ACS

• CAD
• Cardiogenic shock/poor perfusion
• Stimulants abuse(eg coccaine, amphetamine)
• Embolus in left ventrcle/atrium

is chest pain on exertion/emotional stress related to a 70% narrowing of the lumen of epicardial artery or 50% of major artery

• Classic/Stable 2/2 plaque
• Vasospastic/variant/Prinzmetal's 2/2 reversible spasm of coronary arteries
• Unstable angina/AC- incr feq/severity of attacks; combo of plaque rupture, plt aggregation and vasospasm (immediate precursor to MI). Leads to fibrin clot formation.

• Imbalance in O2 supply/demand
• Demand- HR, contractility, preload, afterload

• HR
• contractility
• preload (diastolic )- blood volume/ venous tone
• afterload (systolic)- arterial blood pressure/arterial tone

partial or total occlusion of coronary artery by thrombus diminishing blood fflow and O2 supply.

• Unstable angina (UA)
• NSTEMI- UA w/ ischemia, usually limited to sub endocardial myocardium
• STEMI (Q wave/ST elevation)- extensive transmural ischemia

Plts, cause incomplete occlusion and more associated w/ NSTEMI

Fibrin which traps RBC, often complete occlusions and more w/ STEMI

epinephrine, serotonin and thrombin

Often occurs after MI (from activation of RAAS, catecholamines etc) and major cause of HF (systolic + diastolic)

Slowed/reversed by ACE-I, BB, Aldosterone antagonist (decrease mortality)

• HF
• cardiogenic shock
• arrhythmias
• VTE
• bradycardia
• heart block

• Chest discomfort, lasts about 20mins (constant in STEMI; new onset, at rest or worsening in STEMI)
• may radiate down left arm/back/jaw
• N/V
• SOB
• Diaphoresis

• ST elevation with STEMI
• ST depression
• T-wave inversion
• No change

Troponin and CKMB rise within 6hrs ffg coranary artery occlusion and myocardail cell death

• Troponin falls slowly (10 days)
• CKMB rises and falls (48hrs) rapidly

Must take at least 3 serial labs over 24hrs ffg presentation. +Ve MI w/ 1 elevated troponin or 2 CKMB

• Fibrinolytics- 30mins
• PCI-90mins

Both at least <12hrs from Sx onsent to be eligible

• 5 E’s of angina:
• Exercise
• Exposure to cold
• Emotional stress
• Eating large meals
• severe anEmia

• 1.Substernal chest pain with characteristic quality and duration
• 2.Provoked by exertion or emotional stress 3 Relieved by rest or nitroglycerin

Atypical meets only 2 of above; non-cardiac- 1 </= 1

Diagnostic to determine cause of angina; can determine presence of plaque, can also be treatment as per removing plaque

• Immediate relief of ischemia
• Restoration of blood flow
• Prevention of death/reinfarction
• Secondary prevention of MIs

• MONA + BB + anticoag
• Morphine
• Oxygen
• Nitrates
• Aspirin
• Beta blockers
• Heparin/lovenox

• MOA: Blocks sympathetic efferent discharge at CNS level resulting in minimal peripheral venous and arterial dilation Established efficacy, quick onset of action, sedative• Give if ischemia is not relieved by NTG Dose: 2-4 mgIV q5 15min until pain relief or ADR
• Monitor:– BP for hypotension HR for bradycardia
• RR for reduced respiratory drive
• Mental status for CNS depression

• Reduce demand on the heart by increasing oxygen delivery. Patients are often hypoxemic (SaO2 < 90% • Oxygen saturation is measured by continuous pulse‐ox
• Dose:2‐4 L/min adminstered by nasal cannula (NC) or face mask

• IV- 10/10/5 x24hrs
• oral- 0.4mg q 5min x 3 doses
• Coronary and peripheral vasodilator– Decreases preload and O2demand, Increases Odelivery2
• Avoid in Patients with initial SBP < 90 mmHg or Recent PDE‐5 inhibitors use
• Monitoring– BP for hypotension – HR for reflex tachycardia

• Produces rapid clinical antithrombotic effect – Inhibits platelet aggregation, irreversible inhib. of COX‐1 pathway and decr production of thromboxane
• Chew 325mg in the ER – not enteric coated ASAP
• C/I– Aspirin allergy/Active or severe bleedingDosing

• Give promptly w/o C/I
• Improves mortality
• May give IV if BP high- metoprol 5mg q5min x 3 doses. Atenolol same x2doses.
• May use CCB if BB C/I like coccaine induced MI, give PO, don't use if EF<40%

Decr mortality, remodelling, reinfarction, arrhythmias

Use captopril, most flexible, transition to longer b4 d/c. Avoid IV use

• Pleiotropic effecrs, w/24hrs
• Lipid profile also w/24hrs. high dose recce. Zocor 80 or atorvastatin 80