{"id":9557,"date":"2021-12-26T23:23:06","date_gmt":"2021-12-26T20:23:57","guid":{"rendered":"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/acute-coronary-syndrome-symptoms-diagnostic-complications\/"},"modified":"2022-01-01T14:13:08","modified_gmt":"2022-01-01T12:13:08","slug":"acute-coronary-syndrome-symptoms-diagnostic-complications","status":"publish","type":"page","link":"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/acute-coronary-syndrome-symptoms-diagnostic-complications\/","title":{"rendered":"Acute coronary syndrome (symptoms, diagnostic, complications, PCI, CABG, secondary prevention)"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Acute coronary syndrome (ACS) is the clinical manifestation of coronary occlusion, due to atherosclerotic plaque rupture or thrombosis.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>ACS presents as <strong>unstable angina<\/strong>, <strong>NSTEMI<\/strong>, or <strong>STEMI<\/strong>.<\/li><li>The outcome depends on the severity of the obstruction and which vessel is occluded.<\/li><\/ul>\n\n\n<span class=\"block-heading\" id=\"header_1\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Presentation<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_1\">\n\n<\/span><span class=\"block-heading\" id=\"header_2\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">Unstable angina<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_2\">\n\n\n<p class=\"wp-block-paragraph\">Angina pectoris occurs due to insufficient oxygen supply to the heart. <\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Stable angina<\/strong> is due to insufficient oxygen supply <strong>during <\/strong>increased demand (e.g. exercise)<\/li><li><strong>Unstable angina<\/strong> is due to insufficient oxygen supply <strong>without <\/strong>increased demand (i.e. rest)<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Unstable angina is angina pectoris which:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><strong>Appears at rest<\/strong> (&gt;20min)<\/li><li><strong>New onset angina that is severe and progressive<\/strong><\/li><li><strong>Any change in the characteristics of an existing stable angina<\/strong> (duration, frequency, onset, intensity, flavor)<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">It may appear with transient ECG changes (ST-elevation\/depression, T-wave inversion).<\/p>\n\n\n<\/span><span class=\"block-heading\" id=\"header_3\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">NSTEMI<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_3\">\n\n\n<p class=\"wp-block-paragraph\">NSTEMI is MI limited to only the inner third of the myocardium (<strong>subendocardial MI<\/strong>), leading to necrosis.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>As myocardial necrosis is taking place, CK-MB and troponin-I\/T elevation (&lt;1.0ng\/L) can be detected.<\/li><li>NSTEMI produces <strong>no <\/strong>ST-elevation in the ECG (but may present with ST-depression, T-wave inversion, and rarely, pathologic Q-waves).<\/li><li>The difference ebwteen unstable angina and NSTEMI in terms of findings is the elevated cardiac markers which are seen in NSTEMI but not UA.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_4\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">STEMI<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_4\">\n\n\n<p class=\"wp-block-paragraph\">STEMI is MI affecting the full-thickness of the myocardium (<strong>transmural MI<\/strong>). It has the worst prognosis out of the three.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Cardiac markers are present and are substantially elevated (CK-MB and troponin).<\/li><li>STEMI produces ST-elevation (1mm or more) and may produce pathologic Q-waves.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_5\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Symptoms<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_5\">\n\n\n<ul class=\"wp-block-list\"><li>Chest pain and tightness<\/li><li>Pain radiating to the shoulder, neck, arm, jaw<\/li><li>Nausea and vomiting<\/li><li>Dyspnea<\/li><li>Heavy sweating<\/li><li>Feeling of fainting<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_6\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Diagnosis<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_6\">\n\n\n<ul class=\"wp-block-list\"><li><strong>Cardiac markers<\/strong> (myoglobin, CK-MB, Tn)<ul><li>Help differentiate between unstable angina and NSTEMI.<\/li><li>Cardiac markers in STEMI are substantially higher than in NSTEMI.<\/li><\/ul><ul><li>Myoglobin is the first to elevate, but is not specific for MI<\/li><li>CK-MB and troponin-I\/T can be detected as early as 4 hours<\/li><li>LDH and Troponins can be detected for much longer than CK-MB<\/li><li>New hs-cTn (high-sensitive) essay can detect much lower levels of troponin, allowing even earlier diagnosis than the standard essays (cTn).<\/li><\/ul><\/li><li><strong>ECG<\/strong><ul><li>STEMI presents with ST-elevations (1mm or more) and may produce pathologic Q-waves.<\/li><li>Other changes (T-wave inversion, R-wave changes, arrhythmias) may also be present in UA and NSTEMI.