ACUTE CORONARY
SYNDROME (ACS)
STU WILLIS, MD
ACS CATEGORIES
• Unstable angina
• Non-ST-elevation myocardial
infarction (NSTEMI)
• ST-elevation myocardial infarction
(STEMI)
♥ Cardiac sudden death can occur with
any of the three
KEY COMPONENTS
• Initial treatment of possible
acute ischemic chest pain
• Identification and treatment of
ischemic chest pain
• Early reperfusion of STEMI
GOALS
• Chest pain relief
• Prevent adverse events
• Death
• Non-fatal MI
• Need for revascularization
• Treat life-threatening
complications (rhythms)
PATHOPHYSIOLOGY
• Unstable plaque & inflammation
• Plaque rupture, platelet aggregation &
thrombus generation
• Partial occlusion = unstable angina
• Anti-platelet therapy = aspirin, clopidogrel,
Glycoprotein IIb/IIIa receptor inhibitor
• Microemboli = distal “micro” infarct
• Typically NSTEMI
• Mild troponin elevation
• Occlusive thrombus
• Typically STEMI
• Percutaneous coronary intervention (PCI)
or fibrinolysis
CHEST DISCOMFORT
• Quality
• Does not need to be “pain”
• Often pressure, tightness, heaviness, squeezing
• Sometimes aching, dull, burning; less often sharp
• Can be just unexplained dyspnea, especially on exertion
• Location
• Does not need to be retrosternal or the chest
• Can be across chest, or in shoulder, arm, neck, jaw,
back, epigastric
• Severity
• Does not need to be severe; pain/discomfort is subjective
• Other symptoms
• Does not need associated symptoms
• Dyspnea, diaphoresis, nausea, palpitations, lightheadedness,
syncope
INITIAL ASSESSMENT
& TREAMENT
• Based upon suspicion
• ABCs first
• Caution: no nitroglycerin for inferior
infarction unless right-sided ECG
reveals no involvement
INITIAL ASSESSMENT
& TREAMENT
•Pre-hospital responders (EMS)
• Cardiac monitor & vital signs
• Prepare for possible CPR and defibrillation
• 12-lead ECG
• Intravenous access
• Aspirin, nitroglycerin, morphine (or other),
oxygen
INITIAL ASSESSMENT
& TREAMENT (cont)
Emergency Department
• Monitor, vital signs, aspirin, oxygen
IV access, 12-lead ECG (within 10 min)
• Targeted history & examination
• Nitroglycerin, analgesic (morphine or other)
• Laboratory (minimum)
• Cardiac markers – troponin (and others as desired)
• Electrolytes
• Coagulation studies (if using fibrinolytic)
• Chest x-ray (within 30 min)
ECG
• 12-lead ECG central to treatment
decisions
• ECG categories
• Normal or non-diagnostic
• ST segment depression - ischemia
• ST segment elevation - infarct
ST DEPRESSION
• Hallmark of ischemia
ST DEPRESSION
Antero-lateral – leads V2-6
ST ELEVATION
• Hallmark of infarct
ST ELEVATION
Antero-lateral – leads V2-6
ST ELEVATION
Anterolateral & high lateral – leads V4-6, I, AVL
(note “reciprocal” inferior changes – leads II, III, AVF)
ST ELEVATION
Inferior – leads III, AVF
STEMI TREATMENT GOAL
TARGETS
• Reperfusion by PCI within
90 minutes
OR
• Reperfusion by fibrinolytic within
30 minutes
FIBRINOLYTIC CRITERIA
• Less than 12 hours
• STEMI at least 1 mm or
presumably new LBBB
• No contraindications
FIBRINOLYTIC
ABSOLUTE
CONTRAINMDICATIONS
• Prior intracranial hemorrhage
• Structural CNS vascular lesion
• Malignant intracranial neoplasm
• Ischemic stroke within 3 months
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
• Significant closed head or facial trauma within 3
months
• Intracranial or intraspinal surgery within 2
months
• Persistent severe hypertension despite treatment
(BP higher than 180/110 mm Hg)
FIBRINOLYTIC RELATIVE
CONTRAINMDICATIONS
• Severe hypertension on presentation (BP
higher than 180/110 mm Hg)
• Ischemic stroke more than 3 months prior
• Significant dementia or CNS pathology not
already in contraindications
• GI/GU bleed in last 2 to 4 weeks
• Major surgery or CPR greater than 10 minutes in
past 3 weeks
• Pregnancy
• Active peptic ulcer disease
• Current use of anticoagulant producing INR greater
than 1.7; current use of NOAC medication
• Spinal or noncompressible vascular punctures within
past 2 days
ADJUNCTIVE STEMI
THERAPY
• Intravenous nitroglycerin
• Beta- adrenergic receptor blocker
(metoprolol)
• Heparin – UFH or LMWH (enoxaparin)
• Platelet aggregation inhibitor
(ticagrelor, clopidogrel)
• Angiotensin-converting enzyme (ACE)
inhibitor
THROMBUS CASCADE
Aspirin
Thrombin
Thromboxane A2 Collagen ADP UFH
LMWH
Ticagrelor Bivalirudin
Clopidogrel Fondaparinux
Ticlopidine
Glycoprotein IIb / IIIa Activation Fibrinogen
Abciximab
Eptifibatide Von Williebrand Factor
Tirofiban
Platelet Aggregation
Fibrinolytics
Thrombus formation Fibrin
QUESTIONS ?
