Acute Coronary Syndrome
History
1) Introduction
2) PC
3) HPC
I.
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II.
Describe chest pain
At what time & what he was doing when chest pain occured
Site
Onset
Character – throbbing, aching or tightening type pain
Radiation of the pain
Associated features of the pain – Sweating, SOB, Syncope, Palpitations, Vomiting, Faintishness
Timing of the pain – At this point make a graphical representation of the pain and mark the time
taken for the pain to reach a peak, the duration of the pain, resolution and the pain free period
Exacerbating and relieving factors of the pain - Resting/lying down, GTN
Severity – Ask the patient to grade the pain and assess the severity
Exclude DDs
MI
Tension pneumothorax
Aortic dissection
Pulmonary embolism
Acute Pericarditis
Acute onset central chest pain, Tightening in
nature
Radiating along the left arm and to the jaw
Lasts for more than 30 minutes
Associated with autonomic symptoms such as
sweating
Not relived by rest or GTN
Acute SOB
Pleuritic chest pain
May radiate to back or shoulder
Sudden severe tearing type central chest pain
Radiates to arm & interscapular area
Transient weakness of the part of the body
Hx of Marfan syndrome
Sudden onset
Pleuritic type chest pain
Tachypnea, hemoptysis
Previous hx of DVT, long term immobilization
Diffuse stabbing pain
Radiates to neck, left arm or shoulder
Aggravated by deep breathing & movements
Relieved by leaning forward
Pneumonia
GORD
Muscular skeletal
Psychological
III.
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Complications
Acute LVF – orthopnea, PND
Arrhythmias – palpitations
IV.
V.
Risk factors
Management upto now
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Systemic inquiry
PMHx
Previous similar episodes
Comorbidities – DM, HTN, Anemia
PSHx
Allergic Hx
Drug Hx
FHx
DM, HTN, IHD
10) SHx
 Occupation
 Exercise
 Lifestyle – alcohol and smoking
 Psychological aspect
 ICE
Pleuritic chest pain
Productive cough
Fever Wheezing Hemoptysis
Retrosternal burning pain
At night or bending forward
Belching, burping, heart burn, regurgitation of
food
Cough due to laryngeal irritation
Risk factors- dairy products, fatty meals,
chocolate, coffee, smoking, alcohol, NSAIDs
History of trauma, exercise, fever
Aggravated by deep breathing, movement &
touching
Exact site of pain & tenderness
Anxiety
Depression
Family problems
Social problems
Examination
General
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Ill looking
Obese
Febrile [Pneumonia, pericarditis, pulmonary embolism]
Pale - In MI, anaemia
Cyanosis - LVF
Xantholesma, xanthoma, corneal arcus [hypercholesterolemia]
Nicotine stains
B/L pitting ankle oedema
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Inspection: Dyspnoea (Pulmonary oedema due to LHF)
Pulse: Unequal radial pulses in aortic dissection, Check peripheral pulses (PVD & aortic
dissection), Irregularly irregular pulse in AF
BP: Low in aortic dissection
Precordium: Look for apex location and character(heaving)
Auscultation: MR (Papillary muscle rupture), VSD (Complication of MI), Gallop rhythm (Acute
LVF)
CVS
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Respi
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Bi basal crepitations – heart failure
Abdomen
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Epigastric tenderness or masses
Investigations
1) ECG
2) Biomarkers
V1-V2
V3-V4
V5-V6
I, aVL
II, III, aVF
V7-V9
V4R
Right Ventricle
Interventricular septum
Anterolateral
Lateral
Inferior
Posterior
Right Ventricle
Management
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Immediately attend to the patient
Acute side or HDU bed
ABCD approach
Airway – Patency
Breathing - Saturation, Respiratory rate, if saturation <92%, give oxygen via nasal cannula
Circulation – Connect to multi-monitor
Insert two wide bore cannulae, take blood for investigations,
Full blood count, Trop I, Blood urea and electrolytes, PT/INR, APTT
Disability- Assess GCS, Check pupillary reaction, Capillary blood sugar
12 lead ECG within 10 minutes
UA/ NSTEMI
