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Acute Coronary Syndromes
© Resuscitation Council (UK)
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Objectives
• To discuss the clinical spectrum of ischaemic heart disease
• To recognise different presentations of the disease process
• To discuss treatment of the different clinical presentations encountered
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Fissuring Plaque
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Acute Coronary Syndromes
Clinical syndromes form spectrum of the same disease process:
Unstable angina
Non-Q wave myocardial infarction
Q wave myocardial infarction
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Stable angina• Pain from myocardial ischaemia
–tightness/ache across chest
–radiating to throat/arms/back/epigastrium
–provoked by exercise
–settles when exercise ceases
• NOT an acute coronary syndrome
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Unstable angina
• Angina of effort with increasing frequency and provoked by less exertion
• Angina occurring recurrently and unpredictably - not specific to exercise
• Unprovoked and prolonged episode of chest pain - no ECG or laboratory evidence of MI
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Non-Q wave myocardial infarction• Symptoms suggesting MI
• Non-specific ECG abnormalities initially
– ST segment depression
– T wave inversion
• Elevated cardiac enzymes
• Unstable coronary artery disease
– unstable angina
– non-Q wave MI
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Non-Q wave myocardial infarction
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Q wave myocardial infarction
• Prolonged chest pain
• Acute ST segment elevation
• Q waves
• Elevated cardiac enzymes
- creatine kinase
• Troponins
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Anterolateral myocardial infarction
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New terminology• Q waves (or a lack of them) take time to
develop clinically• Treatment is based on the admission
and subsequent 12 lead ECGs• Is ST segment elevation present or not ?• STEMI or NSTEMI
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STEMI
• ST Elevation MI
• Usually develops into Q wave MI
• Troponin positive
• However, early effective treatment may prevent full thickness infarct
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NSTEMI
• Non ST Elevation MI• Usually do not develop Q waves
(but may do)• May or may not be troponin positive• Treatment may depend on other
clinical factors and history
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Immediate management and treatment in all
acute coronary syndromes• A,B,C,D,E approach• “MONA”
–Morphine (or diamorphine)–Oxygen–Nitroglycerine (GTN spray or tablet)–Aspirin 300 mg orally (crush/chew)
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Patients with ST Elevation MI or MI with LBBB
Early coronary reperfusion therapy:
• Thrombolytic therapy• Percutaneous transluminal coronary angioplasty (PTCA)• Coronary artery bypass surgery (CABG)
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Left Bundle Branch Block
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Absolute contraindications to thrombolytic therapy
• Previous haemorrhagic stroke
• Other stroke or CVA within 6 months
• Active internal bleeding
• Aortic dissection
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Unstable angina and Non-Q wave MI (NSTEMI)
• ‘MONA’• Heparin
– continuous infusion unfractionated, or– subcutaneous low molecular weight
• Intravenous nitrate • If ‘high risk’
– glycoprotein IIb/IIIa inhibitor• Consider beta-blockers
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Any Questions?
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Summary
• In acute coronary syndromes consider A, B, C, D, E approach and ‘MONA’
• Start reperfusion therapy early if indicated
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