Acute Coronary Syndromes
Overview
Definition & DDx Anatomy & Risks
Acute presentations of ischaemic heart Risk factors
disease - Age / M / FH
- STEMI - Smoking
- NSTEMI - DM
- Unstable angina - HTN/stress
IHD = CHD = Coronary Artery Disease - Obesity/inactivity
- Hypercholesterolaemia
Symptoms & Complications
Chest pain Also
- Central/LHS - Dyspnoea
- Radiate under jaw/L arm - Sweating/clammy
- Heavy/constricting - Pale/syncope
Diabetics/elderly/women may not - N&V/epigastric pain
experience any chest pain - Few physical signs e.g., mild
tachycardia, DM hyperglyc. crisis
Investigations
ECG
Kilip Class used to stratify risk post MI:
I. No clinical signs heart failure
II. Lung crackles, S3
III. Frank pulmonary oedema
IV. Cardiogenic shock
Treatment/Management & Side effects
MOANA 2º prevention
- Morphine (only if severe pain) - Aspirin 75mg OD
- O2 (only if sats <94%) - Antiplatelet
- Aspirin o E.g., clopidogrel 75mg OD
- Nitrates (SL or IV; caution in - BB (e.g., bisoprolol)
hypotension) - ACEi (e.g., ramipril)
- Antiplatelet - Statin (e.g., atorvastatin 80mg ON)
(Clopidogrel/prasugrel/ticagrelor) - ECHO and cardiac rehab
,STEMI
Anatomy & Risks
Criteria
- Clinical symptoms consistent with ACS (≥20mins)
- Persistent (≥20mins) ST elevation in ≥2 contiguous leads of:
o 2.5mm/≥2.5 small squares V2/V3 in ≤40M
o ≥2.0mm/≥2 small squares in V2/V3 in ≥40M
o 1.5mm V2/V3 women
o 1mm in other leads
- Or - new LBBB
Symptoms & Complications
Dressler’s syndrome (form of pericarditis)
- Pleuritic chest pain, low-grade fever, pericarditis (up to 6wks post MI)
Investigations
ECG
- T wave inversion occurs within 24hrs
o Can last days-months
- Pathological Q waves develop hrs-days
o Change persists indefinitely
Posterior MI causes ST depression
Treatment/Management & Side effects
Assuming: presentation within 12hrs onset, not high bleed risk, not on oral anticoagulants:
- Aspirin 300mg
- If PCI possible within 2hrs
o Give prasugrel (clopidogrel if already on anticoagulant)
o Radial access (Give Unfractioned heparin with GPI bailout)
o Drug-eluting stents if possible
- If PCI not possible
o Fibrinolysis (tPA)
▪ CI: aortic dissection, current GI bleed, allergy, current neuro signs,
severe uncontrolled HTN
o Give antithrombin
o Following procedure give ticagrelor
o If ST elevation on ECG 90mins post-fibrinolysis has not resolved – transfer for
PCI required
NSTEMI/Unstable angina
Definition & DDx
NSTEMI – severe but incomplete occlusion of coronary artery
Unstable angina: Present in patients with ischaemic symptoms and no elevation in troponins
+/- ECG ischaemic changes; partial occlusion of coronary artery
- Rise in trop may take hours so treated the same as NSTEMI until trop result is known
, Investigations
GRACE (ischaemic risk score)
- Age
- HR + BP
- Kilip class and serum creatinine (cardiac and renal function)
- Cardiac arrest on presentation
- ECG findings
- Trop levels
o Non-ACS causes can give raised trop; Rx can start if ECG changes w/o trop
Coronary angiography (check renal function for contrast):
- Immediately if unstable
- Within 72hrs if ≥intermediate risk
Troponins (at least 3hrs after pain starts, then repeated 3-6hrs after first level)
- hsTroponinT <14 + pain>6hrs = rules out MI
- Trop change ≤7 and <30 = review alternative cause
- Probable MI
o Trop >14 in moderate/high risk pt / cardiac sx
o ACS sx hx / Trop >30
o Trop change ≥+/-7 or above 30 after 3hrs
Treatment/Management & Side effects
Assuming: pt not high bleed risk or on oral anticoagulant
- Aspirin 300mg
- Fondaparinux if no immediate PCI planned (consider alternative drug if high bleed
risk)
o Bleeding risk = CRUSADE score
- GRACE score (ischaemic risk)
- Low risk
o Ticagrelor and conservative management
- Intermediate-High risk
o PCI within 72hrs or sooner if unstable
o Prasugrel
▪ If on oral anticoagulant + low bleed risk: ticagrelor
▪ If on oral anticoagulant + high bleed risk: clopidogrel
o Unfractionated heparin
o Drug eluting stent
Complications - LV free wall rupture (occurs 1-2wks
- Acute/chronic heart failure post-MI)
o Pulmonary oedema - Acute mitral regurg (papillary
o Raised JVP muscle rupture)
o Hypotension - VSD
- Cardiogenic shock - Pericarditis (normally within first
- Ventricular/supraventricular 48hrs)
arrhythmias - Dressler’s syndrome (Rx =
- AV block NSAIDs/high dose aspirin
