Description
Acute Coronary Syndrome (ACS) is a term used to describe a group of potentially life-threatening conditions related to the heart and blood vessels. ACS encompasses a spectrum of cardiac emergencies, including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). The hallmark of ACS is inadequate blood supply to the heart muscle due to partial or complete blockage of coronary arteries, often caused by atherosclerosis or blood clot formation. STEMI, the most severe form of ACS, is characterized by ST-segment elevation on an electrocardiogram and demands immediate reperfusion therapy, such as angioplasty or thrombolytic drugs, to restore blood flow to the affected area. NSTEMI and unstable angina are also serious conditions requiring medical attention. NSTEMI involves elevated cardiac biomarkers but no ST-segment elevation, while unstable angina presents with chest pain at rest or with minimal exertion and no biomarker elevation.
Summary Listen
- Acute coronary syndrome (ACS) encompasses a spectrum of conditions, including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina. While understanding of ACS is evolving, it remains a leading cause of death, even affecting younger individuals.
- The pathogenesis of ACS involves plaque disruption, leading to platelet formation and thrombus development. STEMI results from complete coronary occlusion, causing significant myocardial damage and elevated biomarkers, while NSTEMI involves partial obstruction and less myocardial necrosis. Unstable angina is now categorized under NSTEMI as high-risk NSTEMI.
- Biomarkers like troponin and CPK-MB are crucial for diagnosing myocardial infarction. Troponin is the preferred marker due to its rapid elevation and prolonged presence in the serum. Biomarker trends also help detect reinfarction.
- Reperfusion is the primary management strategy for ACS, with percutaneous coronary intervention (PCI) preferred over thrombolytic therapy. Early intervention is critical to minimize myocardial damage and improve prognosis. "Time is muscle" emphasizes the importance of prompt diagnosis and treatment.
- Thrombolysis, using tissue plasminogen activators (tPA), is an alternative reperfusion strategy, especially when PCI is not readily available. However, it has limitations such as lower recanalization rates and potential bleeding complications. Absolute and relative contraindications to thrombolytic therapy must be carefully considered.
- Adjunctive therapies, including oxygen, nitroglycerin, morphine, aspirin, and beta-blockers, play a vital role in managing ACS. The combination of aspirin and clopidogrel has shown significant benefits in improving reperfusion and reducing mortality. Ticagrelor can also be used instead of clopidogrel. Glycoprotein IIb/IIIa inhibitors may be beneficial in select cases.
- Antithrombotic agents like heparin and low-molecular-weight heparin (LMWH) are essential for preventing further thrombus formation. ACE inhibitors and aldosterone antagonists are recommended for patients with compromised left ventricular function, hypertension, diabetes, and heart failure.
- Mechanical complications of myocardial infarction, such as ventricular septal defect and papillary muscle rupture, may require surgical correction. Electrical complications, including arrhythmias, need prompt management with antiarrhythmic agents, cardioversion, or defibrillation.
- Unstable angina and NSTEMI are managed based on risk stratification using scores like TIMI. High-risk patients benefit from invasive strategies such as PCI, while conservative strategies with antiplatelet and antithrombotic agents may be appropriate for lower-risk patients. Lifestyle modifications and follow-up care are essential for long-term management of ACS.
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About the Speakers
Dr Aklesh Tandekar
Consultant Critical Care , Apollo Hospitals, Mumbai
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