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DAPT
- Aspirin 300mg chewed
- Clopidogrel 300mg
High intensity statins
- Atorvastatin 40-80mg
- Rosuvastatin 20-40mg
Anticoagulation
Beta Blockers
ACEI – Ramipril/ Perindopril
O2 if saturation < 92%
Pain relief – GTN, IV
Morphine 5mg + IV
Metoclopramide 10mg
STEMI
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Reperfusion – PPCI,
Thrombolysis
Medical management
 Reperfusion therapy is indicated in all patients with symptoms of ischemia of <12hr duration
with persistent STEMI
 Primary Percutaneous Coronary Intervention (PCI) is preferred over fibrinolysis
 Thrombolysis
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Start as soon as (within 10 minutes) STEMI diagnosis
Antiplatelet and anticoagulation co-therapy is indicated with fibrinolysis
For patients who undergo fibrinolysis, rescue PCI is indicated if fibrinolysis fails (ST segment
resolution < 50% within 60-90 min of administration) or in the presence of hemodynamic or
electrical instability, worsening ischemia or persistent chest pain
Patients with successful fibrinolysis should undergo early invasive angiography within 2-24hr
from time of lytic bolus injection
For patients presenting after 12hr of symptom onset, PPCI is preferred over fibrinolysis in all
cases
 Fibrinolytic agents
 Exclude
contraindications
 Before starting tenecteplase, give enoxaparin
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Signs of successful thrombolysis
Reduced chest pain
ST segment resolution > 50% within 60-90 min of administration
Drop of troponin I
Restoration of hemodynamic stability
 Classical angina
 ‘Heavy’, ‘Tight’ or ‘Gripping’ central or retrosternal pain radiating to the jaw or arms
 Pain that occurs with exercise or emotional stress
 Pain eases rapidly with rest or with GTN
 Types of MI
type 1
type 2
type 3
type 4a
type 4b
type 5
Spontaneous MI with ischemia due to a primary coronary event, e.g. plaque
erosion/rupture, fissuring or dissection
MI secondary to ischemia due to increased oxygen demand or decreased supply, such
as in coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension or
hypotension
Diagnosis of MI in sudden cardiac death
MI related to PCI
MI related to stent thrombosis
MI related to CABG
 STEMI diagnosis
 Complications of MI
1. Low BP
 Reinfarction
 Inferior MI
o RV infarction : low BP, elevated JVP, clear lungs ; fluid bolus (1-2l), avoid nitrates,
diuretics, other vasodilators, ACEI/ARB
o Arrythmias - brady/tachy
 Acute valvular incompetencies - Chordae tendinae rupture/ papillary dysfunction
 Bleeding - TNK, enoxaparin, DAPT
 Medications - GTN/Diuretics (RV infarction), beta blockers
2. Acute LVF
 Prop up, 100% O2 (tight fitting non-breathable mask), DOC - IV frusemide, IV morphine+
metoclopramide, look for a cause, CPAP
3. Myocardial rupture & aneurysmal dilation
 Myocardial rupture of L/Ventricle is an early, fatal event, where as the aneurysmal dilation of
infarcted myocardium is a late complication.
4. Ventricular septal defect
 May be associated with delayed or failed thrombolysis
5. Mitral regurgitation
 An early complication of MI
 May be due to severe LV dysfunction & dilation, dysfunction of papillary muscles or sudden
severe pulmonary edema & cardiogenic shock
6. Cardiac arrhythmias
 VT, VF, AF
 Sinus bradycardia, Heart blocks - Atropine, isoprenaline, dopamine/epinephrine, cardiac pacing
7. Dressler’s syndrome
 Next ward round
History
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Ongoing chest pain
Palpitations
Orthopnea/ PND
Bleeding manifestations
Examination
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PR – Rate, rhythm, volume, character
BP
Murmurs
Bi-basal crepitations
Investigations
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ECG
2D Echocardiogram
 Discharge Plan
At the discharge,
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Aspirin
ADP-Receptor blocker
High intensity Statin
Beta blocker
ACE inhibitor
Follow up
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Routinely at the clinic with investigation reports (FBS, Lipid profile, FBC)