Acute Coronary Syndrome

Acute Coronary Syndrome Epidemiology 157 events per day in adults aged 25 and over High rate of hospital admission 2.3 times higher in men 2 times higher rate in first nation people Common ED presentation 50-70% recurrence risk of a 30-day event Risk Factors Older age – over 75 Diabetes Hypertension Hypercholesterolemia Obesity Smoking Family history Types of ACS Type Description Angina: retrosternal pain that lasts for less than 10 minutes Stable Angina Due to a fixed coronary obstruction by a stable atherosclerotic plaque Myocardial ischemia at rest of on minimal exertion Unstable Angina Absence of acute cardiomyopathy injury or necrosis ST elevation Medical emergency NSTEMI Elevated cardiac markers Non-ST Elevation Acute Coronary Syndrome (NSTEACS) Most common type of ACS Unstable angina No elevated cardiac markers Types of Myocardial Infarction Type Description Atherothrombotic coronary occlusion Most commonly due to plaque disruption Other causes: erosion and dissection Compromise of blood flow Criteria: Rise and or fall cardiac troponin values with at least one assay above the 99 th Type I (spontaneous) percentile of the upper normal limit AND at least one of: Symptoms of acute myocardial ischemia New ischemic ECG changes Development of pathological Q waves Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of coronary thrombosis by angiography or autopsy Imbalance between oxygen supply and demand Secondary to: Anaemia Arrythmia Type II (ischemia related) Spasms Hypotension Hyperthyroidism May cause STEMI and acute coronary occlusion In this case should be managed as type I MI suggested by symptoms of ECG changes Type III (sudden death) Death happens before biomarker conformation Autopsy shows evidence of thrombosis IV a: PCI related Type IV (procedure related) IV b: stent thrombosis IV c: restenosis after PCI Type V CABG (not sure if this is considered MI associated with a CABG a type for sure) Myocardial Injury Cardiac troponin levels elevated to above the upper normal limits DO NOT rise and/or fall Not associated with ischemia or infarction May happen without MI Clinical Features Chest pain Most common Substernal discomfort or pressure May radiate to neck, arms or jaw Made worse by excretion Relieved 15 to 20 minutes after rest Older patients and patients with diabetes may not feel pain Shortness of breath Fatigue Nausea Diaphoresis Vomiting Assessment and Diagnosis History Examination Vitals Associated symptoms and ACS risk factors ECG 12 leads Within 10 minutes of presentation If continue to experience ischemia symptoms, hemodynamic comrpomsie or new ECG findings -> continuous ECG monitoring Troponin testing All patients Repeat every 3 to 6 hours? Routine studies CBC, BMP and coagulation studies Management Management of reversible risk factors Hypertension management Smoking cessation Dyslipidaemia management Exercise and health eating Exercise and nutrition Body weight management Diabetes STEMI Management Priority: Re-establishing blood flow in occluded artery -> reperfusion If occlusion is not resolved within 6 to 12 hours and BF not restored -> myocardial infarction Dual anti-platelet therapy for patients undergoing PCI Aspirin at 300 mg orally or chewed or dissolved before swallowing Prasugrel or ticagrelor Preferred if patient is undergoing PCI If not available or contraindicated -> clopidogrel Dual antiplatelet therapy for patients undergoing thrombolytic therapy Aspirin + clopidogrel (only suitable P2Y12 inhibitor suitable if undergoing thrombolytic therapy) Emergency reperfusion therapy PCI or fibrinolytic therapy if presenting within 12 hours of symptom onset If more than 12 hours -> do PCI if still have evidence of continuing myocardial ischemia: persistent ischemic symptoms hemodynamic compromise or life threatening arrythmias major complications such as a cardiogenic shock, heart failure or malignant arrhythmias PCI is the preferred method Should be done within 120 minutes of first medical contact Should receive unfractionated heparin or enoxaparin Fibrinolytics Within 120 minutes of first medical contact Used when PCI cannot be done within 120 minutes Should be given within 20 minutes of first medical contact Alteplase IV followed by IV infusion or Tenecteplase IV followed by an IV infusion Alongside give parenteral anticoagulation with enoxaparin or unfractionated heparin