1. Acute Coronary Syndrome
Carrie Hurst FY1

2. 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

3. What is Acute Coronary Syndrome?
Stable Angina
Unstable Angina
NSTEMI
STEMI
Some degree of plaque rupture in the ACS spectrum conditions

4. Definitions Unstable angina: NSTEMI: STEMI:
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

5. 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
Plaque rupture
Trauma to surface of plaque
Sudden plaque expansion

6. Clinical features Tachycardia or bradycardia Chest pain Nausea
Heart murmurs
Dyspnoea
Palpitations
Sweaty
Vomiting
Hypotension or hypertension
Don’t forget the rest of the history : Past medical hx
Family hx
Drug Hx
Allergies
Social
Systems review
Pallor
Syncope
Asymptomatic/silent
Indigestion
Acute confusion
Fever

8. Distinguishing features
SA: plaque formation
UA: platelet adhesion
NSTEMI: platelet aggregation
STEMI: complete occlusion
SA: resting, GTN, lifestyle modification
Precipitated by stress or exertion
Lasts <20 minutes
Relieved by GTN or resting
At rest or minimal exertion
Lasts >20 minutes
Often accompanied by other s/s
Poor GTN relief

9. Risk Factors Modifiable Non-Modifiable Smoking Obesity Diet
Lack of exercise
High serum cholesterol
Hypertension
? Diabetes
Increasing age
Gender (male)
Ethnicity
Family History
?Diabetes

10. Differential Diagnosis
Chest pain
Cardiac MI
Angina
Pericarditis
Aortic dissection
Respiratory
Pulmonary embolism
Pneumothorax
Pneumonia GI
Oesophageal spasm
GORD
Pancreatitis
Musculoskeletal
Costochondriasis
Trauma
Rule these out during your examination i.e.
- Aortic dissection: pulseless upper limb/asymmetry of pulses – don’t fibrinolyse!! - respiratory examination ? Deviated trachea, reduced chest expansion

11. 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
* ECG normal
* Possible ST depression
* ST depression
* Can be normal * Possible T wave inversion
* ST elevation
* Hyperacute T waves
* New LBBB
* T inversion (hours)
* Q waves (days)
* ST elevation is >1mm in limb leads and >2mm in chest leads

12. Important ECG findings

13. 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

14. 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

15. 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

16. 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

17. Scoring systems GRACE scoring TIMI
Predicts 6/12 mortality in NSTEMI patients
Age
HR and systolic BP
Killip class (CCF, pulmonary oedema, shock)
Cardiac arrest on admission
Elevated cardiac markers
ST segment change
Risk of cardiac events in 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

18. 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
Reperfuse urgently if <12hr from onset to get blood back to myocardium that isnt yet irreversibly damaged
CI include: known bleeding disorder, ischaemic stroke in last 6/12, haemorrhagic stroke ever, active bleeding, suspected aortic dissection

19. 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

20. Complications Early <72hr Late Death Cardiogenic shock
Heart failure
Ventricular arrhythmia
Myocardial rupture
Thromboembolism
Ventricular wall rupture
Valvular regurgitation
Ventricular aneurysms
Cardiac tamponade
Dresslers syndrome
Thromboembolism
SPARED: sudden death, pericarditis, aneurysm/arrhythmia, ruptured ventricualr wall, embolism, dresslers

21. 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

22. Case study – Mr FB
A 54 year old gentleman presents to A&E with chest pain…

23. 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”

24. What are his risk factors?
Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol
? Hypertension
?Diabetes
Increasing age
Gender (male)
Family History

25. How would you Ix him?

26. Case study – Mr FB Initial management in acute setting? MONA
Reperfusion
BB and ACEi
Long-term management?
Aspirin, Clopidogrel, Statin, modification of lifestyle…..

27. 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

28. References BNF 64 Advance Life Support emodule handbook 6th Edition
OHCS 7th Edition
Great ECG example website: ECG/ecg_index.html