CARDIO

• Acute Coronary Syndrome (ACS)


  A range of conditions related to sudden, reduced blood flow to the heart. Acute coronary syndrome often causes severe chest pain or discomfort. It is a medical emergency that needs a diagnosis and care right away. The goals of treatment include improving blood flow, treating complications and preventing future problems.
• Types of ACS


  • Stable Angina
  • Unstable Angina
  • NSTEMI
  • STEMI
• 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 troponins elevation
• STEMI


  Sustained chest pain suggestive of AMI, Acute ST elevation or new LBBB
• Clinical features of ACS


  • Dyspnea
  • Heart murmurs
  • Palpitations
  • Chest pain
  • Nausea
  • Acute confusion
  • Pallor
  • Hypotension or hypertension
  • Sweaty
  • Vomiting
  • Syncope
  • Indigestion
  • Tachycardia or bradycardia
  • Fever
  • Asymptomatic/silent
• Distinguishing features of ACS types


  • UA: platelet adhesion
  • NSTEMI: platelet aggregation
  • STEMI: complete occlusion
  • SA: plaque formation, precipitated by stress or exertion, lasts <30 minutes, relieved by Nitroglycerin or rest
• Risk Factors for ACS


  • Modifiable: Smoking, Obesity, Diet, Lack of exercise, High serum cholesterol, Hypertension, Diabetes Mellitus
  • Non-Modifiable: Increasing age (>45 for male, >55 for female), Gender (male), Ethnicity, Family History (>55 for male, >65 for female), Chronic Kidney Disease
• Important ECG findings in ACS


  • ST Elevation or new LBBB (STEMI)
  • Non-specific ECG (Unstable Angina)
  • ST Depression or Dynamic T wave Inversions (NSTEMI)
  • Normal or non-diagnostic EKG
• ECG findings in ACS


  • ST elevation and tall T waves in V1-V4 (anterior injury pattern with hyperacute T waves) - Acute anterior infarction
  • Acute inferior myocardial infarction
  • Acute inferior-posterior myocardial infarction
  • Acute lateral wall Myocardial infarction
• Timing of Release of Various Biomarkers After Acute Myocardial Infarction
• Management of ACS


  • UA or NSTEMI: Evaluate for Invasive vs. conservative treatment, Directed medical therapy
  • STEMI: Assess for reperfusion, Select & implement reperfusion therapy, Directed medical therapy
• Cardiac Care Goals


  • Decrease amount of myocardial necrosis
  • Preserve LV function
  • Prevent major adverse cardiac events
  • Treat life threatening complications
• Risk categories for UA/NSTEMI


  • Low risk
  • Intermediate risk
  • High risk
• Management of UA/NSTEMI


  1. Evaluate for conservative vs. invasive therapy based upon risk

  2. Conservative therapy for low risk

  3. Invasive therapy option for intermediate risk

  4. Invasive therapy for high-risk ACS
• Medical Therapy for UA/NSTEMI


  • MONA (Morphine, Oxygen, Nitroglycerin, Aspirin)
  • Heparin (UFH or LMWH)
  • Clopidogrel/Ticagrelol
  • Beta-Blockers
  • ACE-Inhibitors/ARB
  • Glycoprotein IIb/IIIa inhibitors
  • Aldosterone blockers
• Secondary Prevention


  • Disease management (HTN, DM, HLP)
  • Behavioral interventions (smoking, diet, physical activity, weight)
  • Cognitive interventions (Education, cardiac rehab program)