1. Acute Coronary Syndromes

2. Learning outcomes To understand the clinical spectrum of coronary disease To recognise different presentations of the disease process To be aware of the different treatment options for each clinical presentation

3. Acute coronary syndromes Spectrum of clinical presentation caused by: Atherosclerotic plaque rupture Smooth muscle constriction Thrombus formation

4. Fissured plaque

5. Acute coronary syndromes Clinical syndromes caused by the same disease process: Unstable angina Non-ST-elevation myocardial infarction ST-elevation myocardial infarction

6. Stable angina Pain or discomfort from myocardial ischaemia: Tightness/ache usually across chest May radiate to throat/arms/back/epigastrium Consistently provoked by exercise Settles when exercise stops NOT an acute coronary syndrome

7. Unstable angina 1. Angina on exertion with increasing frequency over a few days, provoked by less exertion 2. Angina occurring recurrently and unpredictably - not specific to exercise 3. Unprovoked and prolonged episode of chest pain ECG may be normal ST segment depression suggests high risk No troponin release Cardiac enzymes usually normal or

8. Acute ST depression

9. Non-ST-elevation myocardial infarction (NSTEMI) Symptoms suggesting acute MI Non-specific ECG abnormalities ST segment depression T wave inversion Troponin release Usually elevated cardiac enzymes e.g. creatine kinase (CK)

10. NSTEMI

11. ST-elevation myocardial infarction (STEMI) Symptoms suggesting acute MI Acute ST segment elevation Q waves likely to develop Troponin release Usually elevated cardiac enzymes (e.g. CK) Early effective treatment may limit myocardial damage and prevent Q wave development Atypical presentation possible e.g. diabetics

12. Anterolateral STEMI

13. Left bundle branch block

14. Immediate treatment for all acute coronary syndromes ABCDE approach Aspirin 300 mg orally (crush/chew) Nitrate (GTN spray or tablet) Tablet preferred in event of first ever exposure to nitrates Oxygen if appropriate Morphine (or fentanyl or diamorphine)

15. Unstable angina and NSTEMI Anti-thrombotic Aspirin Clopidogrel or prasugrel (Prasugrel for PCI patients only) LMW heparin or fondaparinux If very high risk: glycoprotein IIb/IIIa inhibitor (e.g. Tirofiban) Pain relief Nitrate Morphine Betablocker Oxygen if appropriate Myocardial protection Beta blocker Coronary angiography/PCI in many patients

16. STEMI (or acute MI with new LBBB) Emergency reperfusion therapy: Percutaneous coronary intervention (PCI) Fibrinolytic therapy Effective if given early – only choice for many remote areas Caution in ATSI population with choice of agent Avoid delay – “Time is muscle”

17. Access to emergency reperfusion

18. Absolute contraindications to fibrinolytic therapy Previous haemorrhagic stroke Other stroke or CVA within 6 months CNS damage or neoplasm Active internal bleeding Aortic dissection Recent major surgery or trauma Known bleeding disorder

19. STEMI – further management Anti-thrombotic/platelet therapy Beta blocker ACE inhibitor Statin Coronary angiography and reperfusion strategies e.g. PCI

20. Any questions?

21. Summary Recognise the different presentations Use ABCDE approach Start appropriate immediate treatment Arrange emergency reperfusion therapy when appropriate Identify other high-risk patients for further investigation and treatment

22. Advanced Life Support Course Slide set All rights reserved © Australian Resuscitation Council and Resuscitation Council (UK) 2010