4. Acute coronary syndrome is a term used to describe a range of
conditions associated with sudden, reduced blood flow to the
heart muscle result in impaired myocardial oxygen supply and
demand.
1. STEMI
2. NSTEMI
3. Unstable Angina
5. • symptoms and signs of myocardial ischemia either at rest
or with minimal exertion.
• substernal chest pain or
• discomfort that may radiate to the jaw, left shoulder or arm. Dyspnea,
nausea,
• diaphoresis, or syncope may either accompany the chest
discomfort or may be the only symptom of acute coronary
syndrome.
• About one-third of patients with MI have no
chest pain per se—these patients tend to be older, female,have
diabetes, and be at higher risk for subsequent mortality.
6.
7. • signs of heart failure in about 10% of cases, and this is also
associated with higher risk of death.
8. Risk factors
• Modifiable
– Hypertension
– DM
– Smoking
– Dyslipedemia
– Obesity
• Non Modyfyable
– Age
– Sex
– Family Hx
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. Management
• Hospitalization
• Strict bed rest
• Sedation with Benzodiazepine
• Heparin , antiplatelet, nitrate and Beta Blockers
• Revascularization
21. Dyslipidemia treatment
• The treatment of dyslipidemia is central in aiming for
– long-term relief from angina,
– reduced need for revascularization, and
– reduction in myocardial infarction and death.
• The control of lipids can be achieved by the combination of
medicine, a diet low in saturated and transunsaturated fatty
acids, exercise, and weight loss.
22. Anticoagulation
• since use of anticoagulants can cause increased bleeding intra- and
postoperatively.
• Alternatively, too little anticoagulation can lead to severe morbidity
(eg, stroke, MI, and stent thrombosis) and even death.
•
23. Antiplatlets
• Aspirin, P2Y12 Inhibitors Prasugrel, Ticagrelor, and Clopidogrel
• dual antiplatelet therapy is indicated for 1 year in
all patients (including those with medical therapy and these
patients undergoing revascularization irrespective of stent type).
24. Fibrinolytic
• Fibrinolytic therapy reduces mortality and limits infarct size in
patients with STEMI
• Contra indicated in
• Previous hemorrhagic stroke
• Cerebrovascular events with one year
• Intracranial neoplasm
• Recent head trauma
• Acute internal bleeding (except menses)
• Suspected aortic dissection
25. cont
• Relatively contraindicated in
• BP>180/110 mmHg
• Trauma within 2-4 weeks
• Major surgery within 3 weeks
• Diabetic retinopathy
• Pregnancy
• Active peptic ulcer disease
• INR> 2-4
• Allergic reaction history with streptokinase
26. • The organic nitrates are a valuable class of drugs in the
management of angina pectoris .
• Their major mechanisms of action include systemic venodilation
with concomitant reduction in LV end-diastolic volume and pressure,
thereby reducing myocardial
wall tension and oxygen requirements;
• dilation of epicardial coronary vessels; and increased blood flow in
collateral vessels.
• Nitrates also exert antithrombotic activity
27. Beta Blockers
• a-Adrenergic Blockers These drugs represent an important
component of the pharmacologic treatment of angina pectoris.
• They reduce myocardial oxygen demand by
• inhibiting the increases in heart rate,
• arterial pressure, and
• myocardial contractility caused by adrenergic activation.
28. Calcium channel blockers
• are coronary vasodilators that produce variable and dose dependent
reductions in myocardial oxygen demand, contractility,
and arterial pressure.
• These combined pharmacologic effects are
advantageous and make these agents as effective as beta blockers
They are indicated when beta blockers are contraindicated, poorly
tolerated, or ineffective.
• They are more likely to aggravate LV failure, particularly when used
in patients with LV dysfunction, especially if the patients are
also receiving beta blockers.
29. ACE inhibators
• ACE inhibitors reduce mortality by approximately 20% in patients with
symptomatic heart failure
• prevent ho spitalizations,
• increase exercise tolerance, and
• reduce symptoms in these patients.
• As a result, ACE inhibitors generally should
be part of first-line treatment of patients with symptomatic
LV systolic dysfunction (EF less than 40%)
30. Revascularization
• Symptoms Despite medical therapy
• Left Main coronary artery stenosis >50% with or without
symptoms
• Three Vessels disease with LVEF < 50% or previous MI
• U/A after Symptoms control by medical therapy continue to
exhibit ischemia
• Post MI continue Angina severe ischemia
• Two vessels disease
– LV dysfunction
– Critical lesion > 90%
– Early positive ETT
