ACUTE 2 CORONARY SYNDROMES-Dr.Katdemiah.pptx

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1. ACUTE CORONARY SYNDROMES Dr.Nehemiah Katukesige PLE, UCE, UACE, MBChB( Mak-Chs ) , JH0 (KNRH)

2. ACUTE CORONARY SYNDROME I ncludes unstable angina and myocardial infarctions ( MI s). These share a common underlying pathology—plaque rupture, thrombosis, and infl ammation . MYOCARDIAL INFARCTION M eans there is myocardial celldeath , releasing troponin. An MI can be a STEMI or NSTEMI despite having increased Troponin levels. NSTEMI — ECG may show; ST depression T -wave inversion N on-specific changes, or be normal . S ignificant necrosis can occur even without ST elevation. Ischaemia means a lack of blood supply, +/- cell death Risk factors Non-modifiable : Age, Gender, Family history of IHD ( MI in 1 st-degree relative < 55 yrs). Modifiable : Smoking, Hypertension, DM , H yperlipid aemia , Obesity, Sedentary lifestyle, cocaine use. Controversial risk factors include : Stress, type A personality, LVH , fi brinogen , H yperinsulinaemia .

3. Incidence: 5 / 1000 per annum ( UK ) for ST -segment elevation (declining in UK & USA ) Symptoms Acute central chest pain, lasting > 20 min, with nausea, S weatiness, dyspnoea , palpitations. -Can be ‘silent’ without chest pain; Silent MI s may present with: syncope, pulmonaryoedema , epigastric pain and vomiting, oliguria, acute confusional state, stroke, and diabetic hyperglycaemic states. Signs Distress, anxiety, pallor, sweatiness, pulse or BP raise or decrease , 4 th heart sound. S igns of heart failure or pansystolic murmur, Low-grade fever pericardial friction rub or peripheral oedema -USE THE NYHA for functional limitation

4. FUNCTIONAL CLASSIFICATION

5. Investigations ECG; STEMI : classically, hyperacute (tall) T waves, ST elevation, N ew LBBB occur within hours. T -wave inversion and pathological Q waves follow over hours to days. NSTEMI /unstable angina : ST depression, T wave inversion, non-specific changes, or normal. In 20 % of MI , the ECG may be normal initially. Paced ECG s and ECG s with chronic bundle branch block are unhelpful for diagnosing CHEST X-RAY ,CB C, RBS, lipidS , cardiac enzymes, Coronary angiogram.

6. Cardiac enzymes: Cardiac troponin levels ( T and I ) are the most sensitive and specific markers of myocardial necrosis

7. DIFFERENTIAL DIAGNOSIS Stable angina myocarditis A ortic dissection pneumothorax musculoskeletal pain, Takotsubo cardiomyopathy Pericarditis pancreatitis. Takotsubo cardiomyopathy PE O esophageal reflux/spasm

8. ST elevation in V2-6, indicating anterolateralmyocardial infarction

9. Initial treatment Take brief history, do a quick physical examination and a 12 -lead ECG . Other tests on admission: U&E , troponin, glucose, cholesterol, C BC , CXR . • Aspirin: 300 mg PO consider ticagrelor ( 180 mg PO ) or prasugrel ( 60 mg PO if no history of stroke/ TIA and < 75 y) • Morphine: 5 – 10 mg IV (repeat after 5 min if necessary). Give anti-emetic with the 1 st dose of morphine: metoclopramide 10 mg IV ( 1 st line), or cyclizine 50 mg IV ( 2 nd line). • GTN : routine use now not recommended in the acute setting unless patient is hypertensive or in acute LVF. Useful as anti-anginal in chronic/stable patients. • Oxygen is recommended if patients have SPO 2 < 95 %, are breathless or in acute LVF . • Restore coronary perfusion in those presenting < 12 h after symptom onset. • Anticoagulation: An injectable anticoagulant must be used in primary PCI . Bivalirudin is preferred, if not available use enoxaparin ― Management

10. • B -blockers provide additional benefit when started early, E g bisoprolol 2 . 5 mg PO OD . Ensure no evidence of cardiogenic shock, heart failure, asthma/ COPD, or heart block Reperfusion therapy; Primary Percutaneous Intervention, Thrombolysis MNEMONIC ; MONA (Morphine, Oxygen, Nitrates, Aspirin –anticoagulants) Approach to management Modify Risk factors Optimize cardioprotective medication (Antiplatelets, consider PPI, anti coagulant, B-blockade, High Dose statin) Do echo to asses LV failure consider Eplerenone) Revascularization Manage Complications Complications

11. Complications Cardiac arrest Bradyarrhythmias ( Sinus bradycardia, 1st-degree AV block, Wenckebach phenomenon : (Mobitz type I AND I I ) bundle branch block etc … Tachyarrhythmias Right ventricular failure Pulmonary embolism Pericarditis

12. References Davidson’s principles and practice of medicine 20 th edition by Nichlas A Boon, Nicki R. Colledge etaal . Oxford handbook of Clinical medicine pg.118-122 and 196 Harrison’s Principles of Internal Medicine, 19thEdition, 2015 Medscape, coronary artery syndromes/MI Approach to Diagnosis of Cardiac Disease, 2024 by Dr.Owachi Darius