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Acute coronary syndromes

Overview
  • Definition: Spectrum of conditions resulting from decreased blood flow in the coronary arteries, encompassing unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).
Etiology
  • Atherosclerotic plaque rupture leading to thrombus formation and vessel occlusion.
  • Coronary artery spasm, embolism or dissection (less common).
Clinical Presentation
  • Chest pain: Central chest pain, often radiating to the jaw, arm, or back. May be associated with nausea, vomiting, and diaphoresis.
  • Shortness of breath.
  • Palpitations, syncope, or sudden cardiac death.
Investigations
  • ECG: ST-elevations in STEMI, ST-depression or T-wave inversion in NSTEMI/UA.
  • Bloods: Cardiac enzymes (troponin, CK-MB) elevated in MI.
  • Echocardiogram: Evaluate left ventricular function and possible complications.
  • Coronary angiography: Visualisation of coronary artery occlusion.
Management
  • Immediate:
    • MONA: Morphine, Oxygen, Nitrates, Aspirin.
    • Antiplatelet agents (e.g., clopidogrel, ticagrelor).
    • Anticoagulants (e.g., heparin, fondaparinux).
  • STEMI: Primary percutaneous coronary intervention (PCI) is the treatment of choice if available within 120 mins. Otherwise, consider thrombolysis.
  • NSTEMI/UA: Invasive strategy (angiography and revascularisation) for high-risk patients; conservative strategy for others.
  • Statins, beta-blockers, ACE inhibitors for secondary prevention.
Complications
  • Heart failure.
  • Cardiogenic shock.
  • Arrhythmias: Ventricular tachycardia, ventricular fibrillation, heart block.
  • Cardiac rupture.
  • Pericarditis.
Key Points
  • ACS represents a spectrum of disease based on coronary artery occlusion and resultant myocardial damage.
  • Time is myocardium: rapid diagnosis and treatment are crucial.
  • Revascularisation (PCI or CABG) is key in management along with medications for secondary prevention.

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