Acute Coronary Syndromes

Acute Coronary Syndromes is a topic covered in the Pocket ICU Management.

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First Things First (assess for & treat the following)

  • Is patient hemodynamically stable?
  • Is patient continuing to have ischemia symptoms?
  • Are high-risk features present (see below under specific treatment)?
    • Start anticoagulation and antiplatelet therapy.
  • Does ECG show ST-segment elevation or new LBBB?
    • Consider angioplasty vs. thrombolytic therapy.
    • Are there contraindications to thrombolytic therapy (if indicated)?

Clinical syndromes

Chronic stable angina

  • Fixed & stable coronary stenosis with absence of ischemia at rest
  • Ischemia provoked by increases in myocardial metabolic demand (e.g., physical exertion, emotional stress, postprandial)

Acute coronary syndrome: defined as spectrum of clinical syndromes that arise from coronary plaque rupture & intracoronary thrombus formation (unstable angina, NSTEMI, STEMI)

  • Unstable angina:
    • Self-limited ischemia in the absence of myocardial damage
    • Absence of serum cardiac enzyme elevation
    • Coronary plaque rupture with accumulation of intracoronary platelets & formation of transiently obstructing thrombus
      • Angina at rest, may be nocturnal
      • May follow recent history of MI
      • Represents the highest-risk group of patients with unstable angina
    • Progressive narrowing coronary stenosis
      • Restenosis in the months following angioplasty
      • Gradually worsening exertional angina
    • Ischemia provoked by abnormal physical states (despite fixed coronary arteries)
      • Increased myocardial metabolic demand: anemia, fever, tachyarrhythmia, hypotension, hyperthyroidism, cocaine
      • Symptoms abate as underlying disease process is corrected.
    • Coronary vasospasm
  • Myocardial infarction:
    • Death of myocardium & abnormal elevation of serum cardiac enzymes
    • Non-ST-segment-elevation MI (NSTEMI)
      • Infarction without elevation of ST segment
      • Occlusive thrombus, coronary vasospasm or fixed stenosis
      • Supply-demand mismatch: myocardial oxygen demand exceeds oxygen delivery
    • ST-segment-elevation MI (STEMI)
      • Infarction with elevation of ST segment
      • ST elevation localized to the region of infarcting myocardium
      • Persistent coronary occlusion results in significant myocardial necrosis.

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Last updated: April 12, 2010