Acute coronary syndrome (ACS) refers to a range of conditions caused by a sudden reduction or blockage of blood flow to the heart muscle, often due to the rupture of a plaque in the coronary arteries. ACS is a medical emergency and includes three main types: unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Unstable angina involves a partial blockage and causes chest pain or discomfort, serving as a warning sign of a potential heart attack. NSTEMI is less severe, with partial or temporary blockage leading to some heart muscle damage. STEMI is the most severe, involving a complete blockage and causing significant heart muscle damage, requiring immediate medical attention.
Epidemiology
Acute coronary syndrome (ACS): Leading cause of morbidity and mortality worldwide, affecting millions annually.
Incidence: Varies by region, age, and other factors; common cardiovascular emergency.
Prevalence: Influenced by risk factors such as hypertension, diabetes, smoking, and obesity.
Gender differences: Historically more common in men, but the gender gap is narrowing; significant cause of death and morbidity in both genders.
Seasonal pattern: Increased incidence during winter; cold weather and other factors may contribute to this variation.
Anatomy
Pathophysiology
Acute coronary syndrome (ACS): Involves a reduction in blood flow to a segment of the heart muscle.
Primary cause: Typically, due to the rupture of a plaque within a coronary artery.
Thrombus formation: The rupture leads to the formation of a blood clot (thrombus).
Other causes: Can also be attributed to vasospasm, with or without underlying atherosclerotic conditions.
Family history: Early myocardial infarction (before age 55) is a significant risk factor.
Genetics
Prognostic Factors
Clinical History
Acute coronary syndrome (ACS) often affects individuals with risk factors like coronary artery disease (CHD), smoking, hypertension, diabetes, hyperlipidemia, and a family history of heart disease. Patients may have a history of angina or heart attacks.
Symptoms include new or worsening chest pain (crushing, squeezing, or pressure-like), shortness of breath, nausea, vomiting, and sweating.
ACS typically has a sudden onset and can present with persistent or intermittent symptoms, including rest and exertional angina. The exact symptoms can vary among individuals.
Age group Middle-Aged Adults (40-60 years):
This is a more common age range for ACS, as risk factors such as hypertension, high cholesterol, smoking, and diabetes tend to accumulate during this period.
Men typically have a higher incidence of ACS in this age group, although the gap is narrowing as cardiovascular risk factors in women rise.
Older Adults (Over 60 years):
ACS becomes much more common in this age group, with the risk increasing as people age due to the natural progression of coronary artery disease (CAD), which often goes undiagnosed for many years.
Physical Examination
Patients with ACS often exhibit general distress and diaphoresis. Heart sounds are usually normal, but in some cases, healthcare providers may detect additional sounds like gallops or murmurs. Lung examination typically reveals no abnormalities, though crackles may be heard in some cases, suggesting associated congestive heart failure. Bilateral leg swelling or edema may be present, which can be indicative of CHF. Evaluations of other body systems typically yield results within normal limits unless there are concurrent medical conditions. When abdominal tenderness is noted upon palpation, healthcare providers should consider the possibility of other conditions, such as pancreatitis or gastritis. The presence of unequal pulses should raise suspicion of aortic dissection, warranting further evaluation. If unilateral leg swelling is detected, a thorough work-up for pulmonary emboli is advisable.
Most acute: Sudden, severe chest pain, often crushing in nature, with rapid deterioration. Immediate intervention (e.g., PCI or thrombolysis) is critical to minimize heart damage.
Non-ST-Elevation Myocardial Infarction (NSTEMI):
Moderately acute: Chest pain, shortness of breath, and discomfort may be less intense but still severe. Requires urgent care with antiplatelet therapy and potential angiography.
Unstable Angina:
Less acute but still urgent: Chest pain at rest or with minimal exertion, with no significant muscle damage (no troponin elevation). Needs close monitoring and possible early revascularization.
Psychological support:
Addressing the emotional impact of ACS
Ensuring comprehensive care and better patient outcomes
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Encourage patients to make lifestyle changes, such as quitting smoking, adopting a heart-healthy diet, losing weight if necessary, and managing underlying risk factors like hypertension and diabetes.
Effectiveness of Antiplatelet and Anticoagulant Therapy in treating Acute Coronary Syndrome
Cardiology
Aspirin is administered promptly to inhibit platelet aggregation. Additional antiplatelet agents like P2Y12 inhibitors (e.g., clopidogrel, ticagrelor, or prasugrel) are initiated. Anticoagulants such as heparin or enoxaparin are given to prevent further clot formation.
