Acute
Coronary
Syndrome
Carrie Hurst FY1
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
What is Acute Coronary Syndrome?
Stable Angina
Unstable Angina
NSTEMI
STEMI
Definitions
 Unstable angina:
 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
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
Clinical features
 Tachycardia or
bradycardia
 Chest pain
 Nausea
 Heart murmurs
 Dyspnoea
 Palpitations
 Hypotension or
 Sweaty
 Vomiting
hypertension
 Syncope
 Pallor
 Asymptomatic/silent
 Indigestion
 Acute confusion
 Fever
Distinguishing features
 SA:
 UA:
plaque
formation
 Precipitated by
stress or exertion
 Lasts <20 minutes
 Relieved by GTN or
resting
platelet
adhesion
 NSTEMI:
 STEMI:
platelet
complete
aggregation occlusion
 At rest or minimal exertion
 Lasts >20 minutes
 Often accompanied by other s/s
 Poor GTN relief
Risk Factors
Modifiable
Non-Modifiable
 Smoking
 Increasing age
 Obesity
 Gender (male)
 Diet
 Ethnicity
 Lack of exercise
 Family History
 High serum cholesterol
 ?Diabetes
 Hypertension
 ? Diabetes
Differential Diagnosis
Cardiac
• MI
• Angina
• Pericarditis
• Aortic dissection
Respiratory
• Pulmonary embolism
• Pneumothorax
• Pneumonia
Chest pain
GI
Musculoskeletal
• Oesophageal spasm
• GORD
• Pancreatitis
• Costochondriasis
• Trauma
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
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
Important ECG findings
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
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
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
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
Scoring systems
GRACE scoring
TIMI
 Predicts 6/12 mortality in
 Risk of cardiac events in
NSTEMI patients
next 30 days
 Age
 Age >65
 HR and systolic BP
 Known coronary artery
 Killip class (CCF,
pulmonary oedema,
shock)
 Cardiac arrest on
admission
 Elevated cardiac
markers
 ST segment change





disease
Aspirin in last 7/7
Severe angina (>2 in
24hr)
ST deviation >1mm
Elevated troponins
> CAD risk factors
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
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
Complications
Early <72hr
Late
 Death
 Ventricular wall rupture
 Cardiogenic shock
 Valvular regurgitation
 Heart failure
 Ventricular aneurysms
 Ventricular arrhythmia
 Cardiac tamponade
 Myocardial rupture
 Dresslers syndrome
 Thromboembolism
 Thromboembolism
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
Case study – Mr FB
A 54 year old gentleman presents to A&E with chest pain…
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”
What are his risk factors?
 Smoking
 Increasing age
 Obesity
 Gender (male)
 Diet
 Family History
 Lack of exercise
 High serum cholesterol
 ? Hypertension
 ?Diabetes
How would you Ix him?
Case study – Mr FB
 Initial management in acute setting?
 MONA
 Reperfusion
 BB and ACEi
 Long-term management?
 Aspirin, Clopidogrel, Statin, modification of
lifestyle…..
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
References
 BNF 64
 Advance Life Support emodule handbook 6th
Edition
 OHCS 7th Edition
 Great ECG example website:
www.meds.queensu.ca/central/assets/modules/
ECG/ecg_index.html