1. Acute Coronary Syndrome
Nicholas Shaw

2. ACS
STEMI
New onset LBBB
NSTEMI
Unstable angina

3. Risk Factors for ACS Age Smoking Male Obesity Ethnicity Dyslipidaemia
Family history
CKD
Smoking
Obesity
Dyslipidaemia
Hypertension

4. Stable Angina Cardiac chest pain precipitated by exercise
Caused by atheroma, but also: anaemia, AS, tachyarrhythmias, HOCM
Eases with rest / GTN
4 classes:
I: angina on strenuous exercise
II: Slight limitation of ordinary activities
III: difficulty climbing stairs
IV: unable to carry out any physical activity
Risk of progression to ACS (1% non-fatal MI/year)

5. Angina investigations
ECG
Ecercise ECG
FBC – anaemia
Glucose – diabetes
Lipids – dyslipidaemia
TFTs - thyrotoxicosis

6. Angina Management Lifestyle modification Modifying risk factors
Medication
Aspirin
Beta blockers
Calcium channel blockers
Statins
Nitrates
Surgical – PTCA, CABG

7. Unstable Angina
Presence of angina without precipitating cause / at rest
Spectrum with stable angina and NSTEMI

8. Presentation of ACS Typical chest pain Silent MI Atypical chest pain
Male
Left sided chest pain
Radiating to left arm
Radiating to neck
Silent MI
Cool
Clammy
Nausea
Dyspnoea
Pulmonary oedema
Confusion
Palpitations
Collapse
Death
Atypical chest pain
Right sided chest pain
Abdominal pain
Female
Diabetic
Elderly

9. Differential Diagnosis
Musculoskeletal chest pain
Pulmonary embolus
Aortic dissection
Gastric reflux

10. Diagnostic criteria of acute MI
ECG changes
Chest pain
Rise in cardiac enzymes

11. Investigations ECG Bloods CXR FBC U&E Trop T Cardiomegaly
Pulmonary oedema
Widened mediastinum

12. NSTEMI Subocclusive thrombus ECG changes: ST depression
T wave inversion

13. NSTEMI

14. ECG Leads
High lateral
Septal
Inferior
Lateral
Anterior

15. Arteries Affected Location of MI Artery Lateral Left circumflex
Anterior LAD
Septum LAD
Inferior RCA
Posterior RCA
Right Ventricle RCA

18. Anterior MI ST elevation is maximal in the anteroseptal leads (V1-4).
Q waves are present in the septal leads (V1-2).
There is also some subtle STE in I, aVL and V5, with reciprocal ST depression in lead III.
There are hyperacute (peaked ) T waves in V2-4.
These features indicate a hyperacute anteroseptal STEMI

19. Tombstoning

20. Posterior MI

22. Inferior MI

23. STEMI - ST elevation > 1mm in two or more limb leads and/or
- ST elevation > 2mm in two or more consecutive precordial leads and/or
- Left Bundle Branch Block (LBBB) which is known or suspected to be of new onset and in the presence of cardiac symptoms

24. Treatment of STEMI Morphine Antiemetics (metoclopramide)
Antiplatelets – aspirin (300mg) and ticagrelor (180mg)
IV access
Bloods
Primary Coronary Intervention
Thrombolysis (tPA / streptokinase)

25. Further inpatient management
Education
Echocardiogram (LV function)
Clopidogrel (or ticagrelor)
Beta blockers
ACE-I
Statins
Risk factor modification

26. Late Complications Dresslers syndrome Papillary muscle rupture
Fibrosis
Aneurysm
Heart failure
Death