Acute Coronary syndrome explanation.pptx

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1. Acute Coronary Sydrome (ACS) Mr.Bashir Ullah Date: 22 June 2025

2. Do You Know? Every 40 seconds, someone in the world has a heart attack.

3. Objectives By the end of this presentation, the Students of 5 th Semester, Cardiology should be able to ; Define Acute Coronary Syndrome. Describe Causes of ACS. E xplain Risk factors for ACS Identify Sign, Symptoms and Investigation Explain Differential Diagnosis Discuss Management and treatment strategies for ACS.

4. C oronary circulation: Like every other organ/Tissue of the body, the heart muscle, also needs oxygen-rich blood to survive. Two main coronary arteries; LCA and RCA. These coronary arteries branch off into smaller arteries, which supply oxygen-rich blood to the entire heart muscle. What is the function of coronary arteries?

5. Acute Coronary Sydrome (ACS) Broad term for three t ypes of Coronary artery diseases: These syndromes; involves Acute coronary ischemia, and are distinguish based on symptoms, ECG finding and Cardiac Bio- markers levels. ACS Result from acute obstruction of artery.

6. Aetiologies of ACS Most Common cause Acute thrombus formation Rare causes Coronary artery embolism Coronary spasm  spasm induced MI Spontaneous coronary artery dissection

7. Risk factors for ACS Non-modifiable: Age Male gender F amily history of IHD. Modifiable: Smoking, Hypertension DM, Hyperlipidaemia Obesity, sedentary lifestyle cocaine use.

8. Symptoms & Signs of ACS Symptoms Acute central chest pain, lasting >20min, often associated with nausea, sweatiness , dyspnoea, palpitations. Silent Infarct, (Elderly or diabetics). Presentations may include: syncope, pulmonary oedema, epigastric pain and vomiting, acute confusional state, stroke, and diabetic hyperglycaemic states. Signs Distress, Anxiety Pallor, Increase or decrease pulse Decrease or Increase BP, 4th heart sound. May be signs of heart failure

9. Investigations for ACS ECG Cardiac Bio-marker CXR Echocardiography C oronary Angiography

10. Investigations for ACS ECG Classically, hyper acute (tall) T waves, ST elevation or new LBBB occur within hours of trans-mural infarction. T wave inversion and development of pathological Q waves follow over hours to days . In other ACS: ST depression, T wave inversion, non-specific changes, or normal . In 20% of MI, the ECG may be normal initially. Evolution of STEMI

11. Investigations for ACS II. Cardiac Enzymes Most sensitive & Specific: Cardiac troponin levels (T and I ). Serum levels increase within 3–12h from the onset of chest pain , peak at 24–48h , and decrease to baseline over 5–14 days. CK-MB levels Increase within 3–12h of onset of chest pain, reach peak values within 24h , and return to baseline after 48–72h .

12. Coronary Angiography

13. Echocardiography U seful for assessing of Regional Wall Motion Abnormality (RWMA ), left and right ventricular function. D etecting important complications such as mural thrombus, cardiac rupture, ventricular septal defect, mitral regurgitation and pericardial effusion.

14. Differential Diagnosis

15. Management of acute coronary syndrome (ACS) Pre-hospital Arrange emergency ambulance. Aspirin 300mg chewed (if no absolute CI) and GTN sublingual. Analgesia , eg morphine 5–10mg IV + metoclopramide 10mg IV (not IM because of risk of bleeding with thrombolysis).

16. In hospital O2 , IV morphine, aspirin. Then the key question for subsequent management of ACS is whether there is ST segment elevation (includes new onset LBBB or a true posterior MI).

17. In hospital Management ST -segment elevation First choice; PPCI or Coronary artery bypass graft (CABG) Second choice; Thrombolysis/ f ibrinolytic therapy, if no contraindication ACS without ST-segment elevation B -blocker , eg atenolol 5mg IV and nitrates IV (if not contraindicated). Antithrombotic fondaparinux if low bleeding risk and no angiography planned for 24h, otherwise consider low molecular weight heparin (eg enoxaparin 1mg/kg/12h SC for 2–8 days) Assess risk, eg GRACE ( Global Registry of Acute Coronary Events) Score. GPIIb / IIIa antagonist (eg tirofiban ),or bivalirudin, and angiography within 96h . (Revascularization= Angio + Stenting)

18. Clinical Case 60-year-old male with crushing chest pain, sweating, and left arm numbness. ECG shows ST-elevation in leads II, III, aVF. Troponin elevated What type of Acute Coronary Syndrome is this ? What are the initial emergency management steps?

19. Hints STEMI; Acute Inferior Wall MI MONA

20. Activity Determine diagnosis type (UA/NSTEMI/STEMI ) Plan management, and Suggest investigations

21. Quiz Q1:Which marker is most specific for myocardial injury? LDH CK CK-MB Troponin Q2: Which of the following ECG changes is most commonly associated with a STEMI? T-wave flattening ST-segment depression ST-segment elevation U wave prominence Q3: Initial management of a patient with suspected ACS includes all of the following EXCEPT: Oxygen if hypoxic Nitro-glycerine Morphine Aspirin Corticosteroids

22. Answer Q1: D Q2: C Q3: E

23. Summary ACS is an emergency required timely diagnosis and prompt action. Early diagnosis = better outcomes. Types; UA/NSTEMI/STEMI. ECG findings and Management. Time is basically myocardium so treat ACS fast.

24. Any Question

25. References Oxford handbook of cardiology. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine 2020 ESC Guidelines for the Management of ACS Up To Date articles on Acute Coronary Syndrome

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