Acute Coronary Syndrome

What is Acute Coronary Syndrome: 

  • Unstable Angina
  • Myocardial infarction –> Non ST elevated myocardial infarction (NSTEMI) or ST elevated myocardial infarction (STEMI)

Note:

  • Stable angina doesn’t typically change in frequency and it doesn’t worsen over time. 
  • Unstable angina is chest pain that occurs at rest or with exertion or stress. The pain worsens in frequency and severity.


Below is an ECG graph showing the difference in STEMI and NSTEMI

High-sensitivity blood tests for serum troponin are used to differentiate between NSTEMI and unstable angina.

Non Pharmacological Treatment

The decision regarding choice of these management depends on the type of ACS, time since symptom onset, clinical condition of the patient, other co-factors, and their risk of future cardiovascular events

Revascularisation procedures such as percutaneous coronary intervention (PCI)- Primary PCI (if within 12 hours of symptom onset and within 120 minutes of fibrinolysis) is the preferred strategy for most patients.

Coronary artery bypass graft (CABG)

Initial Management 

Pain relief should be offered as soon as possible with glyceryl trinitrate (sublingual or buccal). I

Intravenous opioids such as morphine may also be administered, particularly if acute myocardial infarction (MI) is suspected.

A loading dose of aspirin should be given as soon as possible.

All patients admitted to hospital should be closely monitored for hyperglycaemia. Those with a blood-glucose concentration greater than 11.0 mmol/litre should receive insulin—consider administration via a dose-adjusted infusion.

STEMI and NSTEMI Treatment

The management of a STEMI focuses on restoring the coronary blood flow as quickly as possible to reduce mortality.

Aspirin and where appropriate a second antiplatelet agent (prasugrel, ticagrelor, or clopidogrel) should be offered unless aspirin alone may be appropriate for some patients with a high bleeding risk not undergoing a PCI.

Prasugrel is the preferred agent for most patients undergoing a primary PCI (based on benefit vs risk) 

For NSTEMI antithrombin therapy with fondaparinux sodium should also be offered, unless the patient is undergoing immediate coronary angiography, or has a high bleeding risk. Alternatively Heparin (unfractionated) may be used in patients with severe renal impairment.

Secondary Prevention of CVD

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Angiotensin-converting enzyme (ACE) inhibitor

If intolerant to an ACE inhibitor, an angiotensin II receptor blocker (ARB) should be offered instead.

Beta-blocker

In those without reduced Left Ventricular Ejection Fraction, it may be suitable to discontinue beta-blocker therapy after 12 months;

Dual antiplatelet therapy (unless they have a separate indication for anticoagulation should be continued for up to 12 months unless contraindicated.

For patients with hypersensitivity with Aspirin, Clopidogrel monotherapy should be considered

Rivaroxaban in combination with either aspirin alone or aspirin and clopidogrel is also recommended as an option for preventing atherothrombotic events following an ACS with elevated cardiac biomarkers.

Statins