<\/li><\/ul><\/li><li><strong>Echocardiography <\/strong>(can detect ischemia, wall motion, LV size and function, valvular disease)<\/li><li><strong>Coronary angiography<\/strong> (immediate for STEMI, delayed for NSTEMI and unstable angina)<\/li><li><strong>Stress-testing is contraindicated in ASC!<\/strong><\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_7\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Treatment<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_7\">\n\n\n<p class=\"wp-block-paragraph\">The treatment plan consists of <strong>early treatment<\/strong> (stabilization), <strong>revascularization<\/strong>, and <strong>post-ACS therapy<\/strong>.<\/p>\n\n\n\n<ol class=\"wp-block-list\"><li>Early treatment (stabilization)<ol><li>Patients suspected for ACS should be given <strong>aspirin<\/strong> (325mg chewable) immediately as symptoms appear, and admitted to the hospital.<\/li><li>Create IV-access, provide oxygen, analgesics (morphine + metoclopramide), nitrates sublingually or as a spray (better), along with:<ul><li><strong>Heparin<\/strong><\/li><li><strong>Beta blockers <\/strong>administered IV (<strong>metoprolol<\/strong>, <strong>atenolol<\/strong>) which help reduce the risk of arrhythmias and decrease cardiac oxygen demand.<\/li><li>Nicorandil (vasodilator), ivabradin (funny-current inhibitor)<\/li><\/ul><\/li><\/ol><\/li><li>Revascularization<ul><li>In case of <strong>STEMI<\/strong> or <strong>complicated NSTEMI\/UA<\/strong> (recurrence in spite of treatment and unstable patients):<ol><li><strong>Urgent angiography<\/strong> and <strong>PCI <\/strong>if available <strong>within 90 minutes<\/strong><\/li><li>If PCI is not available, start with fibrinolytic therapy (streptokinase or tPa) and perform PCI as soon as possible.<\/li><\/ol><\/li><li>In patients not suitable for PCI (see below), perform <strong>CABG<\/strong>.<\/li><\/ul><\/li><li>Post-ASC therapy<ul><li><strong>ACEi<\/strong> (lisinopril) or <strong>ARB<\/strong><\/li><li><strong>Clopidogrel<\/strong> along with abcixiban, specially after PCI<\/li><li><strong>High-dose statins<\/strong><\/li><\/ul><\/li><\/ol>\n\n\n<\/span><span class=\"block-heading\" id=\"header_8\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Complications<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_8\">\n\n\n<ul class=\"wp-block-list\"><li>Arrthythmias<\/li><li>Heart failure and cardiogenic shock<\/li><li>Ventricular pseudoaneurysm, aneurysm and rupture<\/li><li>Intramural thrombus formation<\/li><li>Papillary muscle necrosis and mitral regurgitation<\/li><li>Pericarditis (Dressler post-MI syndrome; appearing 2 weeks as an autoimmune reaction)<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_9\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Revascularization<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_9\">\n\n\n<p class=\"wp-block-paragraph\">The revascularization is done by PCI or CABG.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Before performing the interventions, heparin, clopidogrel, and GPIIb\/IIIa inhibitors are discontinued. Aspirin and beta-blockers are allowed. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Generally, PCI is preferred, but the choice of intervention depends on several factors, namely the <strong>SYNTAX score<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">SYNTAX score is a scoring system to help determine which procedure should be done. Generally, a score over 22 means that CABG is preferable.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Examples for cases in which CABG may be preferred over PCI (they are a part of the SYNTAX score):<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>LV dysfunction<\/li><li>DM<\/li><li>Multiple lesions, and lesions near bifurcations or proximal LAD<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">The procedures are followed by additional imaging and the patients are monitored closely.<\/p>\n\n\n<\/span><span class=\"block-heading\" id=\"header_10\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">PCI<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_10\">\n\n\n<p class=\"wp-block-paragraph\">PCI is commonly used synonymously with coronary angiopolasty; it is a procedure used for treating narrowed coronary vessels.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Coronary angioplasty and stent implantation are minimally-invasive procedure involving the insertion of a catheter from the femoral\/radial artery into the coronaries under fluoroscopy, and the inflation of a balloon, and\/or the placement of a stent in the site of occlusion.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Once the catheter is placed in the coronary artery, the vasculasture is visualized using a radio-opaque dye.<\/li><li>A guidewire is passed into the site of occlusion. The angioplasty catheter is pushed to the site of the guidewire, and the balloon is inflated, compressing the atherosclerotic plaque.<\/li><li>Balloon angioplasty is rarely done on its own. Typically, a stent is placed on the balloon, and once it inflates, the stent opens and helps keep the vessel open.<\/li><li>The stent may be coated with polymers or drugs (drug-eluting) or uncoated (bare-metal).