Acute Coronary Syndromes

Acute Coronary
Syndromes
Dr. Horea Feier
Definition
• = an acute reduction of blood supply to the heart muscle
• Cardiovascular diseases are the leading cause of death in

industrialized countries
•
EPIDEMIOLOGY
CLINICAL PRESENTATIONS
OF CAD
• The clinical presentations of CAD include:
• silent ischaemia
• stable angina pectoris
• heart failure
• unstable angina
• myocardial infarction (MI)
• sudden death Acute Coronary Syndromes

Acute coronary syndromes
• ST-elevation ACS
• (STE-ACS):
• typical acute chest pain and

persistent (>20 min)
• ST-segment elevation
• generally reflects an acute

total coronary occlusion
• most will ultimately develop an

ST-elevation MI (STEMI).
STEMI
• non-STE-ACS
• (NSTE-ACS):
• acute chest pain
• without persistent
• ST-segment elevation
• persistent or transient ST segment

depression or
• T-wave inversion
• further qualified into non-ST elevation

MI (NSTEMI) or unstable angina.
NSTEMI
Physiopathology
• Atherothrombosis
• Atherosclerosis - a fixed and barely reversible process of

gradual luminal narrowing (slowly over decades)
• Thrombosis - a dynamic and potentially reversible

process causing rapid complete or partial occlusion of the
coronary artery
Risk Factors for
Atherosclerosis
• Major risk factors:
• Diabetes, HTA, Smoking, Dyslipidemia (LDL>100 mg/dl,

HDL< 60 mg/dl), Age (Men>45, Women>55), Family
history, Homocysteinemia, Sex
• Minor risk factors
• Obesity, Physical inactivity, Estrogen deficiency

Diagnosis of AMI
2 from 3 criteria must be fulfilled :
•Clinical symtoms
–Chest pain
•ECG changes
–ST elevation or depression
–negative T wave
•Elevated cardiac biomarkers
–Troponin I or T
–CK-MB
–myoglobin
Hospital vs. 1-year Mortality
Prognosis of STEMI vs.
NSTEMI
• The causes of the higher death rates of NSTE-ACS
than of STE-ACS pts. during long-term follow-up are:
• older pts.
• more co-morbidities (diabetes and renal failure).
• a greater extent of coronary artery and vascular diseases
• persistent triggering factors such as inflammation

Clinical diagnosis
• STE/NSTE-ACS:
• Intense prolonged (20 min) pain at rest - retrosternal pressure or heaviness (‘angina’)
radiating up to the neck, shoulder and jaw and down to the ulnar aspect of the left arm
• May be accompanied by other symptoms such as
• diaphoresis, nausea, abdominal pain, dyspnoea
• Unstable angina:
• New onset severe angina (class III of CCS)
• Recent destabilization of previously stable angina with
• at least CCS III angina characteristics (crescendo angina)
• Post-MI angina.
Clinical diagnosis
• Typical chest pain
• Nausea
• Sweating
Clinical diagnosis
• Atypical presentations are not uncommon
• epigastric pain
• recent-onset indigestion
• stabbing chest pain
• chest pain with some pleuritic features
• increasing dyspnoea
• often can be observed in younger (25-40y.), older (75y.

in women, in pts. with diabetes, chronic renal failure,
or dementia.
Physical examination
• Frequently normal
• Signs of heart failure or haemodynamic instability
• Diff. dg.:
• - nonischaemic cardiac disorders: pulmonary

embolism, aortic dissection, pericarditis, valvular
heart disease
• - extra-cardiac causes: pneumothorax,

pneumonia, pleural effusion
Physical examination
• Heart failure
• Tachycardia, tachypnoe
• Pulmonary rales (pulmonary congestion)
• RV failure - ↑ jugular congestion, hepatomegaly
• Hypotension ↓ 100/60 mmhg
• cardiac shock (tachycardia)
• ↑ vagal nerve activity (bradycardia - inferior IM)
• Bradycardia
• AV block
• Inferior IM - non-serious, frequent
• Anterior IM - serious, rare

ECG
• The first-line diagnostic tool
• ST segment elevation =>

STEMI
• no ST-segment elevation/
ECG normal => NSTEMI/
Unstable angina
A normal ECG doesn’t rule out AMI

Location of AMI
• ST elevation only:
• Anteroseptal - V1-V3
• Anterolateral - V1-V6
• Inferior wall - II, III, aVF
• Lateral wall - I, aVL, V4-V6
• Right ventricular - RV4,

RV5
• Posterior- R/S ratio >1 in

V1 and T wave inversion
Markers
• Markers of myocardial injury:
• cardiac troponins (I and T)

