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DRUGS & DISEASES

Acute Coronar Sndro!e "#ER#IE$

Practice Essentials

Acute coronar sndro!e %ACS re'ers to a spectru! o' clinical presentationsranging 'ro! t(ose 'or S)*seg!ent elevation !ocardial in'arction %S)EMI topresentations 'ound in non+S)*seg!ent elevation !ocardial in'arction %NS)EMIor in unsta,le angina- It is al!ost alwas associated wit( rupture o' anat(erosclerotic pla.ue and partial or co!plete t(ro!,osis o' t(e in'arct*relatedarter-

Essential update/ Stud 0nds t(at S)EMI !ec(anis!s and stenting outco!e aresi!ilar in wo!en and !en

Despite t(eir s!aller coronar vessels and (ig(er ris1 pro0le2 wo!en wit( S)EMIappear to respond 3ust as well as !en to pri!ar PCI and stenting2 according tot(e "ptical Co(erence )o!ograp( Assess!ent o' Gender Diversit in Pri!arAngioplast %"C)A#IA stud- "C)A#IA2 w(ic( was designed to e4a!ine genderdi5erences at t(e ti!e o' pri!ar PCI2 included 678 S)EMI patients at 67 Italiancenters2 !atc(ed , age and ris1 'actors2 w(o received an everoli!us*elutingstent-96:

"n initial "C)2 no di5erences , gender were 'ound in t(e proportion o' rupturedor eroded pla.ues2 t(us suggesting t(at t(e pat(op(siolog o' S)EMI is nearlidentical in !en and wo!en- "n repeat "C) at nine !ont(s2 intended to assessstent (ealing2 !ore t(an ;8< o' ,ot( !en and wo!en (ad 'ull covered stentstruts- Alt(oug( "C)A#IA was not powered 'or clinical end points2 no signi0cantdi5erences in deat(2 rein'arction2 stro1e2 stent t(ro!,osis2 or target vesselreintervention were evident at one ear-96:

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Signs and s!pto!s

At(erosclerosis is t(e pri!ar cause o' ACS2 wit( !ost cases occurring 'ro! t(edisruption o' a previousl nonsevere lesion- Co!plaints reported , patients wit(

ACS include t(e 'ollowing/

Palpitations

Pain2 w(ic( is usuall descri,ed as pressure2 s.uee=ing2 or a ,urning sensationacross t(e precordiu! and !a radiate to t(e nec12 s(oulder2 3aw2 ,ac12 uppera,do!en2 or eit(er ar!

E4ertional dspnea t(at resolves wit( pain or rest

Diap(oresis 'ro! s!pat(etic disc(arge

Nausea 'ro! vagal sti!ulation

Decreased e4ercise tolerance

P(sical 0ndings can range 'ro! nor!al to an o' t(e 'ollowing/

>potension/ Indicates ventricular ds'unction due to !ocardial isc(e!ia2!ocardial in'arction %MI2 or acute valvular ds'unction

>pertension/ Ma precipitate angina or re?ect elevated catec(ola!ine levelsdue to an4iet or to e4ogenous s!pat(o!i!etic sti!ulation

Diap(oresis

Pul!onar ede!a and ot(er signs o' le't (eart 'ailure

E4tracardiac vascular disease

@ugular venous distention

Cool2 cla!! s1in and diap(oresis in patients wit( cardiogenic s(oc1

A t(ird (eart sound %S and2 're.uentl2 a 'ourt( (eart sound %S7

A sstolic !ur!ur related to dna!ic o,struction o' t(e le't ventricular out?owtract

Rales on pul!onar e4a!ination %suggestive o' le't ventricular ds'unction or!itral regurgitation

Potential co!plications include t(e 'ollowing/

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Isc(e!ia/ Pul!onar ede!a

Mocardial in'arction/ Rupture o' t(e papillar !uscle2 le't ventricular 'ree wall2and ventricular septu!