<\/li><li>According to current research, the stent is useful for the first three months after the procedure.<\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Other procedures could be done during PCI include atherectomy, and brachytherapy.<\/p>\n\n\n<\/span><span class=\"block-heading\" id=\"header_11\">\n<h4 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title2\">CABG<\/h4>\n<\/span><span class=\"block-content\" id=\"contents_11\">\n\n\n<p class=\"wp-block-paragraph\">Coronary artery bypass grafting is a much more demanding surgical procedure, in which a vascular graft is sewn to the site distal to the stenosis. The surgery is done under general anesthesia and intubation.<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>The procedure can be done using an &#8220;<strong>on-pump<\/strong>&#8221; or &#8220;<strong>off-pump<\/strong>&#8221; surgery:<ul><li>On-pump is the traditional technique in which the heart is connected to a heart-lung bypass machine and is stopped.<\/li><li>Off-pump is a newer method which is considered less invasive using fixation devices. It is considered a &#8220;beating heart surgery&#8221; with less complications but requires higher expertiese, not always possible, and has a higher graft failure and bleeding rate.<\/li><li>When muliple small vessels are affected, on-pump surgery is preferred.<\/li><\/ul><\/li><li>A medial sternotomy is performed to allow access to the heart. Newer methods (especially off-pump) may use a much smaller incision.<\/li><li>The bypass is performed:<ul><li>In case the <strong>internal thoracic artery<\/strong> is used (best outcome), its origin is left at its place, and the distal end is sewn to the site distal to the stenosis.<\/li><li>In case a vascular graft is collected from the radial artery or sephanous vein, one end is sewn to an opening made in the aorta, and the other end to the site distal to the stenosis.<\/li><li>Multiple bypasses and grafts may be required.<\/li><\/ul><\/li><li>Blood flow is tested and monitored using Doppler ultrasound.<\/li><li>A pacemaker may also be placed.<\/li><\/ul>\n\n\n<\/span><span class=\"block-heading\" id=\"header_12\">\n<h3 class=\"wp-block-heading\" class=\"wp-block-heading\" class=\"title_collection title1\">Primary and secondary prevention<\/h3>\n<\/span><span class=\"block-content\" id=\"contents_12\">\n\n\n<ul class=\"wp-block-list\"><li>Primary prevention aims to prevent MI in <strong>asymptomatic <\/strong>patients<ul><li>Diet, habits (smoking), exercise<\/li><\/ul><\/li><li>Secondary prevention aims to prevent MI in <strong>symptomatic<\/strong> patients<ul><li>Reduce blood pressure (ACEi\/ARBs, BB) and blood lipids (statins, ezetimibe)<\/li><\/ul><\/li><\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">References: https:\/\/www.thecardiologyadvisor.com\/home\/decision-support-in-medicine\/cardiology\/selecting-pci-cabg-or-medical-therapy-current-recommendations\/<\/p>\n<\/span><div id=\"the_titles\" style=\"display:none;\"><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Presentation<\/h3><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">Unstable angina<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">NSTEMI<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">STEMI<\/h4><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Symptoms<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Diagnosis<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Treatment<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Complications<\/h3><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Revascularization<\/h3><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">PCI<\/h4><h4 class=\"wp-block-heading\" class=\"wp-block-heading\">CABG<\/h4><h3 class=\"wp-block-heading\" class=\"wp-block-heading\">Primary and secondary prevention<\/h3><\/div>","protected":false},"excerpt":{"rendered":"<p>Acute coronary syndrome (ACS) is the clinical manifestation of coronary occlusion, due to atherosclerotic plaque rupture or thrombosis. ACS presents as unstable angina, NSTEMI, or STEMI. The outcome depends on the severity of the obstruction and which vessel is occluded. Presentation Unstable angina Angina pectoris occurs due to insufficient oxygen supply to the heart. Stable [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":410,"menu_order":8,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-9557","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Acute coronary syndrome (symptoms, diagnostic, complications, PCI, CABG, secondary prevention) &#8211; Meddists<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/meddists.com\/learn\/clinical\/internal-medicine\/cardiology\/acute-coronary-syndrome-symptoms-diagnostic-complications\/\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/cardiology\\\/acute-coronary-syndrome-symptoms-diagnostic-complications\\\/\",\"url\":\"https:\\\/\\\/meddists.com\\\/learn\\\/clinical\\\/internal-medicine\\\/cardiology\\\/acute-coronary-syndrome-symptoms-diagnostic-complications\\\/\",\"name\":\"Acute coronary syndrome (symptoms, diagnostic, complications, PCI, CABG, secondary prevention) &#8211; 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