IHD and Angina Pectoris:Acute coronary syndromeName: Nur A’isyah Binti IdrisMatric no.: 08201210068

Definition • A term encompasses

both unstable angina and MI• Characterised by• New-onset/rapidly

worsening angina• Angina on minimal

exertion • Angina at rest

• caused by dynamic obstruction usually due to complex ulcerated with adherent platelet rich thrombus • Along with coronary

artery spasm

Acute Myocardial Infarction (MI)Criteria for MI:Detection of a rise/fall of cardiac biomarkers with at least 1 value above 99th centile upper reference limit with at least 1 of following:1. Signs of ischemia2. New or presumed new significant ST segment –

T wave or bundle branch block 3. Pathological Q wave in ECG4. Imaging evidence of new loss of viable

myocardium

• Criteria for previous MI:1. Pathological Q waves with or without

symptoms in the absence of non-ischemic causes

2. Imaging evidence of a region of loss of viable that is thinned and fails to contract, in absence of non ischemic causes

Clinical feature

Symptoms• Prolonged cardiac pain • Anxiety and fear of impending death• Nausea and vomiting• Breathlessness• Collapse/syncope

Physical sign• Sign of sympathetic activation: pallor, sweating,

tachycardia.• Sign of vagal activation: vomiting, bradycardia• Sign of impaired myocardial function: Hypotension,

oliguria, cold peripheries, narrow pulse pressure, raised JVP, S3 heart sound, diffuse apical impulse, lung crepitations• Sign of complication: mitral regurgitation,

pericarditis

Diagnosis

• Precise history taking and examination• ECG changes • Serum biomarkers

Investigation Electrocardiography –changes STEMI• Proximal occlusion of major CA• ST elevation• Diminution size of R wave• Development Q wave• T wave become inverted

A – normal B – within minutes C – within hours D – within daysE – after several weeks or months

Electrocardiography –changes NSTEMI• Partial occlusion of major vessel / complete occlusion

of minor vessel unstable angina / partial thickness MI• ST depression• T wave become inverted

Difference ECG changes in STEMI & NSTEMI

Plasma cardiac biomakers• In unstable angina, there is no detectable rise in

cardiac biomakers• In MI, the cardiac biomakers are :

1. Creatine kinase (CK-MB)(12H)2. Troponin I and T3. Lactate dehydrogenase(LDH)4. Aspartate aminotransferase

• Other blood test : leucocytosis, ESR & CRP • Chest x-ray : pulmonary edema, cardiomegaly• Echocardiography: assessing ventricular function

& detect other complication.

Management

• Immediate management: 12 hours• Analgesia • Antithrombotic therapy• Antiplatelets • Anticoagulants

• Anti-anginal therapy• Reperfusion therapy

• Late management

Immediate management:

• should be admitted to hospital • Patients are manage in cardiac unit & if there is no

complications, patient can be mobilise from 2nd day & discharged after 3-5 days.

• Analgesiato relieves distress and to lower adrenergic drive

iv opiates(morphine sulphate 5-10mg)/diamorphine 2.5-5mg) Antiemetics ( metoclopramide 10mg)

Anticoagulant therapy

1. Antiplatelet therapy • Within 12 hours , 300 mg aspirin PO + 600 mg

clopidogrel • Followed by 75 mg aspirin daily + 150 mg (first 1

week) 75 mg clopidogrel • Alternative drug is ticagrelor 180 mg, followed by

90 mg twice daily

2. Anticoagulants• To reduce risk of re-infarction and

thromboembolic complications • Heparin, low molecular weight heparin or

pentasaccharide • E.g : Fondaparinux ( sc 2.5mg/day)• Enoxaparin (sc 1mg/kg twice daily)• Should be continue for 8 days/ until discharge

Anti-anginal therapy• Sublingual glyceral trinitrate 300-500mcg• i.v GTN 0.6 – 1.2 mg/hr • Isosorbide dinitrate 1-2 mg/hr

• i.v B-blockers to reduce arrhythmias and improve short term mortality • Atenolol 5-10mg • Metoprolol 5-15 mg over5 min

Reperfusion therapy

Non-ST segment elevation ACS1. Coronary angiography2. Coronary revascularisation

ST segment elevation ACSPercutaneous coronary intervention (PCI)• Treatment of choice of STEMI• Used in combination with GpIIb/IIIa receptor antagonist and

stent implantation• Results in reduced risk of recurrent stroke or MI• It is ideally done within 2 hours

Thrombolysis therapy• Due to availability and resource, thrombolytic

therapy remains as the treatment of choice• Reduce mortality rate by 25 – 50%• Alteplase 15 mg i.v bolus given over 90 minutes

followed by • 0.75 mg/kg over 30 min followed by • 0.5 mg/kg over 60 min

Complication of ACS

Arrhythmias• Ventricular /

atrial fibrillations

• Ventricular / Atrial tachycardia

• Bradycardia

Ischaemia

Acute circulatory failure

PericarditisEmbolism

Mechanical complication

Impaired ventricular function,

remodelling, aneurysm

Late management of ACS• Lifestyle modification

Diet Cessation of smoking Regular exercise• Secondary prevention

drug therapy Antiplatelet therapy Beta-blocker ACEI/ARB Statin

Additional therapy for control of diabetes and hypertension

Mineralocorticoid receptor antagonist

• Device therapy Implantable cardiac

defibrillator

THANK YOU