinopril
NSTEMIlessseriousthenSTEMI,
butstillcausesdamagetothe
myocardium.Unstableanginadoes
notcausemyocardialdamageinitself,
butmayprogresstoMI
ManagementofNSTEMI/Unstable
angina
1 Betablockerunless
contraindicated(e.g.
asthma)e.g.atenolol
5mgIV
2 LMWHe.g.enoxaparin
for28days
3 Nitratesusuallygiven
IV
4 Clopidogrelmaybe
consideredinadditionto
aspirin,forupto12
monthsespeciallyin
patientswithraised
troponin.Thesepatients
areconsideredhighrisk
1 Inpatientswith
normaltroponin,
youmayconsider
dischargeafter
48h,astheseare

lowrisk

NHSpolicyyouhavetotreatMI
within36minutesdoortoneedle
timeamaximumof36minutes
betweenaraisedSTsegmentMI
patientcomingintotheemergency
departmentandreceivingPCI/
thrombolysis.
MONAforacutemanagementofMI

AllACSpatients
MMorphine
OOxygen
NNitrates
AAspirin
IfHighRiskNSTEMIorSTEMI
MONAT/MONAC
MMorphine
OOxygen
NNitrates
AAspirin
TClopidogrel(stillpracticeinmany
hospitals)orTicagrelor(PLATOTrail
'09)
Afteracuteeventwhenstable
Betablocker
AceInhibitor
Statin
Subacutemanagement

Bedrestfor48h,withconstantECG
monitoring
Examinedailyincludingheartlungs

andlegsforcomplications
Cardiacenzymeseverydayfor3
daysshouldseetroponinlevels
begintofall
Prophylaxisagainst
thromboembolism,atleastuntilfully
mobile,e.g.heparin
1 Warfarinrecommended
foratleast3monthsin
thosewithlargeanterior
MI,duetohighriskof
embolusasaresultofLV
dysfunction.
Betablockershouldbecontinued
for1year+.Doesshouldbehigh
enoughoreducepulseto<60bpm
1 Longtermbetablocker
usereducestheriskof
mortalityby25%
ACEishouldbecontinued.
Reducesmortalityby2530%at2
years
DISCHARGEifnocomplications,
dischargeafter57days.
1 Workpatientsshould
returntoworkafter2
months.Certaincareers
maynolongerbe
allowed:
1 Airlinepilot
2 Airtraffic
controller
3 DriverSome
drivingjobsallow
patientstoreturn
toworkifthey
meetcertain
criteria
4 Somephysically
demandingjobs
(e.g.involving

heavylifting)may
notbesuitable.
Longtermmanagement
(SecondaryPreventionmeasures)
Cardiacrehabilitationprograms
Allpatientsshouldbeofferedplaces
ontheseprograms,andprograms
shouldalwaysinvolveanexercise
component.Youshouldnotexcludea
patientfromanypartoftheprogramif
theychosenottoattendanyindividual
parts
Theseprogramsgenerallyoffer
supporttoachievethegoalslisted
below:
SmokingcessationIncreaseinexercise
encourageregulardailyexercise,
andatleast30minutes,3x/week
strenuousexercise
SexShouldavoidfor1monthafter
MI
Travelavoidairtravelfor2months
ReductioninweightReductionin
alcoholintakeDietarymodification
(reducedfatintake)dietshouldbe:
Highinoilyfish,fibre,freshfruit
andveg
Lowinsaturatedfat
Drugmanagement
Allpatientsshouldbeplacedonthe
followingmedications:
Aspirin
Thisisanantiplateletdrug.Ifthe
patientishypersensitive,then
considerclopidogrel.Somepatients

maybeputonaspirinandclopidogrel
intheacutephaseafteranMI;but
theyshouldnotbeonthis
combinationformorethan12months.
Inpatientswithdyspepsia,youshould
alsoconsidergivingaPPIwithaspirin
toreducetheriskofulceration.
blocker
thishasantihypertensiveeffects,by
encouragingperipheralvasodilation,
anditalsoreducescardiacoutput,by
reducingtherateandcontractilityof
theheart.Italsoreducesrenin
secretion.
ACEinhibitor(oralternativeanti
aldosteronedrug)

