Acute Coronary Syndrome (ACS)

  Hi guys!

From previous post, the topic that we discuss is about chest discomfort. Based on the differentials acute coronary syndrome is one of it hence, what is ACS? 

In UA, myocardial injury is absent and cardiac biomarkers are normal.

In myocardial injury, cardiac biomarkers are raised.

It is important to distinguish between myocardial injury and myocardial infarction
(MI).

Myocardial Injury	Myocardial Infarction (MI)
Myocardial injury may be due to: • ischaemia and/or • non-ischaemic causes (eg myocarditis, renal failure)	MI is myocardial injury due to ischaemia. It is defined pathologically as myocardial cell death due to prolonged ischaemia.

MI is diagnosed when there is a rise and/or fall in cardiac troponins, with at least
one value above the 99th percentile of the URL, and accompanied with at least one
of the following:

     I.        Clinical history consistent with chest pain of ischaemic origin of > 30 minutes.
    II.        ECG changes of ischaemia/infarction and/or the development of pathological Q waves.
  III.        Imaging evidence of new loss of viable myocardium 

           or new regional wall motion abnormality.
  IV.        Identification of an intracoronary (IC) thrombus by angiography or autopsy.

MI may be STEMI or NSTE-ACS based on the ECG.

STEMI is diagnosed when there is:

• ST elevation of > 1 mm in 2 contiguous leads or

• a new onset LBBB in the resting ECG

more about LBBB - check out ->https://litfl.com/left-bundle-branch-block-lbbb-ecg-library/

• in a patient with ischaemic type chest pains of > 30 minutes and

• accompanied by a rise and fall in cardiac biomarkers.

In NSTE-ACS, ST elevation is absent on the resting ECG. In addition, patients having prolonged ischaemic type chest pain and having a non-interpretable resting ECG (eg paced rhythm, new RBBB etc) without ST elevation are having NSTE-ACS.

reference: CPG Management of Acute ST Elevation Myocardial Infarction (STEMI) (4^th ED) 2019; Malaysia

Pathogenesis: 

Acute coronary syndrome almost always occurs in patients who have atherosclerosis (already mention in previous post https://avisenaremarques.blogspot.com/2021/01/coronary-arterial-disease.html) .

credit 

https://www.thrombosisadviser.com/en/professionals/

reference: Haslett, C. (2018). Davidson’s Principles and Practise of Medicine. (23^rd Edition). London: Churchill Livingstone.

* vomiting is a symptom

Symptoms:

Signs:

Immediate investigation:

• ECG
• cardiac biomarkers
• - troponins
  
• - CK-MB

reference: CPG Management of Acute ST Elevation Myocardial Infarction (STEMI) (4^th ED) 2019; Malaysia

unable to imagine what is time to wire, this video can help you understand it clearly:

*might be a bit different to our country but most of it similar and the most important term here is 

TIME IS MUSCLE/MYOCARDIUM

credit: 

https://www.nhrmc.org/

credit: 

https://www.mercy.net/

For NSTE- ACS:

Pre-hospital Management

Based on the triage:
If the history is suggestive of ACS :

-Give soluble aspirin 300 mg crushed stat

- Give sublingual GTN

- Do 12 lead ECG and cardiac biomarkers

If the ECG and cardiac biomarkers are suggestive of ACS

- Give clopidogrel 300 mg stat if available.

- Send the patient to the nearest healthcare facility where definitive treatment can be given.

If the ECG and cardiac biomarkers are inconclusive for ACS

Low risk patients : they can be referred as outpatient for cardiac assessment. 

Intermediate / High Risk patients : should be admitted

REFERENCE: CPG MANAGEMENT OF UNSTABLE ANGINA/NON ST ELEVATION MYOCARDIAL INFARCTION (UA/NSTEMI) 2011; MALAYSIA

CAD prevention

 

Coronary Arterial Disease

 

reference:

Haslett, C. (2018). Davidson’s Principles and Practice of Medicine. (23^rd Edition). London: Churchill Livingstone.

reference:Toy, E. C., T., P., & Warner, M. T. (2009). Case files internal medicine. New York: MCGRAW-HILL.

more info on CAD:

https://www.cdc.gov/heartdisease/coronary_ad.htm

more visual, to see beyond

https://www.youtube.com/watch?v=flJsXOMhuK0

credit 

https://www.thrombosisadviser.com/en/professionals/

continue: chest discomfort

 DDX

Life threatening :

• ·        ACS – MI or unstable angina
• ·        Pulmonary embolism
• ·        Aortic dissection

Other differential:

Haslett, C. (2018). Davidson’s Principles and Practise of Medicine. (23^rd Edition). London: Churchill Livingstone. 

From the differential diagnosis 

 lets find the culprit!!

IS IT ACS (acute coronary syndrome)? 

IS IT due to pulmonary embolus?

AORTIC disection?

OR OTHERS? 

to know which is the culprit we need to have a good knowledge on each disease.. 

hence, lets us learn each of it and we get back to this later😎

chest discomfort

 

reference:

Toy, E. C., T., P., & Warner, M. T. (2009). Case files internal medicine. New York: MCGRAW-HILL.

credit: Medical City ER

Already have differential in mind? 

Focus on life threatening first!

 

DDX

Life threatening :

• ·        ACS – MI or unstable angina
• ·        Pulmonary embolism
• ·        Aortic dissection

Other differential:

Red flag pointers for acute chest pain

• Dizziness/syncope

• Pain in arms L>R, jaw

• Thoracic back pain

• Sweating

• Palpitations

• Dyspnoea

• Pain or inspiration

• Pallor

• Past history: ischaemia, diabetes, hypertension

Chest pain represents an acute coronary event until proved otherwise.

reference:

Talley, N. J., & O'Connor, S. (2013). Clinical examination: A systematic guide to physical diagnosis (7th ed.). London: Elsevier.

Hall, T. (2013). PACES for the MRCP: With 250 clinical cases (Third ed.). Edinburgh etc., Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto: Churchill Livingstone/Elsevier.

Haslett, C. (2018). Davidson’s Principles and Practise of Medicine. (23^rd Edition). London: Churchill Livingstone. 

 

to be continue....

Becoming a detective in medical field

 

This blog is dedicated for my buddy line and even for me. Interchange the language between English and Malay do help me in understanding. I don’t care if others would judge me about the language, my aim is to understand more. And, when I understand, then I will remember, right? Well in this blog it is more about case discussion in super basic ways. It might evolve one day as I go along the journey of becoming a good doctor. So be it! Have fun while learning while helping others.