ACUTE CORONARY

SYNDROME AND
ARRHYTHMIAS

STEMI

Patients with acute chest pain and persistent (>20 min) ST-segment
elevation.

Reflects acute total coronary occlusion. Most patients will ultimately

develop an ST-elevation myocardial infarction (STEMI).
Mainstay of treatment in these patients is immediate reperfusion by
primary angioplasty or fibrinolytic therapy

NSTEMI

Patients with acute chest pain but no persistent ST-segment elevation.

ECG changes may include transient ST-segment elevation, persistent or

transient ST-segment depression, T-wave inversion, flat T waves or
pseudo-normalization of T waves or the ECG may be normal.

WHO PRESENTS WITH ATYPICAL SYMPTOMS?

Only
Atypical
Symptoms
(no chest
pain)

Any Typical
Symptoms
(chest pain
present)

74.2

66.9

Mean time between first

symptoms and
presentation (hours)

7.9

5.3

Women

49.0%

38.0%

% diagnosed with MI on
admission

22.2%

50.3%

Diabetes

32.6%

25.4%

% receiving reperfusion
treatment

25.3%

74.0%

Prior heart
failure

26.4%

12.3%

In-hospital mortality

23.3%

9.3%

Older
patients
(mean age,
years)

Atypical Typical

UA
Definition

NSTEMI

Ischemia without
necrosis
Negative Biomarkers

Necrosis
(nontransmural)
Positive biomarkers

STEMI
Transmural necrosis

Positive biomarkers

Diagnosis
No ECG ST-segment elevation

Treatment

Invasive or conservative depending on risk

SPECTRUM OF ACS

ECG ST-segment
elevation
Immediate reperfusion

TIMING OF RELEASE OF VARIOUS

BIOMARKERS AFTER ACUTE MYOCARDIAL
INFARCTION

Non-MI Causes of Troponin Elevation

TREATMENT OF ACUTE CORONARY SYNDROME

Fibrinolytics

Unfractionated heparin

Dual platelet inhibition

Beta blockade

ACE inhibition for LV dysfunction

Minerocorticoid receptor antagonism for LV dysfunction, e.g. EF <

40%

Spironolactone or Epleronone

Statins

Thrombolysis if onset of symptoms < 2 hours

Primary PCI if onset of symptoms > 2 hours

FIVE DRUGS

Beta blockers
Antiplatelet agents
Statins
Nitrates
Antihypertensive and other risk factor medications

MEDICAL TREATMENT

BED REST

CONTINUOUS ECG MONITORING

AMBULATION PERMITTED IF NO RECURRENCE OF

ISCHEMIA OR NO BIOMARKER OF ISCHEMIA AFTER 1224HRS

ANTI ISCHEMIC TREATMENT

NITRATES

BETA BLOCKERS

CALCIUM CHANNEL BLOCKERS

NITRATES(GTN)

S/L OR BUCCAL SPRAY- 0.3-0.6mg

Rpt EVERY 5MIN- THREE DOSES

IF PAIN PERSISTS IV NTG 5-10 microgm/min

C/I
HYPOTENSION
USE OF SILDENAFIL WITHIN PREVIOUS 24 HR

ISOSORBIDE DINITRATE (10-60 mg bd or tid)

SLOWER-PEAK IN 5-8 min
t1/2 40 min .SR PREPARATION 6-10 hrs

ISOSORBIDE MONONITRATE
HIGH BIOAVAILABILITY .t1/2 4-6hrs

OTHER PREPARATIONS
NITROGLYCERINE OINTMENT
SR TRANSDERMAL PATCHES

BETA ADRENERGIC BLOCKADE

REDUCE MYOCARDIAL O2 DEMAND

METOPROLOL 5mg IV Rpt 3 TIMES 5 min APART

FOLLOWED BY 50 -100 mg BD
C/I :BRADYCARDIA <60
ADVANCED AV BLOCK
PERSISTENT HYPOTENSION
PULMONARY OEDEMA
H/O BRONCHOSPASM

CALCIUM CHANNEL BLOCKERS

DILTIAZEM SR 60 -120 mg BD
VERAPAMIL SR 180-240 mg OD
ACE INHIBITORS

LIPID LOWERING AGENTS

ASPIRIN 162-325 mg NONENTERIC FORMULATION

FOLLOWED BY 75-160 mg/day
CLOPIDOGREL 300 mg FOLLOWED BY 75 mg/day
C/I DOCUMENTED ASPIRIN ALLERGY
ACTIVE BLEADING
KNOWN PLATELET DISORDER

ANTITHROMBOTIC THERAPY

UFA BOLUS -60-70IU/KG FOLLOWED BY 12-15 U/KG

INFUSION
LMWH
DALTEPARIN 120 IU/KG S/C BD
ENOXAPARIN 1mg/KG S/C BD
MOA : anti F IIa AND anti F Xa

HEPARIN

ABCIXIMAB 0.25 mg/kg BOLUS FOLLOWED BY

0.125 microgm/kg/min INFUSION FOR 1224hrs
EPTIFIBATIDE 180microgm/kg BOLUS
FOLLOWED BY 2microgm/kg INFUSION FOR
72-96hrs
TIROFIBAN 0.4 microgram/kg/min FOR 30
min FOLLOWED BY 0.1 microgm/kg/min
INFUSION FOR 48-96 hrs

GP IIB/IIIA INHIBITOR

RISK FACTOR MODIFICATION

BETA BLOCKERS
ACE INHIBITORS
STATINS
ASPIRIN
CLOPIDOGREL

LONG TERM MANAGEMENT

CONTROL OF PAIN

S/L NITROGLYCERINE
MORPHINE 2-4 mg IV
S/E :Venous pooling, hypotension
Diaphoresis and nausea
Bradycardia ,heart block
BETABLOCKERS
HR >60
SYSTOLIC BP>100
PR INTERVAL <0.24
RALES NOT HIGHER THAN 10 CM FROM
DIAPHRAGM

AGENTS USED
Non selective streptokinase and urokinase
Specific agents alteplase ,reteplase , tenecteplase

ADJUVANTS Aspirin ,heparin, betablockers and

lignocaine

THROMBOLYSIS

RELATIVE C/I - THROMBOLYSIS

USE OF ANTICOAGULANTS
RECENT SURGERIES
KNOWN BLEEDING DIATHESIS
PREGNANCY
KNOWN HGIC OPHTHAL CONDITION
ACTIVE PEPTIC ULCER DISEASE

STREPTOKINASE-1.5MU IN 100 ml saline over 1 hr

CAUSE HYPOTENSION AND IS ANTIGENIC
ALTEPLASE(tPA)-15 mg bolus ,0.75mg/kg over 30
min,0.5mg/kg over 60 min
rPA double bolus regime-10MU bolus over 2-3 min
followed by 10 MU bolus 30 min later
TNK IV bolus of 0.53 mg/kg over 10 sec

THANK YOU