Notonlydoesthisdrughelptoreduce
bloodpressureandreducetheriskof
chronicrenalfailure,butitalsohelps
toreduce/delaytheonsetofheart
failure,bypreventingremodellingof
theleftventricle.
Statin

Thisisusefuleveninpatientswitha
normalcholesterollevel!Sometrusts
treatallMIpatientswithastatin,
othersonlytreatthosewithtotal
cholesterol>4mmol/L

Review

At5weeksforcomplications,and
angina.Treatanginainnormal
method.Considerangioplastyif
severe
At3monthscheckforraised
cholesterolandconsiderstatinifnot
alreadyprescribed.

COBRAAforSecondaryPrevention
inACS
CClopidogrelantiplatelets
OOmacarOmega3
BBisoprololblocker
RRamiprilACEi
AAspirin

AAtorvastatinverypotentstatin!
ComplicationsofMI
Cardiacarrest
Unstableangina
Bradycardia,heartblock
Tachyarrhythmias
Leftventricularfailure
Rightventricularfailure
Pericarditis
DVT&PE
Systemicembolus
Cardiactamponade
MitralRegurg
Ventricularseptaldefect
Latemalignantventricular
arrhythmias
Dresslerssyndrome
Leftventricularaneurysm
Muralthrombusthisisathrombus
attachedtothewallofthe
endocardiuminadamagedarea,or
sometimesitisattachedtotheaortic
walloveranintimallesion.MIleads
toakineticareasofventricularwall.
Thisstasisallowstheformationofa
thrombusonthewall.Thelargerthe
infarct,thegreatertheriskof
thrombus.Partsofthethrombuscan
easilybreakoffanembolise.Common
sitesofischaemiaare;brain,spleen,

gut,kidney,lowerlimbs.
especiallyinposteriorinfarcts.Post
Ventricularwallrupturethisoccurs
ischaemicfibrosingandshorteningof
about510daysaftertheinitial
thepapillarymusclescanalsocause
infarct.Atthistimethemyocardium
incompetence.Insomepatients,the
isparticularlysoft.Bloodcanthen
papillarymusclescanbecompletely
comeoutoftherupture,andenterthe
destroyedbytheinfarct,resultingin
pericardialsack,causing
instantandcompletetorrentialmitral
haemopericardium.Thisusuallyleads
valveincompetence.
tocardiactamponadeasitisanacute
effect.Thisclassicallypresentswith
DresslersSyndrome
electromechanicaldissociationa
perfectlynormalECG,butnocardiac
AAnautoimmunepericarditis,
outputandnopulse.Asyouknow
provokedbyMI.Occursin510%
PEA(pulselesselectricalactivity)isa
ofcasesofMI.Onset13weeks
nonshockablerhythmandthus
postMI.Localisedpericarditis.
almostalwaysresultsindeath
Causesfever,pericardialeffusions,
Ventricularaneurysmthisisalate
anaemia,raisedESR,enlargedheart
complicationofatransmuralMI.the
onCXR,pericardialrub(on
infractedmusclewillbereplacedbya
auscultation).maybesimilartoPE
thinlayerofcollagenousscartissue,
anotherpostMIcomplication.It
thatwillgraduallystretchas
isoftenselflimiting,andsymptoms
intraventricularpressurerisesduring
lastafewdays.Treatedwith
systole.Theaneurysmitselfhas
NSAIDs,andinmoreserious
complicationsofleftventricular
cases,steroids.
failure,arrhythmias,muralthrombus.
Ruptureoftheaneurysmisrare.
Mitralvalveincompetence
commonlycausedbyischaemic
damagetothepapillarymuscles,