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20.4 Acute Coronary Syndrome (Unstable Coronary Artery Disease)

Table of Contents

Unstable Angina (UA)

Unstable angina is a medical emergency and if untreated can progress to Non-ST Elevation Myocardial Infarction (NSTEMI) 11, 12, 13.

Diagnostic Criteria

Presents as chest pain or discomfort like stable angina but with the following additional characteristics:

  • Angina at rest or minimal effort, occurring for the first time, particularly at rest and prolonged > 10 minutes, not relieved by sublingual nitrates.
  • The pattern of angina accelerates and gets worse
  • The chest pain may be associated with ST segment depression or T wave inversion or normal ECG without rise in cardiac enzymes (biomarkers ie Total Creatine, Creatine -MB and Troponin).

20.4.1 Non-ST Elevation Myocardial Infarction (NSTEMI)

Non-ST Elevation Myocardial Infarction is medical emergency characterized with chest pain that is increasing in frequency and/or severity or occurring at rest. The chest pain is associated with elevated cardiac enzymes and ST segment depression or T wave inversion or normal ECG 14, 16

Diagnostic Criteria

Presents with typical chest pain with the following additional characteristics.

  • Electrocardiogram (ECG) may show ST segment depression or transient ST segment elevation, or normal ECG which does not exclude the diagnosis.
  • Raised Cardiac Biomakers – Total Creatine Kinase (Total-CK), Creatine Kinase – MB (CK-MB) and Standard/High Sensitive Troponin I or T.

Non-Pharmacological Treatment

Both UA and NSTEMI are medical emergencies with the same pathophysiological progressive instability of CAD, which share similar management approach nonpharmacological and pharmacological treatment.

Supportive Therapy

  • Admit patient into high dependent ward/ICU/CCU for haemodynamic monitoring, bed rest in Fowler’s position and reassurance.
  • Oxygen via nasal blog cannula or face mask if saturation < 92%
  • Establish Peripheral Intravenous – IV line for intravenous fluid or drug administration
  • Haemodynamics blood pressure, heart rate and electrocardiogram rhythm monitor

Pharmacological treatment

Adjunctive therapy

Control cardiac pain

C: Glyceryl trinitrate (Nitroglycerine) sub–lingual/ spray 0.5mg (make sure patient hasn’t taken phosphodiesterase–5 inhibitor).

For persistent pain and if oral therapy is insufficient

C: Glyceryl Trinitrate (Nitroglycerine) IV, 1–2 µg/kg/min titrated with chest pain over 8–24 hours.

OR

C: Morphine, IV, 1–2 mg/minute dilute 10 mg up to 10 mL with sodium chloride solution 0.9%. Total maximum dose10 mg, repeat after 4 hours if necessary15.

Note: But pain not responsive to this dose may suggest ongoing unresolved ischaemia. This requires immediate referral to high level of care where resources available to manage cute Coronary Syndrome or to exclude differential diagnosis

Antiplatelet Therapy

A: Aspirin 300mg start (PO) then followed by 75mg/100mg daily

AND

D: Clopidogrel 300mg /600mg start then followed by 75mg daily

Statin high dose

C: Simvastatin 80mg start then 40mg daily

OR

D: Atorvastatin 80mg start then 40mg daily

D: Rosuvastatin 10mg-40mg daily

Anticoagulant

D: Heparin UFH 70–100U/Kg body weight IV a day

OR

D: Enoxaparin 1mg/kg body weight SC 12 hourly

Beta blocker (ß –blockers)

In case of LV dysfunction

C: Carvedilol initial dose 6.25mg (PO) 12 hourly preferred, titrate the dose upward. Max. dose 25mg (PO) 12 hourly

OR

Others ß –blockers in the settings of normal LV systolic function

B: Atenolol 25–50mg once daily,

OR

C: Metoprolol 25–50mg once daily

Angiotensin Converting Enzyme Inhibitors (ACEIs)

C: Enalapril 10mg (PO) 12 hourly

OR

B: Captopril 6.25mg–25mg (PO) 8 hourly

OR

S: Perindopril 4mg–8mg (PO) daily

Referral

High suspicion index of acute coronary syndrome immediate consider referral to high level of care where resources are available to manage. In acute settings before referral from low to high level of care if available consider giving the following urgently:

  • Glyceryl trinitrate (Nitroglycerine) sub-lingual 0.5mg/ spray prn for intolerable chest pain
  • Aspirin 300mg stat. oral
  • Clopidogrel 300mg/600mg stat oral
  • High dose statin simvastatin 80mg stat OR atorvastatin 80mg stat oral

20.4.2 ST Elevation Myocardial Infarction (STEMI) / Acute Myocardial Infarction (AMI)

STEMI/AMI is a medical emergency caused by the complete or partial occlusion of a coronary artery and requires prompt hospitalization and intensive care intervention management.