See Clinical Presentation 'or !ore detail-

Diagnosis

Guidelines 'or t(e !anage!ent o' non*S)*seg!ent elevation ACS were releasedin B866 , t(e European Societ o' Cardiolog %ESC-9B: )(e guidelines includet(e use o' t(e CRUSADE ris1 score %Can Rapid ris1 strati0cation o' Unsta,leangina patients Suppress ADverse outco!es wit( Earl i!ple!entation o' t(eACCA>A guidelines-

In t(e e!ergenc setting2 electrocardiograp( %ECG is t(e !ost i!portantdiagnostic test 'or angina- ECG c(anges t(at !a ,e seen during anginalepisodes include t(e 'ollowing/

)ransient S)*seg!ent elevations

Dna!ic )*wave c(anges/ Inversions2 nor!ali=ations2 or (peracute c(anges

S) depressions/ )(ese !a ,e 3unctional2 downsloping2 or (ori=ontal

La,orator studies t(at !a ,e (elp'ul include t(e 'ollowing/

Creatine 1inase isoen=!e M %C*M levels

Cardiac troponin levels

Moglo,in levels

Co!plete ,lood count

asic !eta,olic panel

Diagnostic i!aging !odalities t(at !a ,e use'ul include t(e 'ollowing/

C(est radiograp(

Ec(ocardiograp(

Mocardial per'usion i!aging

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Cardiac angiograp(

Co!puted to!ograp(2 including C) coronar angiograp( and C) coronararter calciu! scoring

See $or1up 'or !ore detail-

Manage!ent

Initial t(erap 'ocuses on t(e 'ollowing/

Sta,ili=ing t(e patientFs condition

Relieving isc(e!ic pain

Providing antit(ro!,otic t(erap

P(ar!acologic anti*isc(e!ic t(erap includes t(e 'ollowing/

Nitrates %'or s!pto!atic relie'

eta ,loc1ers %eg2 !etoprolol/ )(ese are indicated in all patients unlesscontraindicated

P(ar!acologic antit(ro!,otic t(erap includes t(e 'ollowing/

Aspirin

Clopidogrel

Prasugrel

)icagrelor

Glcoprotein II,IIIa receptor antagonists %a,ci4i!a,2 epti0,atide2 tiro0,an

P(ar!acologic anticoagulant t(erap includes t(e 'ollowing/

Un'ractionated (eparin %U>

Low*!olecular*weig(t (eparin %LM$>H dalteparin2 nadroparin2 eno4aparin

actor a in(i,itors %rivaro4a,an2 'ondaparinu4

Additional t(erapeutic !easures t(at !a ,e indicated include t(e 'ollowing/

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)(ro!,olsis

Percutaneous coronar intervention %pre'erred treat!ent 'or S)*elevation MI

Current guidelines 'or patients wit( !oderate* or (ig(*ris1 ACS include t(e'ollowing/

Earl invasive approac(

Conco!itant antit(ro!,otic t(erap2 including aspirin and clopidogrel2 as well asU> or LM$>

See )reat!ent and Medication 'or !ore detail-

I!age li,rar

A JB*ear*old wo!an wit( a (istor o' c(ronic sta,

A JB*ear*old wo!an wit( a (istor o' c(ronic sta,le angina and a Kvalvepro,le!K presents wit( new c(est pain- S(e is s!pto!atic on arrival2co!plaining o' s(ortness o' ,reat( and precordial c(est tig(tness- >er initialvital signs are ,lood pressure 678;8 !! >g and (eart rate ;- >erelectrocardiogra! %ECG is as s(own- S(e is given nitroglcerin su,linguall2 and(er pressure decreases to 8palpation- Rig(t ventricular isc(e!ia s(ould ,econsidered in t(is patient-

ac1ground

Acute coronar sndro!e %ACS re'ers to a spectru! o' clinical presentationsranging 'ro! t(ose 'or S)*seg!ent elevation !ocardial in'arction %S)EMI topresentations 'ound in non+S)*seg!ent elevation !ocardial in'arction %NS)EMIor in unsta,le angina- In ter!s o' pat(olog2 ACS is al!ost alwas associatedwit( rupture o' an at(erosclerotic pla.ue and partial or co!plete t(ro!,osis o't(e in'arct*related arter- %See Etiolog-

In so!e instances2 (owever2 sta,le coronar arter disease %CAD !a result inACS in t(e a,sence o' pla.ue rupture and t(ro!,osis2 w(en p(siologic stress%eg2 trau!a2 ,lood loss2 ane!ia2 in'ection2 tac(arr(t(!ia increases de!andson t(e (eart- )(e diagnosis o' acute !ocardial in'arction in t(is setting re.uiresa 0nding o' t(e tpical rise and 'all o' ,ioc(e!ical !ar1ers o' !ocardialnecrosis in addition to at least 6 o' t(e 'ollowing9: %See $or1up-/