Overview
Definition & DDx Anatomy & Risks
Acute presentations of ischaemic heart Risk factors
disease - Age / M / FH
- STEMI - Smoking
- NSTEMI - DM
- Unstable angina - HTN/stress
IHD = CHD = Coronary Artery Disease - Obesity/inactivity
- Hypercholesterolaemia
Symptoms & Complications
Chest pain Also
- Central/LHS - Dyspnoea
- Radiate under jaw/L arm - Sweating/clammy
- Heavy/constricting - Pale/syncope
Diabetics/elderly/women may not - N&V/epigastric pain
experience any chest pain - Few physical signs e.g., mild
tachycardia, DM hyperglyc. crisis
Investigations
ECG
Kilip Class used to stratify risk post MI:
I. No clinical signs heart failure
II. Lung crackles, S3
III. Frank pulmonary oedema
IV. Cardiogenic shock
Treatment/Management & Side effects
MOANA 2º prevention
- Morphine (only if severe pain) - Aspirin 75mg OD
- O2 (only if sats <94%) - Antiplatelet
- Aspirin o E.g., clopidogrel 75mg OD
- Nitrates (SL or IV; caution in - BB (e.g., bisoprolol)
hypotension) - ACEi (e.g., ramipril)
- Antiplatelet - Statin (e.g., atorvastatin 80mg ON)
(Clopidogrel/prasugrel/ticagrelor) - ECHO and cardiac rehab
,STEMI
Anatomy & Risks
Criteria
- Clinical symptoms consistent with ACS (≥20mins)
- Persistent (≥20mins) ST elevation in ≥2 contiguous leads of:
o 2.5mm/≥2.5 small squares V2/V3 in ≤40M
o ≥2.0mm/≥2 small squares in V2/V3 in ≥40M
o 1.5mm V2/V3 women
o 1mm in other leads
- Or - new LBBB
Symptoms & Complications
Dressler’s syndrome (form of pericarditis)
- Pleuritic chest pain, low-grade fever, pericarditis (up to 6wks post MI)
Investigations
ECG
- T wave inversion occurs within 24hrs
o Can last days-months
- Pathological Q waves develop hrs-days
o Change persists indefinitely
Posterior MI causes ST depression
Treatment/Management & Side effects
Assuming: presentation within 12hrs onset, not high bleed risk, not on oral anticoagulants:
- Aspirin 300mg
- If PCI possible within 2hrs
o Give prasugrel (clopidogrel if already on anticoagulant)
o Radial access (Give Unfractioned heparin with GPI bailout)
o Drug-eluting stents if possible
- If PCI not possible
o Fibrinolysis (tPA)
▪ CI: aortic dissection, current GI bleed, allergy, current neuro signs,
severe uncontrolled HTN
o Give antithrombin
o Following procedure give ticagrelor
o If ST elevation on ECG 90mins post-fibrinolysis has not resolved – transfer for
PCI required
NSTEMI/Unstable angina
Definition & DDx
NSTEMI – severe but incomplete occlusion of coronary artery
Unstable angina: Present in patients with ischaemic symptoms and no elevation in troponins
+/- ECG ischaemic changes; partial occlusion of coronary artery
- Rise in trop may take hours so treated the same as NSTEMI until trop result is known
, Investigations
GRACE (ischaemic risk score)
- Age
- HR + BP
- Kilip class and serum creatinine (cardiac and renal function)
- Cardiac arrest on presentation
- ECG findings
- Trop levels
o Non-ACS causes can give raised trop; Rx can start if ECG changes w/o trop
Coronary angiography (check renal function for contrast):
- Immediately if unstable
- Within 72hrs if ≥intermediate risk
Troponins (at least 3hrs after pain starts, then repeated 3-6hrs after first level)
- hsTroponinT <14 + pain>6hrs = rules out MI
- Trop change ≤7 and <30 = review alternative cause
- Probable MI
o Trop >14 in moderate/high risk pt / cardiac sx
o ACS sx hx / Trop >30
o Trop change ≥+/-7 or above 30 after 3hrs
Treatment/Management & Side effects
Assuming: pt not high bleed risk or on oral anticoagulant
- Aspirin 300mg
- Fondaparinux if no immediate PCI planned (consider alternative drug if high bleed
risk)
o Bleeding risk = CRUSADE score
- GRACE score (ischaemic risk)
- Low risk
o Ticagrelor and conservative management
- Intermediate-High risk
o PCI within 72hrs or sooner if unstable
o Prasugrel
▪ If on oral anticoagulant + low bleed risk: ticagrelor
▪ If on oral anticoagulant + high bleed risk: clopidogrel
o Unfractionated heparin
o Drug eluting stent
Complications - LV free wall rupture (occurs 1-2wks
- Acute/chronic heart failure post-MI)
o Pulmonary oedema - Acute mitral regurg (papillary
o Raised JVP muscle rupture)
o Hypotension - VSD
- Cardiogenic shock - Pericarditis (normally within first
- Ventricular/supraventricular 48hrs)
arrhythmias - Dressler’s syndrome (Rx =
- AV block NSAIDs/high dose aspirin
