Erc Als Lecture 3 Coronary Syndromes

Acute Coronary Syndromes

© Resuscitation Council (UK)

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Objectives • To discuss the clinical spectrum of ischaemic heart disease • To recognise different presentations of the disease process • To discuss treatment of the different clinical presentations encountered ERC

Fissuring Plaque

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Acute Coronary Syndromes Clinical syndromes form spectrum of the same disease process: Unstable angina ↓ Non-Q wave myocardial infarction ↓ Q wave myocardial infarction ERC

Stable angina • Pain from myocardial ischaemia – tightness/ache across chest – radiating to throat/arms/back/epigastrium – provoked by exercise – settles when exercise ceases • NOT an acute coronary syndrome

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Unstable angina • Angina of effort with increasing frequency and provoked by less exertion • Angina occurring recurrently and unpredictably - not specific to exercise • Unprovoked and prolonged episode of chest pain - no ECG or laboratory evidence of MI

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Non-Q wave myocardial infarction • Symptoms suggesting MI • Non-specific ECG abnormalities initially – ST segment depression – T wave inversion • Elevated cardiac enzymes • Unstable coronary artery disease – unstable angina – non-Q wave MI

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Non-Q wave myocardial infarction

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Q wave myocardial infarction Prolonged chest pain Acute ST segment elevation Q waves Elevated cardiac enzymes - creatine kinase • Troponins • • • •

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Anterolateral myocardial infarction

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New terminology • Q waves (or a lack of them) take time to develop clinically • Treatment is based on the admission and subsequent 12 lead ECGs • Is ST segment elevation present or not ? • STEMI or NSTEMI

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STEMI • • • •

ST Elevation MI Usually develops into Q wave MI Troponin positive However, early effective treatment may prevent full thickness infarct

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NSTEMI • Non ST Elevation MI • Usually do not develop Q waves (but may do) • May or may not be troponin positive • Treatment may depend on other clinical factors and history ERC

Immediate management and treatment in all acute coronary syndromes • A,B,C,D,E approach • “MONA” – Morphine (or diamorphine) – Oxygen – Nitroglycerine (GTN spray or tablet) – Aspirin 300 mg orally (crush/chew)

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Patients with ST Elevation MI or MI with LBBB Early coronary reperfusion therapy: • Thrombolytic therapy • Percutaneous transluminal coronary angioplasty (PTCA) • Coronary artery bypass surgery (CABG)

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Left Bundle Branch Block

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Absolute contraindications to thrombolytic therapy • • • •

Previous haemorrhagic stroke Other stroke or CVA within 6 months Active internal bleeding Aortic dissection

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Unstable angina and Non-Q wave MI (NSTEMI) ‘MONA’ • Heparin • continuous infusion unfractionated, or – subcutaneous low molecular weight – Intravenous nitrate • If ‘high risk’ • glycoprotein IIb/IIIa inhibitor – Consider beta-blockers •

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Any Questions?

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Summary • In acute coronary syndromes consider A, B, C, D, E approach and ‘MONA’ • Start reperfusion therapy early if indicated

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