21- Non ST segment elevation Acute Coronary Syndrome I. Etiology, manifestations, diagnosis.

what is acute coronary syndrome

• inbalance of O2 supply + demand

what are the types of ACS without ST elevation

• unstable angina

• NSTEMI

what is the cause of NSTEMI

• partial coronary occlusion

  • usually not complete occlusion

what are the characteristics of NSTEMI

• more freqent than STEMI

• most common indication for coronography

• patients are usually older than in STEMI

• more comorbidities in patients

• equal or wosrse prognosis than STEMI

what are the causes of O2 supply decrease

• acute coronary perfusion deficit

• acute cardiac but not coronary origin

• extracardiac origin

  • severe anaemia

what are the causes of acute coronary perfusion deficits

• C plaque rupture → partial or total occlusion

• C a. stenosis

• C a. spasm

  • prinzmetal angina, cocaine, takotsubi

• C embolisation

what are the causes of acute cardiac but not coronary origin

• severe aortic stenosis

• cardiac decompensation

what are the causes of O2 demand increase

• heavy exercise

• hyperthyrosis

• shock

• sepsis

describe prinzmetal angina

• temporary partial or total coronary occlusion due to coronary spasm

• mainly:

  • at dawn

  • in smoker, middle age women

• can lead to malignant arrhythmia- VF

• urgent coronography

• prognosis is different

  • with coronary stenosis w/o revascualrisation poor, with is good

  • w/o coronary stenosis with medical treatment is good

what are the risk factors for ACS

• family history

• smoking

• HT

• hypercholesterinemia

• DM

what are the complaints in ACS

• pain

• shortness of breath

• sweating

• dizziness

• fear from death

what is visible upon inspection of ACS pts

• pallor, anaemia

• cyanosis

• shortness of breath, orthopnea, periodic (cheyne stokes) respiration

• distention of collar veins

what are the laboratory tests performed

• biomarker release

  • troponin T and I

  • CK- MB

what is the Wash out phenomenon

• rapidly and higher peak of cardiac marker after successful reperfusion therapy

what are the ECG findings

• must be made within 10 min of first contact

• ST segment depression

• T wave inversions

what are some other diseases that mimic the same ECG findings

• ischemia

• CVA

• apical HCM

what is the Dx

• PE

• acute aortic syndrome

  • haematoma, penetrating atherosclerotic ulcer, aortic dissection

• other

  • pleuritis

  • gastro oesophageal disease

  • myositis

  • gastric or duodenal ulcer

  • gallbladder pain

what is the risk stratification

• calculation of acute and long term prognosis

what is the risk stratification based on

• clinical condition

• co morbidity

  • suggests high probability of CHD

• GRACE score

what is the clinical condition in risk stratification

• ongoing chest pain

• haemodynamic status

  • HF, cardiogenic shock, resuscitation

• complication- arrhythmia, mechanical complication

what is NSTE

• NSTEMI → subendocardial infarction → due to partial occlusion of coronary artery

• more common than STEMI

• most common indication of coronary angiography

what is the cause of NSTE ACS

• subendocarial ischemia

what is NSTEMI

• subendocardial necrosis → irreversible injury/ death

• increased cardiac biomarkers

• ST depression + T inversion

what are the comorbidities in NSTE

• DM

• impaired LV function

• previous myocardial infarction

• previous coronary revascularisation- PCI, CABG

what is the GRACE score

risk model that takes different factors into account

()

when is ACS NSTEMI very high risk

• needs immediate invasive strategy

• refractory/ recurrent angina despite intense antianginal treatment

• deep ST depression >2mm in V1-4

• HF or shock

• life threatening arrhythmias

• resuscitation

• other complications

when is ACS NSTEMI high risk

• early invasive needed <24h

• GRACE score ≥140

• elevated troponin

• dyanmic ST-T changes

• DM

• renal failure

• depressed LV function EF<40%

• early post MI angina

• PCI within 6 months

• previous CABG

• intermediate or high risk according to risk score

what are the complications of ACS

• arrhythmias

• HF- LV mass loss >40%

• mechanic complications

what are the life threatening arrhythmias in ACS

• ventricular tachycardia/ ventricular fibrillation

• II-III degree AV block

describe the HF in ACS

• pulmonary congestion

• cardiogenic shock

• RV failure- impaired filling pressure

describe the mechanical complications in ACS

• mitral papillar rupture- acute mitral regurgitation

• ventricular septal rupture

• free wall rupture- pericardial tamponad