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Isc(e!ic s!pto!s

Develop!ent o' pat(ologic waves

Isc(e!ic S)*seg!ent c(anges on electrocardiogra! %ECG or in t(e setting o' acoronar intervention

)(e ter!s trans!ural and nontrans!ural %su,endocardial !ocardial in'arctionare no longer used ,ecause ECG 0ndings in patients wit( t(is condition are notclosel correlated wit( pat(ologic c(anges in t(e !ocardiu!- )(ere'ore2 atrans!ural in'arct !a occur in t(e a,sence o' waves on ECGs2 and !an *wave !ocardial in'arctions !a ,e su,endocardial2 as noted on pat(ologice4a!ination- ecause elevation o' t(e S) seg!ent during ACS is correlated wit(coronar occlusion and ,ecause it a5ects t(e c(oice o' t(erap %urgentreper'usion t(erap2 ACS*related !ocardial in'arction s(ould ,e designatedS)EMI or NS)EMI- %See $or1up-

Attention to t(e underling !ec(anis!s o' isc(e!ia is i!portant w(en!anaging ACS- A si!ple predictor o' de!and is rate*pressure product2 w(ic( can,e lowered , ,eta ,loc1ers %eg2 !etoprolol or atenolol and painstress relievers%eg2 !orp(ine2 w(ile suppl !a ,e i!proved , o4gen2 ade.uate (e!atocrit2,lood t(inners %eg2 (eparin2 II,IIIa agents suc( as a,ci4i!a,2 epti0,atide2tiro0,an2 or t(ro!,oltics2 andor vasodilators %eg2 nitrates2 a!lodipine- %SeeMedications-

In B8682 t(e A!erican >eart Association %A>A pu,lis(ed new guidelinereco!!endations 'or t(e diagnosis and treat!ent o' ACS-97:

Etiolog

Acute coronar sndro!e %ACS is caused pri!aril , at(erosclerosis- Mostcases o' ACS occur 'ro! disruption o' a previousl nonsevere lesion %anat(erosclerotic lesion t(at was previousl (e!odna!icall insigni0cant etvulnera,le to rupture- )(e vulnera,le pla.ue is tpi0ed , a large lipid pool2nu!erous in?a!!ator cells2 and a t(in2 0,rous cap-

Elevated de!and can produce ACS in t(e presence o' a (ig(*grade 04edcoronar o,struction2 due to increased !ocardial o4gen and nutritionre.uire!ents2 suc( as t(ose resulting 'ro! e4ertion2 e!otional stress2 orp(siologic stress %eg2 'ro! de(dration2 ,lood loss2 (potension2 in'ection2t(roto4icosis2 or surger-

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ACS wit(out elevation in de!and re.uires a new i!pair!ent in suppl2 tpicalldue to t(ro!,osis andor pla.ue (e!orr(age-

)(e !a3or trigger 'or coronar t(ro!,osis is considered to ,e pla.ue rupture

caused , t(e dissolution o' t(e 0,rous cap2 t(e dissolution itsel' ,eing t(e resulto' t(e release o' !etalloproteinases %collagenases 'ro! activated in?a!!atorcells- )(is event is 'ollowed , platelet activation and aggregation2 activation o't(e coagulation pat(wa2 and vasoconstriction- )(is process cul!inates incoronar intralu!inal t(ro!,osis and varia,le degrees o' vascular occlusion-Distal e!,oli=ation !a occur- )(e severit and duration o' coronar arterialo,struction2 t(e volu!e o' !ocardiu! a5ected2 t(e level o' de!and on t(e(eart2 and t(e a,ilit o' t(e rest o' t(e (eart to co!pensate are !a3ordeter!inants o' a patientOs clinical presentation and outco!e- %Ane!ia and(po4e!ia can precipitate !ocardial isc(e!ia in t(e a,sence o' severereduction in coronar arter ,lood ?ow-

