management of ACS

1. Acute Coronary
Syndrome
Dr. Mohammad Ali
MBBS, MD (Cardiology)
FCPS part I, MRCP part II
Associate Consultant
Cardiology Department
Bangladesh Specialized Hospital

3. Objectives
At the conclusion of this activity, participants will be able to:
 Definition of ACS
 Causes
 Risk Factors
 Symptoms
 Diagnosis of Differentiate types of ACS
 ECG criteria and others
 Discuss appropriate initial treatment algorithm for different subtypes of ACS

4. Definition of Acute Coronary Syndrome
 Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations
ranging from those for ST-segment elevation myocardial infarction (STEMI) to
presentations found in non–ST-segment elevation myocardial infarction (NSTEMI)
or in unstable angina. In terms of pathology, ACS is almost always associated with
rupture of an atherosclerotic plaque and partial or complete thrombosis of the
infarct-related artery.
http://emedicine.medscape.com/article/1910735-overview

5. Cause
 Atherosclerotic
 Non-atherosclerotic
1. Congenital anomalies
2. Embolus
3. Dissection
4. Spasm
5. Trauma
6. Arteritis
7. Metabolic disorders
8. Intimal proliferation
9. External compression
10. Thrombosis without underlying atherosclerotic plaque
11. Substance abuse
12. Myocardial oxygen demand-supply disproportion
13. Intramural coronary artery disease (small-vessel disease)

6. Risk factors

7. ACS PATHOPHYSIOLOGY
 Disruptions of coronary artery plaque ->
platelet activation/aggregation /activation
of coagulation cascade -> endothelial
vasoconstriction ->intraluminal
thrombus/embolisation -> obstruction ->
ACS
 Severity of coronary vessel obstruction &
extent of myocardium involved determines
characteristics of clinical presentation

8. Definition of MI
Criteria for myocardial injury
The term myocardial injury should be used when there is evidence of elevated cardiac troponin values (cTn) with at least one value above
The 99th percentile upper reference limit (URL). The myocardial injury is considered acute if there is a rise and/or fall of cTn values
Criteria for acute myocardial infarction (types 1, 2 and 3 MI)
The term acute myocardial infarction should be used when there is acute myocardial injury with clinical evidence of acute myocardial
ischaemia and with detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL and at least one of
the following:
• Symptoms of myocardial ischaemia;
• New ischaemic ECG changes;
• Development of pathological Q waves;
• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an
ischaemic aetiology;
• Identification of a coronary thrombus by angiography or autopsy (not for types 2 or 3 MIs).
Post-mortem demonstration of acute athero-thrombosis in the artery supplying the infarcted myocardium meets criteria for type 1 MI.
Evidence of an imbalance between myocardial oxygen supply and demand unrelated to acute athero-thrombosis meets criteria for type 2 MI.
Cardiac death in patients with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes before cTn
values become available or abnormal meets criteria for type 3 MI.

9. Classification of MI
 Type 1 – spontaneous MI related to ischemia due to a primary
coronary event such as plaque erosion and/or rupture,
fissuring, or dissection
 Type 2 – MI secondary to ischemia due to either increased oxygen
demand or decreased supply, e.g. coronary artery spasm,
coronary embolism, anemia, arrhythmias, hypertension, or
hypotension
 Type 3 – sudden unexpected cardiac death, including cardiac arrest
but death occurring before blood samples could be
obtained
 Type 4 – associated with PCI:
 Type 4a – MI associated with the procedure of PCI
 Type 4b – MI associated with stent thrombosis
 Type 5 – MI associated with CABG

10. Types Of Acute Coronary Syndrome

11. How to diagnose
Echocardiography

12. Differential diagnosis

13. Chest pain

15. work up of ACS

16. Investigations

17. Electrocardiogram
 The resting 12-lead ECG is the first-line diagnostic tool in the assessment of
patients with suspected ACS.
 STE-ACS… ST-elevation
 NSTE-ACS…ST-segment shifts and T-wave changes
 A completely normal ECG does not exclude the possibility of ACS.

18. STEMI
 ST-elevation ACS
(STE-ACS):
 typical acute chest pain and persistent (>20
min)
 ST-segment elevation
 generally reflects an acute total coronary
occlusion
 most will ultimately develop an ST-elevation
MI (STEMI).

