Acute Coronary Syndrome

Answer 1

Acute Coronary Syndrome (ACS) is a term that describes symptoms resulting from severe acute myocardial ischaemia. The ischaemia may, or may not, lead to myocardial infarction (heart attack).

Acute coronary syndrome is a term for a group of conditions that suddenly stop or severely reduce blood from flowing to the heart muscle.

Question 2

Risks Factors of Acute coronary syndrome

Answer 2

Risk factors for this condition include

obesity,
diabetes mellitus,
hypertension,
smoking and
hyperlipidaemia.
Poor nutrition practice
Males

Question 3

Causes

Answer 3

Causes
y Atherosclerosis or obstruction of the coronary blood vessels leading to reduction in blood supply to the heart muscle

Question 4

Signs and symptoms

Answer 4

Symptoms
— Chest pain
Sudden onset
Varying degree but often severe and described as tightness, heaviness or constrictive in nature.
Persisting for more than 30 minutes
Not relieved by rest or glyceryl trinitrate
May radiate to the left arm, the neck or jaw

— Nausea
— Vomiting
— Shortness of breath or fatigue (this may be the only presentation in
diabetics and the elderly)
— Loss of consciousness

Signs
— Restlessness and apprehension
— Excessive sweating
— Peripheral or central cyanosis
— Pulse may be thready, fast, irregular, slow or normal
—Bloodpressuremaybehigh, loworunrecordable(followingextensive
damage to heart muscle)
— Bilateral crepitations in the chest (with left ventricular failure)
— Presence of a third or fourth heart sound (suggests heart failure) y Confusion in the elderly

Question 5

Investigations

Answer 5

Investigations
y Standard 12 lead ECG
y Cardiac enzymes: CK-MB, troponins T and I y Myoglobin
y Serum lipid profile
y Chest X-ray
y Random blood glucose
y FBC, ESR
y Serum uric acid
y Blood urea, electrolytes and creatinine
y C-reactive protein
y Echocardiography
y Coronary angiography

Question 6

Treatment
Also view STG page 119

Answer 6

Treatment
Treatment objectives
y To relieve distress and pain
y To limit infarct size
y To prevent and treat complications
y To reverse cardiac remodelling
y To prevent re-infarction
y To identify and manage modifiable risk factors y To improve quality of life
Non-pharmacological treatment
y Reassure patient and encourage bed rest in the first 48 hours
y Encourage cessation of smoking
y Ensureweightreduction(inoverweightandobeseindividuals)inthe
long term
Pharmacological treatment
A. Initial treatment on admission
y Oxygen, intranasal, by face mask or nasal cannula And
Evidence Rating: [A]
y Aspirin, oral (chewable), 300 mg stat. And
y Clopidogrel, oral, 300 mg stat. And
y Glyceryl trinitrate, sublingual, 500 microgram stat. And
y Morphine, IV, 5-10 mg stat. And
y Metoclopramide, IV, 10 mg stat. (to prevent vomiting induced by morphine)
B. Maintenance treatment following immediately after initial treatment
y Aspirin, oral, 75-300 mg daily indefinitely And
y Clopidogrel,oral,75mgdaily(patientswhoreceiverevascularisation therapy will require treatment for up to 12 months)
C. Anticoagulation
y Enoxaparin, SC, 1 mg/kg (100 units/kg) 12 hourly
D. Prevention of cardiac arrhythmias and reduction of myocardial workload
y Atenolol, oral, 25-100 mg daily (avoid only if beta-blockers are con-

traindicated)
Or
y Bisoprolol, oral, 5-20 mg daily Or
y Metoprolol, oral, 50-100 mg 8-12 hourly
And
y Lisinopril, oral, 2.5-20 mg daily Or
y Losartan, oral, 25-50 mg daily Or
y Candesartan, oral, 4-16 mg daily
And
In patients with STEMI:
y Fibrinolytic agents may be given as reperfusion therapy in patients presenting with STEMI under specialist care.
y Manageacutecomplicationssuchaspulmonaryoedema,cardiogenic shock and cardiac arrhythmias
y Manage hyperglycaemia with insulin. Change diabetic patients previously on oral hypoglycaemic agents to insulin
E. Long-term treatment (secondary prevention)
y Aspirin, oral, 75-150 mg daily indefinitely
And
y Atenolol, oral, 25-100 mg daily (avoid only if beta-blockers are con- traindicated)
Or
y Bisoprolol, oral, 5-20 mg daily Or
y Metoprolol, oral, 50-100 mg 8-12 hourly
F� To prevent cardiac remodelling and improve survival
y Lisinopril, oral, 2.5-20 mg daily Or
y Losartan, oral, 25-50 mg daily Or
y Candesartan, oral, 4-16 mg daily
Note 7-3
Avoid ACE inhibitors and Angiotenin receptor blockers in patients with BP < 100 mmHg
G� To stabilise the clot and reduce blood cholesterol levels
y Atorvastatin, oral, 20-40 mg daily Or
y Rosuvastatin, oral, 10-20 mg daily Or y Simvastatin, oral, 40-80 mg daily. Statins are indicated irrespective
of lipid levels
H. To improve coronary dilatation and reduce myocardial workload
y Isosorbide dinitrate, oral, 10 mg 8-12 hourly
I. Control of hypertension and hyperglycaemia, if present
(See appropriate sections)
Referral Criteria
All patients with suspected ACS require an urgent ECG. If ECG is not available or cannot be interpreted, refer immediately to a higher facility.
Patients with confirmed STEMI in any facility should be referred urgently to a Physician Specialist or Cardiologist for reperfusion therapy (after an initial oral dose of 300 mg of aspirin).
Other patients with N-STEMI and unstable angina should be referred to a physician specialist or cardiologist after the initial management above.