Use of Beta-Blockers in treating Acute Coronary Syndrome
Beta-blockers, like metoprolol, may be administered to reduce heart rate, blood pressure, and myocardial oxygen demand, especially if the patient is stable.
Use of Statin Therapy in treating Acute Coronary Syndrome
Statins, such as atorvastatin or rosuvastatin, are initiated or continued to lower cholesterol levels and reduce the risk of future events.
Effectiveness of ACE Inhibitors or ARBs in treating Acute Coronary Syndrome
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be prescribed in the subacute phase to improve cardiac function and reduce the risk of complications.
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Loading dose (following ACS event): 180 mg orally, single dose
The maintenance dose (for 1st 12 months after diagnosis): 90 mg orally two times
The maintenance dose (after 12 months from diagnosis): 60 mg orally two times
Also, continue with aspirin 75-100 mg
PCI
Without the GPIIb or IIIa inhibitor: 70 to 100 unit/kg Intravenous bolus initially
With GPIIb or IIIa inhibitor: 50 to 70 units/kg Intravenous bolus initially STEMI
Patient who are on fibrinolytics: IV bolus of 60 units/kg (maximum: 4000 units), following 12 units/kg in hour as continuous IV infusion (max 1000 units/hr)
The dose must be adjusted to keep the aPTT between 50 to 70 seconds NSTEMI/Unstable Angina
6 to 70 units/kg intravenous bolus initially (maximum: 5000 units), following 12-15 units/kg in hour intravenous infusion initially (maximum: 1000 units/hr)
The dose must be adjusted to keep the aPTT between 50 to 70 secs Dosing considerations
There are several concentrations available; extreme caution is necessary to prevent a medication error
Administer initial dose of 86 anti-Xa units/kg intravenously once bolus and the maximum dose not more than 9500 anti-Xa units
Fixed dosing:
<50 kg: dose of 3800 anti-Xa units once intravenous bolus
≥100 kg: dose of 9500 anti-Xa units once intravenous bolus
Administer maintenance dose of 86 anti-Xa units/kg subcutaneously each 12 hours and the maximum total daily dose not more than 19000 anti-Xa units
Fixed dosing:
<50 kg: dose of 3800 anti-Xa units subcutaneously each 12 hours
≥100 kg: dose of 9500 anti-Xa units subcutaneously each 12 hours
Acute coronary syndrome (ACS) refers to a range of conditions caused by a sudden reduction or blockage of blood flow to the heart muscle, often due to the rupture of a plaque in the coronary arteries. ACS is a medical emergency and includes three main types: unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Unstable angina involves a partial blockage and causes chest pain or discomfort, serving as a warning sign of a potential heart attack. NSTEMI is less severe, with partial or temporary blockage leading to some heart muscle damage. STEMI is the most severe, involving a complete blockage and causing significant heart muscle damage, requiring immediate medical attention.
Acute coronary syndrome (ACS): Leading cause of morbidity and mortality worldwide, affecting millions annually.
Incidence: Varies by region, age, and other factors; common cardiovascular emergency.
Prevalence: Influenced by risk factors such as hypertension, diabetes, smoking, and obesity.
Gender differences: Historically more common in men, but the gender gap is narrowing; significant cause of death and morbidity in both genders.
Seasonal pattern: Increased incidence during winter; cold weather and other factors may contribute to this variation.
Acute coronary syndrome (ACS): Involves a reduction in blood flow to a segment of the heart muscle.
Primary cause: Typically, due to the rupture of a plaque within a coronary artery.
Thrombus formation: The rupture leads to the formation of a blood clot (thrombus).
Other causes: Can also be attributed to vasospasm, with or without underlying atherosclerotic conditions.
Family history: Early myocardial infarction (before age 55) is a significant risk factor.
Acute coronary syndrome (ACS) often affects individuals with risk factors like coronary artery disease (CHD), smoking, hypertension, diabetes, hyperlipidemia, and a family history of heart disease. Patients may have a history of angina or heart attacks.
Symptoms include new or worsening chest pain (crushing, squeezing, or pressure-like), shortness of breath, nausea, vomiting, and sweating.
ACS typically has a sudden onset and can present with persistent or intermittent symptoms, including rest and exertional angina. The exact symptoms can vary among individuals.
