د. اروى فوزي
باطنيةTutorial
27-11-2012
عدد الاوراق (4 )Acute Coronary Syndrome
DefinitionA wide spectrum of clinical entities,
Unstable angina
NSEMI
STEMI
Sudden cardiac death
Pathophysiology
complex ulcerated or fissured atheromatous plaque with adherent platelet-rich thrombus and local coronary artery spasm.dynamic process whereby the degree of obstruction may either increase by accretion and changes in plaque morphology, sometimes leading to complete occlusion of the vessel, or regress, due to the effects of platelet disaggregation and endogenous fibrinolysis.
Clinical presentation of unstable angina
Worsening previous stable angina
New onset angina
Angina at rest or decubitus angina
Post MI angina
Prinzmetal angina
ECG changes in ACS
Normal in one thirdST segment depression or T wave changes.
ST segment elevation.
New BBB.
ECG changes in non ST elevation ACS
Initial managament of ACS
Monitor, access to DCStart 300 aspirin
Vital signs & rapid examination
IV access
12 lead ECG
O2, morphine, GTN
Blood test for biochemical markers
UNSTABLE ANGINA: RISK STRATIFICATION
clinical
High risk
Post-infarct angina Recurrent pain at rest Heart failure
Low risk
No history of MI
Rapid resolution of symptoms
ECG
High riskArrhythmia ST depression Transient ST elevation Persistent deep T-wave inversion
Low risk
minor or no ECG change:Biochemistry
High risk
Troponin T > 0.1 μg/l
Low risk
Troponin T < 0.1 μg/l
Management of non ST elevation ACS
Combined antiplatelet therapy
300 mg aspirin, 300 mg clopidogril
Anticoagulant (heparin and low m wt heparin)
B- blockers
IV nitrate
Statines
For moderate & high risk patients
GP IIb/IIIa antagonist
PCI or CABG
STEMI
Management of STEMI
After immediate measures (slide 10)Acute reperfusion therapy
* Thrombolysis
- streptokinase (1.5 million u in 1 hr)
-alteplase (15 mg- 0.75mg/kg over 30 m-0.5mg/kg over 60 m)
-tenecteplase & reteplase ( single bolus).
*PCI
Maintain vessel potency ( aspirin, clopidogril 75mg& LMWH)
Adjunctive therapy
-IV B blockers
-IV nitrates
-Statines
-ACE inhibitors