ACS

• Acute coronary syndrome includes STEMI, NSTEMI and unstable angia
• Suspected ACS with new onset LBBB on an ECG indicates a STEMI
• ST elevation in leads V1-V4 indicates an anterior STEMI
• ST elevation in leads II, III and aVF indicate an inferior STEMI
• ST elevation in leads I and aVL indicate a high lateral STEMI
• ST elevation in leads V5 and V6 indicates a low lateral STEMI
• Dominant R waves and ST depression in leads V1-V3 (mirror image) indicate a posterior STEMI
• Atypical presentation of ACS includes indigestion, pleuritic chest pain and dyspnoea
• ACS presents as acute central chest pain that can radiate to the arms and jaw. Pain lasting longer than 20 minutes and continues at rest. Can be accompanied by nausea, sweatiness, dyspnoea and palpitations.
• Clinical signs of ACS: distress, ashen grey pallor, low or high BP, low or high pulse and a 4th heart sound. May be signs of acute HF such as raised JVP, basal crepitations and a 3rd heart sound.
• Immediate management for suspected ACS:

  • IV access
  • 12 lead ECG
  • Morphine 5-10mg IV
  • Oxygen therapy if low sats or breathless
  • Nitrates not regularly used but can be useful for unstable angina
  • Aspirin 300mg PO
• Once suspected ACS patient arrives to hospital order: U&E, troponin, glucose, cholesterol, FBC and CXR (do not let delay treatment)
• If a STEMI is confirmed less than 12 hours since the onset of chest pain and primary PCI can be delivered within 120 minutes of when fibrinolysis could of been given- proceed with coronary angiography +/- PCI
• Patients with a confirmed STEMI who are undergoing primary PCI should receive anti thrombin therapy at the same time (unfractionated heparin). Should also receive dual antiplatelet therapy e.g. clopidogrel and aspirin
• Patients with a STEMI but ineligible for PCI will undergo fibrinolysis. They are given the drugs streptokinase and alteplase. Antithrombin therapy to be given at the same time. If 60-90 minutes after an ECG still shows ST elevation, fibrinolysis has failed. Patient should immediately undergo coronary angiography.
• Initial management of unstable angia or NSTEMI:

  • initial antiplatelet therapy- 300mg aspirin and continue indefinitely
  • initial antithrombin therapy- fondaparinux
• Unstable angia can be differentiated from a NSTEMI with serial troponins and ECGs. Troponin will be elevated with a NSTEMI 2-3 hours after onset of chest pain.
• Unstable angina and NSTEMI will cause regional ST depression and T wave inversions/flattening. Any dynamic Q or T changes are indicative.
• A patient with unstable angina/ NSTEMI should still be offered immediate coronary angiography if they are clinically unstable
• If a NSTEACS patient has a GRACE score >3% they should be offered a coronary angiography +/- PCI within 72 hours
• If a NSTEACS patient has a GRACE score of 3 or less, commence conservative management unless ischemia is subsequently experienced. For dual antiplatelet therapy.
• Secondary prevention of ACS:

  • ACE inhibitor e.g. ramipril
  • Dual antiplatelet therapy including aspirin 75mg
  • Beta blocker
  • Statin- atorvastatin 80mg
• All ACS patients should receive an echo prior to discharge to assess LV function
• An anterior MI is usually caused by a blocked left anterior descending artery
• An inferior MI is usually caused by an occluded right coronary artery
• A posterior MI is usually caused by an occlusion in the left circumflex artery