19. STEMI ECG Criteria
 ≥ 2 mm of ST segment elevation in 2 contiguous
precordial leads in men (1.5 mm for women)
 ≥ 1mm in other leads (2 contiguous)
 An initial Q wave or abnormal R wave develops over a
period of several hours to days.
 Within the first 1-2 weeks (or less), the ST segment
gradually returns to the isoelectric baseline, the R
wave amplitude becomes markedly reduced, and the
Q wave deepens.

20. STEMI ECG Criteria
 In addition to patients with ST elevation on the ECG, two other groups of
patients with an acute coronary syndrome are considered to have an STEMI:
 those with new or presumably new left bundle branch block
 those with a true posterior MI
 An elevation in the concentration of troponin or CK-MB is required for the
diagnosis of acute MI

21. ST elevation on the ECG

22. Location of MI

23. STEMI ECG Criteria
 Anterior STEMI: ST elevation in the precordial leads + I and aVL (LAD
territory)
 Inferior STEMI: ST elevation in II. III and aVF (+ ST elevation in R-sided
precordial leads), reciprocal changes in I and aVL (R coronary or L Cx)
 Posterior STEMI: reciprocal ST depressions in V1-V3 (ST elevation in post
leads), may have component of inferior ischemia as well (ST elevations in II, III
and aVF)
 Often occurs w/ inferior MI (L Cx)

24. Location of MI
ST elevation only:
 Anteroseptal - V1-V3
 Anterolateral - V1-V6
 Inferior wall - II, III, aVF
 Lateral wall - I, aVL, V4-V6
 Right ventricular - RV4, RV5
 Posterior- R/S ratio >1 in V1 and T wave
inversion

25. Location of MI

26. Location of MI

27. Location of MI

28. Location of MI

29. NSTEMI
 non-STE-ACS
(NSTE-ACS):
 acute chest pain
 without persistent
ST-segment elevation
 persistent or transient ST segment
depression or
T-wave inversion
 further qualified into non-ST elevation MI
(NSTEMI) or unstable angina.

30. ST depresion on the ECG

31. Prognosis of STE vs. NSTE-ACS
Hospital mortality
- higher in patients with STEMI than among those with NSTE-ACS
(7% vs. 5%)
6 months mortality
- the mortality rates are very similar in both conditions (12 vs. 13%)
Long-term follow-up
- death rates higher among those with NSTE-ACS than with STE-ACS

32. Biochemical markers
Markers of myocardial injury:
 cardiac troponins (I and T)
 creatinine kinase (CK)
 CK isoenzyme MB (CK-MB)
 Myoglobin
 repeated blood sampling and measurements are required 6–12 h after admission
and after any further episodes of severe chest pain

33. Troponin values

34. Treatment

35. Pre-hospital management
 Antiplatelet therapy loading
 Aspirin 300mg
 Clopidogrel 600mg or ticagrelor 180mg or prasugrel 60mg
 Antithrombin therapy
 Heparin 5 000 - 10 000 IU i.v. or enoxaparine
 Others
 Statin 20-80mg
 PPI
 Resolve pain
 analgesic drugs
 benzodiazepine

36. hospital management
 Monitoring vital function and ECG
Oxygen inhalation
ECG monitor
ventricular fibrilation
terminated by cardioversion
CPR

37. In-hospital management
 Nitrates
 Betablockers - tachycardia, hypertension
 Metoprolol - dose 25-50mg oral or 2 mg i.v.
 ACE inhibitors - hypertension
 Perindopril - dose 5 mg oral
 Diuretic - heart failure
 Furosemide 20 - 40mg i.v.
 Anti-arrhythmic drugs -no prophylaxis
 Mesocain 1% 10 mL i.v.
 Amiodarone 150 mg i.v. bolus

38. STEMI treatment algorithm

39. Reperfusion Therapy for Patients with
STEMI

40. NSTEMI

41. Revascularization strategy
Conservative treatment
 non-significant stenosis on CAG
Percuenous coronary intervention
 BMS - „bare metal stents“
 DES - „drug-eluting stent“
Surgical revascularization
 better long-term results
 diffuse coronary artery involvement
 diabetics

42. Thank you for your attention

43. Questions