Diagnostic Criteria

Initial diagnosis: Management including both diagnosis and treatment of STEMI/AMI starts at the point of first medical contact (FMC), defined as the point at which the patient is either initially assessed by a paramedic or physician or other medical personnel in the pre-hospital setting, or the patient arrives at the hospital emergency department.

Simple recognition triage: Two out of three points most likely point to STEMI/AMI diagnosis

  • Symptoms – typical/atypical chest pain
  • ECG – ST elevation in in two contiguous leads≥0.1mV
  • Raised cardiac biomakers– Total Creatine Kinase (Total-CK), Creatine Kinase – MB (CK-MB) and Standard/High Sensitive Troponin I or T

Symptoms: Severe chest pain with the following characteristics, site: retrosternal or epigastric, quality: crushing, constricting or burning pain or discomfort, radiation: to the neck and/or down the inner part of the left arm, duration: at least 20 minutes and often not responding to sublingual nitrates, occurrence: at rest. May be associated with: pulmonary oedema sweating, hypotension or hypertension, arrhythmias

Non-Pharmacological Treatment:

Supportive therapy

  • Consider cardio-pulmonary resuscitation if necessary before transfer (cardiac arrest– cardiopulmonary resuscitation).
  • Oxygen 40% via facemask, if saturation < 92% or if in distress
  • See section 20.4.1 above on supportive therapy for NSTEMI

Adjunctive therapy

Control cardiac pain

C: Glyceryl trinitrate sub-lingual/ spray 0.5mg (make sure patient hasn’t taken phosphodiesterase-5 inhibitor).

For persistent pain and if oral therapy is insufficient

C: Glyceryl Trinitrate IV, 1–2 µg/kg/min titrated with chest pain over 8–24 hours.

OR

C: Morphine, IV, 1–2 mg/minute dilute 10 mg up to 10 mL with sodium chloride solution 0.9%. Total maximum dose: 10 mg, repeat after 4 hours if necessary.

Anti-platelets therapy

A: Aspirin 300mg stat (O) then followed by 75mg/100mg daily

Plus

D: Clopidogrel 300mg/600mg stat then followed by 75mg daily next day

Statin high dose

C: Simvastatin 80mg stat then 40mg daily

OR

D: Atorvastatin 80mg stat then 40mg daily

OR

D: Rosiivastatin 10mg-40mg daily

Anticoagulant

D: Heparin UFH 70–100U/Kg body weight IV a day

OR

D: Enoxaparin 1mg/kg body weight sc bid, Reduce dose in renal failure patient to 0.5mg/kg

Beta blocker (ß –blockers)

In case of LV dysfunction

C: Carvedilol initial dose 6.25mg twice daily preferred, titrate dose upward to maximum dose 25mg twice daily

In the settings of normal systolic function

B: Atenolol 12.5mg or 25mg or 50mg once a day,

OR

C: Metoprolol 25m/ or 50mg once a day

Angiotensin-Converting Enzyme Inhibitors (ACEIs)

B: Captopril 6.25mg or 12.5mg (PO) 8 hourly

OR

C: Enalapril 10mg twice a day

OR

S: Perindopril 4mg/8mg (PO) daily

Definitive management of STEMI – Reperfusion therapy (Myocardial reperfusion)

Myocardial reperfusion with rapid recanalization of infarct related artery is the key to success in the management of ST Elevation Myocardial Infarction (STEMI). Timely reperfusion is crucial for minimization of infarct size and thereby for preservation of left ventricular function and reduction in mortality in STEMI patients17,18,19

The two main reperfusion strategies for STEMI patients are;

  • Thrombolytic/Fibrinolytic therapy) and
  • Primary percutaneous coronary intervention (PPCI)

Thrombolytic agents

C: Streptokinase IV, 1.5 million units diluted in 100 mL sodium chloride 0.9%, infused over 30–60 min

OR

D: Alteplase (TPA) 15mg as bolus, 0.75mg/kg over 30min, then 0.5mg/kg over 60min

OR

D: Tenecteplase 40mg IV bolus (70–79kg body weight) 30 –35mg < 70kg body

Absolute contraindication for Thrombolytics

  • Previous allergy to streptokinase or used within the last year for streptokinase only
  • Stroke CVA within the last 3 months
  • History of recent major trauma
  • Bleeding within the last month
  • Aneurysms
  • Brain or spinal surgery or head injury within the preceding month
  • Active bleeding or known bleeding disorder

Relative contraindication for Thrombolytics

  • Refractory hypertension
  • TIA in the preceding 6 months,
  • Subclavian central venous catheter
  • Warfarin therapy
  • Pregnancy
  • Traumatic resuscitation
  • Recent retinal laser treatment

Referral is urgent for all suspected or diagnosed cases to high level care equipped with cardiac catheterization laboratory.

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