Acute Coronary Syndrome

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Acute Coronary Syndrome

what

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ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina

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type of atherosclerotic plaques that may cause MI

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1-hemodynamically insignificant yet vulnarable with acute event : thrombosis / hrg

2-high grade fixed obstruction + increased demand that leads to total/almost total obstruction

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vulnarable plaque

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- thin fibrous cap

- large lipid core

-numerous inflammatory cells

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Acute Coronary Syndrome

basic pathophysiology

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almost always rupture of an vulnarable atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery.

occasionally it may results from stable disease in absence of plaque upture if increased ((demands))

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causes of increased demands on heart

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trauma

blood loss

anemia

infection

tachyarrhythmia

stress

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transmural and nontransmural (subendocardial) myocardial infarction ??

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transmural and nontransmural (subendocardial) myocardial infarction are no longer used

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ACS-related myocardial infarction ??

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is :

1-STEMI

or

2-NSTEMI.

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acute plaque rupture

pathophysiology

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-activated inflammatory cells.

-release of metalloproteinases (collagenases)

-dissolution of the fibrous cap plaque rupture

-platelet activation/aggregation, coagulation pathway, and vasoconstriction.

- intraluminal thrombosis and variable vascular occlusion.

- may Distal embolization

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determinants of pt's presentation

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1- severity of obstruction

2- duration of obstruction

3- volume of myocardium affected

4-level of demand on the heart

5-ability of the rest of the heart to compensate

6-increased demand : Anemia and hypoxemia

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takotsubo syndrome

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1-chest pain

2-ischemic ST-segment and T-wave changes

3-elevated levels of biomarkers

4-transient left ventricular apical ballooning

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takotsubo syndrome

triggers and pathophysiology

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- emotional or physical stress

- relate to a surge of catechol stress hormones and/or high sensitivity to those hormones.

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troponin

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found in skeletal and cardiac muscle)

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troponin

prognostic indication in acute coronary syndrome

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- permits risk stratification of patients with ACS

- identifies patients at high risk for adverse cardiac events (ie, myocardial infarction, death) up to 6 months after the index event

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lifestyle mofdifications after ACS

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A = Aspirin and antianginals

B = Beta blockers and blood pressure (BP)

C = Cholesterol and cigarettes

D = Diet and diabetes

E = Exercise and education

A cardiac rehabilitation program

follow up visit

ER visit if ..........

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smoking cessation

% of recurrent cardiac events

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The risk of recurrent coronary events decreases 50% at 1 year after smoking cessation.

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dietary ecommendation after acute coronary syndrome

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low-cholesterol, low-salt diet.

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angina

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- a symptom of myocardial ischemia that appears in circumstances of increased oxygen demand.

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typical anginal pain

describtion

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- described as a sensation of chest pressure or heaviness ,(( reproducable )) by activities or conditions that increase myocardial oxygen demand.

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atypical presentations of angina

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Palpitations

Pain, usually as pressure, squeezing, burning sensation across the precordium may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm

Exertional dyspnea resolves with pain or rest

Diaphoresis from sympathetic discharge

Nausea from vagal stimulation

Decreased exercise tolerance

episodic shortness of breath

severe weakness

light-headedness

diaphoresis

nausea and vomiting.

altered mental status.

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pt groups that who are more likely to present with atypical sx of ACS

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elderly

women

diabetics

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DDx of angina

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- indigestion

- anxiety

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types of angina

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Stable angina

unstable angina

Variant angina (Prinzmetal angina)

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stable angina

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- episodic pain

- lasting 5-15 minutes

- provoked by exertion

- relieved by rest or nitroglycerin.

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unstable angina

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- increased risk for adverse cardiac events

( MI / death)

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- New-onset exertional angina

- at rest

- increasing frequency

- increasing duration

- refractory to nitroglycerin.

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variant / prinzmetal angina

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-occurs primarily at rest

- triggered by smoking

- thought to be due to coronary vasospasm

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physical examination

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- usually normal ,

- may anxious, diaphoretic, and pale

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Hypotension

Hypertension

Diaphoresis

Pulmonary edema

Extracardiac vascular disease

Jugular venous distention

Cool, clammy skin and diaphoresis

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new murmur /systolic murmur

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indication of hypotension in ACS

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Indicates ventricular dysfunction due to myocardial ischemia, infarction, or acute valvular dysfunction

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indication of hypertension in pt with ACS

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May precipitate angina or reflect elevated catecholamine levels due to anxiety or to exogenous sympathomimetic stimulatio

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indication of : Cool, clammy skin and diaphoresis in pt with ACS

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cardiogenic shock

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indication of S4 presence in ACS

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- inferior-wall ischemia

- schemia or systolic murmur secondary to mitral regurgitation

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indication of systolic murmur in ACS

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A systolic murmur :

dynamic obstruction of the left ventricular (LV) outflow tract

hyperdynamic motion of the basal left ventricular myocardium

apical infarct.

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indication of new murmur in ACS

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may papillary muscle dysfunction.

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indication of Rales on pulmonary examination in ACS

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may suggest LV dysfunction or mitral regurgitation.