Acute Coronary syndromes REPORT PREPERD BY MASTER MOHAMMED ABD AL-KAREEM MUSTAFA SUPERVISERED BY PROF.DR.KHALEDA ALWAN

Blood Supply To The Heart The left and right coronary arteries and their branches supply arterial blood to the heart. These arteries originate from the aorta just above the aortic valve leaflets. The heart has large metabolic requirements, extracting approximately 70% to 80% of the oxygen delivered (other organs consume, on average, 25%). Unlike other arteries, the coronary arteries are perfused during diastole. An increase in heart rate shortens diastole and decrease myocardial perfusion. Patients, particularly those with coronary artery disease (CAD), can develop myocardial ischemia (inadequate oxygen supply) when the heart rate accelerates.

The left coronary artery has three branches The left coronary artery has three branches. The artery from the point of origin to the first major branch is called the left main coronary artery. Two bifurcations arise off the left main coronary artery. These are the left anterior descending artery, which courses down the anterior wall of the heart, and the circumflex artery, which circles around to the lateral left wall of the heart. The right side of the heart is supplied by the right coronary artery, which progresses around to the bottom or inferior wall of the heart. The posterior wall of the heart receives its blood supply by an additional branch from the right coronary artery called the posterior descending artery. Superficial to the coronary arteries are the coronary veins. Venous blood from these veins returns to the heart primarily through the coronary sinus, which is located posteriorly in the right atrium.

Coronary arteries (red vessels) arise from the aorta and encircle the heart. Coronary veins are shown in blue.

What is Heart Disease? Called Coronary Heart Disease or Coronary Artery Disease Diagnosed when arteries that supply blood to heart muscle becomes hardened and narrowed Caused by plaque on inner walls and called atherosclerosis Eventually Heart suffers from lack of oxygen and causes Chest pain Angina Heart Attack (Myocardial infarction)

Acute Coronary Syndrome: Definitions The term acute coronary syndromes is used to collectively describe acute myocardial infarction (heart attack) and unstable angina (chest pain occurring at rest, new onset of pain with exertion, or angina that is more frequent, longer in duration or lower in threshold than before). Chest pain: Angina: Severe constricting pain w/the sensation of choking/suffocating Heart attack: Blockage of a coronary artery causing tissue damage/death.

Acute: Sudden onset w/severe, sharp pain (compare to chronic) Syndrome: Group of symptoms characteristic of disease/disorder Myocardial: Referring to the heart muscle Ischemia: Decrease of blood supply

Transient Myocardial ischemia Definition : Myocardial Blood Flow Myocardial O2 Demands Transient Myocardial ischemia ACS Severe Chest pain = 8 BACK MAIN EXIT INDEX NEXT

Clogged arteries

Atheroscelerotic changes The underlying cause is Fissuring of atheroscelerotic plaques Platelet aggregation Thrombosis Coronary artery spasm Atheroscelerotic changes 10 BACK MAIN EXIT INDEX NEXT

Who can developing Coronary Artery Disease? (Risk Factors ) Nonmodifiable Risk Factors Family history of coronary heart disease Increasing age Gender (heart disease occurs three times more often in men than in premenopausal women) Race (higher incidence of heart disease in African Americans than in Caucasians) Modifiable Risk Factors High blood cholesterol level Cigarette smoking, tobacco use Hypertension Diabetes mellitus Lack of estrogen in women Physical inactivity Obesity

Signs and Symptoms None: This is referred to as silent ischemia. Blood to your heart may be restricted due to CAD, but you don’t feel any effects. Chest pain: If your coronary arteries can’t supply enough blood to meet the oxygen demands of your heart, the result may be chest pain. Shortness of breath: Some people may not be aware they have CAD until they develop symptoms of congestive heart failure- extreme fatigue with exertion, shortness of breath and swelling in their feet and ankles. Heart attack: Results when an artery to your heart muscle becomes completely blocked and the party of your heart muscles fed by that artery dies.