Age group Middle-Aged Adults (40-60 years):
This is a more common age range for ACS, as risk factors such as hypertension, high cholesterol, smoking, and diabetes tend to accumulate during this period.
Men typically have a higher incidence of ACS in this age group, although the gap is narrowing as cardiovascular risk factors in women rise.
Older Adults (Over 60 years):
ACS becomes much more common in this age group, with the risk increasing as people age due to the natural progression of coronary artery disease (CAD), which often goes undiagnosed for many years.
Patients with ACS often exhibit general distress and diaphoresis. Heart sounds are usually normal, but in some cases, healthcare providers may detect additional sounds like gallops or murmurs. Lung examination typically reveals no abnormalities, though crackles may be heard in some cases, suggesting associated congestive heart failure. Bilateral leg swelling or edema may be present, which can be indicative of CHF. Evaluations of other body systems typically yield results within normal limits unless there are concurrent medical conditions. When abdominal tenderness is noted upon palpation, healthcare providers should consider the possibility of other conditions, such as pancreatitis or gastritis. The presence of unequal pulses should raise suspicion of aortic dissection, warranting further evaluation. If unilateral leg swelling is detected, a thorough work-up for pulmonary emboli is advisable.
Most acute: Sudden, severe chest pain, often crushing in nature, with rapid deterioration. Immediate intervention (e.g., PCI or thrombolysis) is critical to minimize heart damage.
Non-ST-Elevation Myocardial Infarction (NSTEMI):
Moderately acute: Chest pain, shortness of breath, and discomfort may be less intense but still severe. Requires urgent care with antiplatelet therapy and potential angiography.
Unstable Angina:
Less acute but still urgent: Chest pain at rest or with minimal exertion, with no significant muscle damage (no troponin elevation). Needs close monitoring and possible early revascularization.
Psychological support:
Addressing the emotional impact of ACS
Ensuring comprehensive care and better patient outcomes
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Cardiology, General
Encourage patients to make lifestyle changes, such as quitting smoking, adopting a heart-healthy diet, losing weight if necessary, and managing underlying risk factors like hypertension and diabetes.
Cardiology, General
Cardiology
Aspirin is administered promptly to inhibit platelet aggregation. Additional antiplatelet agents like P2Y12 inhibitors (e.g., clopidogrel, ticagrelor, or prasugrel) are initiated. Anticoagulants such as heparin or enoxaparin are given to prevent further clot formation.
Cardiology, General
Beta-blockers, like metoprolol, may be administered to reduce heart rate, blood pressure, and myocardial oxygen demand, especially if the patient is stable.
Cardiology, General
Statins, such as atorvastatin or rosuvastatin, are initiated or continued to lower cholesterol levels and reduce the risk of future events.
Cardiology, General
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be prescribed in the subacute phase to improve cardiac function and reduce the risk of complications.
Cardiology, General
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Cardiology, General
Initial (Pre-Hospital) Phase:
Aspirin to prevent further clotting.
Oxygen if necessary (for low saturation or distress).
Nitroglycerin to relieve chest pain (if no contraindications).
Pain control with morphine.
Anticoagulation (e.g., heparin) to prevent further clot formation.
Hospital (Early) Phase:
Monitoring: Continuous ECG and vital sign monitoring.
Reperfusion therapy for STEMI (PCI or thrombolysis).
Acute coronary syndrome (ACS) refers to a range of conditions caused by a sudden reduction or blockage of blood flow to the heart muscle, often due to the rupture of a plaque in the coronary arteries. ACS is a medical emergency and includes three main types: unstable angina, non-ST segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Unstable angina involves a partial blockage and causes chest pain or discomfort, serving as a warning sign of a potential heart attack. NSTEMI is less severe, with partial or temporary blockage leading to some heart muscle damage. STEMI is the most severe, involving a complete blockage and causing significant heart muscle damage, requiring immediate medical attention.
Acute coronary syndrome (ACS): Leading cause of morbidity and mortality worldwide, affecting millions annually.
Incidence: Varies by region, age, and other factors; common cardiovascular emergency.
Prevalence: Influenced by risk factors such as hypertension, diabetes, smoking, and obesity.
Gender differences: Historically more common in men, but the gender gap is narrowing; significant cause of death and morbidity in both genders.
Seasonal pattern: Increased incidence during winter; cold weather and other factors may contribute to this variation.
Acute coronary syndrome (ACS): Involves a reduction in blood flow to a segment of the heart muscle.