• creatinine kinase (CK)
• CK isoenzyme MB (CK-MB)
• Myoglobin
• repeated blood sampling and measurements are required 6–12 h

after admission and after any further episodes of severe chest pain
Markers
• Non-coronary condition with Troponin elevation
• Severe congestive heart failure
• Aortic dissection, valve disease
• Myocarditis
• Hypertrophic CMP, Stress CMP
• Hypertensive crisis
• Acute and chronic renal failure
• Cerebrovascular accident
Evolution of biochemical markers over time
Non-invasive exams
• Transthoracic ECHO
• Regional and global systolic

function
• Valve assessment (ischemic

MI)
• Presence of complications
(Free wall rupture,
Ventricular septal defect,
Papillary muscle rupture)
Invasive coronary imaging
• Coronary angiography= gold

standard!!!
• Visualization of coronary
anatomy
• Direct PCI/
Thrombusaspiration
Initial decision-making
Treatment of ACS
• Rationale:
• To provide as early a reperfusion as possible (“Time

is muscle”)
• Fibrinolysis (no PCI on-site)/PCI/Surgery (PCI

unsuitable, complications)
• Treatment: high-dose antiplatelet therapy to limit

extension of AMI, lowering O2 demand, vasodilators,
treatment of arrythmias, treatment of heart failure
Reperfusion strategies
Reperfusion according to time
(STEMI)
PCI
Aspiration thrombectomy
= the aspiration (suction) of thrombotic material from the occlusion site

CABG?
• CABG
• No role in uncomplicated
STEMI
• Preferred over PCI in

multivessel/left-main
NSTEMI
• Treatment of choice in
complicated STEMI
CABG?
• On-Pump or Off-Pump
CABG (OPCAB)?
• On-Pump- for most patients
• OPCAB- special subsets

(renal failure, low EF)
• Graft patency better On-

Pump
Mechanical complications
of AMI
1. LV Free Wall Rupture
2. Septum Rupture (Post MI VSD-Ventricular Septal Defect)
3. Papillary Muscle Rupture
4. Acute Aneurysm formation
Emergent Surgery!!!
LV Free Wall Rupture
• Rupture of the LV Wall into the

pericardium
• D3 after extensive AMI in

unprotected circulation
• Hemopericadium,
Tamponade=> Emergent
surgery!!
=> Emergent Surgery (Sutureless Patch Closure ± CABG)

Post AMI VSD
• Rupture of the ventricular

septum => VSD
• D3 after extensive AMI in

unprotected circulation
• Left-to-right shunt=> Acute

RV volume overload => RV
Failure => Hepatic, Renal,
Mesenteric injury
=> Emergent Surgery (VSD Patch Closure ± CABG)
Papillary Muscle Rupture
• Rupture of the postero-medial

Papillary Muscle => MR
• D3 after extensive, inferior

AMI in unprotected circulation
• Severe, Acute MR (mitral

regurgitation)=> Pulmonary
Edema => Acute Heart Failure
=> Emergent Surgery (Mitral replacement± CABG)

Acute LV Aneurysm
• Acute Aneurysm Formation
• Rare
• Muscle replaced by FIbrotic

Tissue => Dyskinesia =>
Acute Heart Failure
=> Surgery (LV Repair ± CABG)

Thank you!

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Acute Coronary

• = an acute reduction of blood supply to the heart muscle

• Cardiovascular diseases are the leading cause of death in

• stable angina pectoris

• myocardial infarction (MI)

• sudden death Acute Coronary Syndromes

• typical acute chest pain and

• generally reflects an acute

• most will ultimately develop an

• acute chest pain

• ST-segment elevation

• persistent or transient ST segment

• T-wave inversion

• further qualified into non-ST elevation

• Atherosclerosis - a fixed and barely reversible process of

• Thrombosis - a dynamic and potentially reversible

• Major risk factors:

• Diabetes, HTA, Smoking, Dyslipidemia (LDL>100 mg/dl,

• Minor risk factors

• Obesity, Physical inactivity, Estrogen deficiency

–ST elevation or depression

•Elevated cardiac biomarkers

• more co-morbidities (diabetes and renal failure).

• a greater extent of coronary artery and vascular diseases

• persistent triggering factors such as inflammation

• May be accompanied by other symptoms such as

• diaphoresis, nausea, abdominal pain, dyspnoea

• New onset severe angina (class III of CCS)

• Recent destabilization of previously stable angina with

• at least CCS III angina characteristics (crescendo angina)

• Typical chest pain

• Atypical presentations are not uncommon

• stabbing chest pain

• chest pain with some pleuritic features

• often can be observed in younger (25-40y.), older (75y.

• Signs of heart failure or haemodynamic instability

• - nonischaemic cardiac disorders: pulmonary

• - extra-cardiac causes: pneumothorax,

• Pulmonary rales (pulmonary congestion)

• RV failure - ↑ jugular congestion, hepatomegaly

• Hypotension ↓ 100/60 mmhg

• cardiac shock (tachycardia)

• ↑ vagal nerve activity (bradycardia - inferior IM)

• Inferior IM - non-serious, frequent

• Anterior IM - serious, rare

• The first-line diagnostic tool

• ST segment elevation =>

A normal ECG doesn’t rule out AMI

• Inferior wall - II, III, aVF

• Lateral wall - I, aVL, V4-V6

• Right ventricular - RV4,

• Posterior- R/S ratio >1 in

• cardiac troponins (I and T)

• repeated blood sampling and measurements are required 6–12 h

• Severe congestive heart failure

• Aortic dissection, valve disease

• Hypertrophic CMP, Stress CMP

• Acute and chronic renal failure

• Regional and global systolic