Assessing Chest Pain for Angina Pectoris

Assessing Chest Pain for myocardial infarction

Assessment of Angina and mi chest pain

Treatment of an acute attack of ACS Sublingual nitroglycerin (0.5 mg ) or isosorbide dinitrate (5 mg ) or Oral spray nitroglycerin (0.4 mg/metered dose), isosorbide dinitrate(1.25 mg/metered dose) Relief within 1-3 min. Persistence of pain Repeat nitroglycerin at 5 min. interval (3 tab. max.) Relief not relieved Infarction HOSPITALIZATION 18 BACK MAIN EXIT INDEX NEXT

Detection Methods Electrocardiogram –non-invasive (85% accurate) Stress Tests Angiograms –invasive (used in other 15% of cases) Blood tests: used to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Chest X-ray: shows the size of your heart and whether there is fluid build up around the heart and lungs. Echocardiogram: shows a graphic outline of the heart’s movement Ejection fraction (EF): determines how well your heart pumps with each beat.

Graduated exercise may open new collaterals General measures Treat Hypertension , Hypercholestrolimia and Diabetes Stop smoking Reduce weight AVOID Severe exertion Heavy meal Emotions Cold Weather Graduated exercise may open new collaterals 20 BACK MAIN EXIT INDEX NEXT

b. For immediate pre-exertional prophylaxis Drug Treatment a. For an acute attack b. For immediate pre-exertional prophylaxis c. For long-term prophylaxis d. Antiplatelet therapy. 21 BACK MAIN EXIT INDEX NEXT

Immediate pre-exertional prophylaxis of Angina Sublingual nitroglycerin (0.5 mg) or isorbide dinitrate (5 mg) should be taken 5 min. before effort. For Long term prophylaxis: Long acting nitrates, Ca++ channel blockers, b-blockers or combinations of these drugs. Antiplatelet therapy: Aspirin in small dose (75-150 mg daily orally) or Dipyridamole (75 mg t.d.s orally) 22 BACK MAIN EXIT INDEX NEXT

Coronary Artery Revascularization Coronary artery bypass grafting (CABG) Percutaneous Transluminal coronary Angioplasty (PTCA) For patients not responding to adequate medical therapy 23 BACK MAIN EXIT INDEX NEXT

Management of Unstable Angina Nitrate + b-blocker Aspirin (low dose) and/or Heparin or Thrombolytic (stryptokinase) to minimize risk of infarction 24 BACK MAIN EXIT INDEX NEXT

Unstable Angina Cause • Thrombus partially or intermittently occludes the coronary artery Signs and Symptoms • Pain with or without radiation to arm, neck, back, or epigastric region • Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea, hypotension or hypertension, decreased arterial oxygen saturation (SaO2) and rhythm abnormalities • Occurs at rest or with exertion; limits activity Diagnostic Findings • ST-segment depression or T-wave inversion on electrocardiography • Cardiac biomarkers not elevated

CONT… Treatment • Oxygen to maintain oxygen saturation level at > 90% • Nitroglycerin or morphine to control pain • b-blockers, angiotensin-converting enzyme inhibitors,), clopidogrel (Plavix), unfractionated heparin or lowmolecular- weight heparin, and glycoprotein IIb/IIIa inhibitors

Non–ST-Segment Elevation Myocardial Infarction (NSTEMI) Signs and Symptoms Longer in duration and more severe than in unstable angina Diagnostic Findings: Cardiac biomarkers are elevated. Treatment: Cardiac catheterization and possible percutaneous coronary intervention for patients with ongoing chest pain, hemodynamic instability, or increased risk of worsening clinical condition

ST-Segment Elevation Myocardial Infarction (STEMI) Cause: Thrombus fully occludes the coronary artery. Diagnostic Findings: • ST-segment elevation or new left bundle branch block on electrocardiography. • Cardiac biomarkers are elevated. Treatment • b-blockers, angiotensin-converting enzyme inhibitors, statins (started on admission and continued long term), clopidogrel (Plavix), unfractionated heparin or low-molecularweight heparin • Percutaneous coronary intervention within 90 minutes of medical evaluation • Fibrinolytic therapy within 30 minutes of medical evaluation