Primary cause: Typically, due to the rupture of a plaque within a coronary artery.
Thrombus formation: The rupture leads to the formation of a blood clot (thrombus).
Other causes: Can also be attributed to vasospasm, with or without underlying atherosclerotic conditions.
Family history: Early myocardial infarction (before age 55) is a significant risk factor.
Acute coronary syndrome (ACS) often affects individuals with risk factors like coronary artery disease (CHD), smoking, hypertension, diabetes, hyperlipidemia, and a family history of heart disease. Patients may have a history of angina or heart attacks.
Symptoms include new or worsening chest pain (crushing, squeezing, or pressure-like), shortness of breath, nausea, vomiting, and sweating.
ACS typically has a sudden onset and can present with persistent or intermittent symptoms, including rest and exertional angina. The exact symptoms can vary among individuals.
Age group Middle-Aged Adults (40-60 years):
This is a more common age range for ACS, as risk factors such as hypertension, high cholesterol, smoking, and diabetes tend to accumulate during this period.
Men typically have a higher incidence of ACS in this age group, although the gap is narrowing as cardiovascular risk factors in women rise.
Older Adults (Over 60 years):
ACS becomes much more common in this age group, with the risk increasing as people age due to the natural progression of coronary artery disease (CAD), which often goes undiagnosed for many years.
Patients with ACS often exhibit general distress and diaphoresis. Heart sounds are usually normal, but in some cases, healthcare providers may detect additional sounds like gallops or murmurs. Lung examination typically reveals no abnormalities, though crackles may be heard in some cases, suggesting associated congestive heart failure. Bilateral leg swelling or edema may be present, which can be indicative of CHF. Evaluations of other body systems typically yield results within normal limits unless there are concurrent medical conditions. When abdominal tenderness is noted upon palpation, healthcare providers should consider the possibility of other conditions, such as pancreatitis or gastritis. The presence of unequal pulses should raise suspicion of aortic dissection, warranting further evaluation. If unilateral leg swelling is detected, a thorough work-up for pulmonary emboli is advisable.
Most acute: Sudden, severe chest pain, often crushing in nature, with rapid deterioration. Immediate intervention (e.g., PCI or thrombolysis) is critical to minimize heart damage.
Non-ST-Elevation Myocardial Infarction (NSTEMI):
Moderately acute: Chest pain, shortness of breath, and discomfort may be less intense but still severe. Requires urgent care with antiplatelet therapy and potential angiography.
Unstable Angina:
Less acute but still urgent: Chest pain at rest or with minimal exertion, with no significant muscle damage (no troponin elevation). Needs close monitoring and possible early revascularization.
Psychological support:
Addressing the emotional impact of ACS
Ensuring comprehensive care and better patient outcomes
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Cardiology, General
Encourage patients to make lifestyle changes, such as quitting smoking, adopting a heart-healthy diet, losing weight if necessary, and managing underlying risk factors like hypertension and diabetes.
Cardiology, General
Cardiology
Aspirin is administered promptly to inhibit platelet aggregation. Additional antiplatelet agents like P2Y12 inhibitors (e.g., clopidogrel, ticagrelor, or prasugrel) are initiated. Anticoagulants such as heparin or enoxaparin are given to prevent further clot formation.
Cardiology, General
Beta-blockers, like metoprolol, may be administered to reduce heart rate, blood pressure, and myocardial oxygen demand, especially if the patient is stable.
Cardiology, General
Statins, such as atorvastatin or rosuvastatin, are initiated or continued to lower cholesterol levels and reduce the risk of future events.
Cardiology, General
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) may be prescribed in the subacute phase to improve cardiac function and reduce the risk of complications.
Cardiology, General
STEMI: Urgent revascularization is the goal. This can be achieved through primary percutaneous coronary intervention (PCI) or thrombolytic therapy. PCI is preferred if available within a timely window.
NSTEMI: An early invasive strategy, involving coronary angiography and PCI if indicated, is commonly employed.
Cardiology, General
Initial (Pre-Hospital) Phase:
Aspirin to prevent further clotting.
Oxygen if necessary (for low saturation or distress).
Nitroglycerin to relieve chest pain (if no contraindications).
Pain control with morphine.
Anticoagulation (e.g., heparin) to prevent further clot formation.
Hospital (Early) Phase:
Monitoring: Continuous ECG and vital sign monitoring.
Reperfusion therapy for STEMI (PCI or thrombolysis).
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