A sndro!e consisting o' c(est pain2 isc(e!ic S)*seg!ent and )*wave c(anges2elevated levels o' ,io!ar1ers o' !octe in3ur2 and transient le't ventricularapical ,allooning %ta1otsu,o sndro!e (as ,een s(own to occur in t(e a,senceo' clinical CAD2 a'ter e!otional or p(sical stress- )(e etiolog o' t(is sndro!eis not well understood ,ut is t(oug(t to relate to a surge o' catec(ol stress(or!ones andor (ig( sensitivit to t(ose (or!ones-

Prognosis

Si4*!ont( !ortalit rates in t(e Glo,al Registr o' Acute Coronar Events%GRACE were 6< 'or patients wit( NS)EMI ACS and < 'or t(ose wit( unsta,leangina-

An elevated level o' troponin %a tpe o' regulator protein 'ound in s1eletal andcardiac !uscle per!its ris1 strati0cation o' patients wit( ACS and identi0espatients at (ig( ris1 'or adverse cardiac events %ie2 !ocardial in'arction2 deat(up to J !ont(s a'ter t(e inde4 event-92 J: %See $or1up-

)(e PR"#E I)*)IMI trial 'ound t(at a'ter ACS2 a @*s(aped or U*s(aped curveassociation is o,served ,etween P and t(e ris1 o' 'uture cardiovascular events-9Q:

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LeLei1o et al deter!ined t(at seru! c(oline and 'ree %B*isoprostane are alsopredictors o' cardiac events in ACS- )(e aut(ors evaluated t(e prognostic valueo' vascular in?a!!ation and o4idative stress ,io!ar1ers in patients wit( ACS todeter!ine t(eir role in predicting 8*da clinical outco!es- Seru! %B*isoprostane (ad an opti!al cuto5 level o' 6B7- pg!L2 and seru! c(oline (ad acuto5 level o' 8- !olL- C(oline and %B*isoprostane (ad a positive predictive

value o' 77< and Q< and a negative predictive value o' ;< and ;8

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was t(e ,iggest 'raction o' Kpre*(ospital ti!e- )(e stud co!pared groups wit(total ti!e to treat!ent o' !ore t(an 6B8 !inutes co!pared wit( 6B8 !inutes orless and 'ound !ortalities were 7 co!pared wit( 8 and trans'ers to a tertiarcare 'acilit were co!pared wit( 62 respectivel-

Patient Education

Patient education o' ris1 'actors is i!portant2 ,ut !ore attention is neededregarding delas in door*to*,alloon ti!e2 and one !a3or ,arrier to i!proving t(isdela is patient education regarding (is or (er s!pto!s- Lac1 o' recognition o's!pto!s !a cause tre!endous delas in see1ing !edical attention-

Educate patients a,out t(e dangers o' cigarette s!o1ing2 a !a3or ris1 'actor 'or

coronar arter disease %CAD- )(e ris1 o' recurrent coronar events decreases8< at 6 ear a'ter s!o1ing cessation- Provide all patients w(o s!o1e wit(guidance2 education2 and support to avoid s!o1ing- S!o1ing*cessation classess(ould ,e o5ered to (elp patients avoid s!o1ing a'ter a !ocardial in'arction-upropion increases t(e li1eli(ood o' success'ul s!o1ing cessation-

Diet plas an i!portant role in t(e develop!ent o' CAD- )(ere'ore2 prior to(ospital disc(arge2 a patient w(o (as (ad a !ocardial in'arction s(ould ,eevaluated , a dietitian- Patients s(ould ,e in'or!ed a,out t(e ,ene0ts o' a low*c(olesterol2 low*salt diet- In addition2 educate patients a,out A>A dietar

guidelines regarding a low*'at2 low*c(olesterol diet-

A cardiac re(a,ilitation progra! a'ter disc(arge !a rein'orce education anden(ance co!pliance-

)(e 'ollowing !ne!onic !a use'ul in educating patients wit( CAD regardingtreat!ents and li'estle c(anges necessitated , t(eir condition/

A Aspirin and antianginals

eta ,loc1ers and ,lood pressure %P

C C(olesterol and cigarettes

D Diet and dia,etes

E E4ercise and education

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or patients ,eing disc(arged (o!e2 e!p(asi=e t(e 'ollowing/

)i!el 'ollow*up wit( pri!ar care provider

Co!pliance wit( disc(arge !edications2 speci0call aspirin and ot(er!edications used to control s!pto!s

Need to return to t(e ED 'or an c(ange in 're.uenc or severit o' s!pto!s

Proceed to Presentation

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