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Acute Coronary Syndrome (ACS)

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⚡ ST elevation changes everything! → Act FAST to restore coronary reperfusion (PCI or thrombolysis). 📉 Always check an ECG after ANY new chest pain. 👵 Large MIs can be silent in elderly/diabetics. 🫀 Early action saves lives → ensure defibrillator is available at bedside.

🚑 Immediate Assessment of Moderate–Severe Cardiac Chest Pain

Management of Suspected ACS (repeat ECG every 15–20 mins)
📋 Clinical assessment, NEWS, Telemetry 💉 IV access + send bloods (FBC, U&E, LFT, Troponin, ± D-dimer if PE/dissection suspected) 🫁 Oxygen if sats <95% 💊 GTN spray 400–800 mcg SL (⚠️ avoid if SBP <100 mmHg) 💉 Morphine 2.5–5 mg IV (or Diamorphine 1.25–2.5 mg IV) + antiemetic (Metoclopramide 10 mg IV) 💊 Aspirin 300 mg PO stat (US: 162–325 mg PO/PR) ➕ Add a P2Y12 inhibitor: Clopidogrel 300–600 mg, Ticagrelor 180 mg, or Prasugrel 60 mg 💊 Consider Metoprolol 5–15 mg IV or 50 mg PO (if no contraindication) ⚡ If ST elevation or new LBBB → activate STEMI pathway (PCI/thrombolysis) ☎️ Consult cardiology early for ongoing pain, hypotension, LVF, or evolving ECG changes

Management of Suspected ACS (repeat ECG every 15–20 mins)

📋 Clinical assessment, NEWS, Telemetry
💉 IV access + send bloods (FBC, U&E, LFT, Troponin, ± D-dimer if PE/dissection suspected)
🫁 Oxygen if sats <95%
💊 GTN spray 400–800 mcg SL (⚠️ avoid if SBP <100 mmHg)
💉 Morphine 2.5–5 mg IV (or Diamorphine 1.25–2.5 mg IV) + antiemetic (Metoclopramide 10 mg IV)
💊 Aspirin 300 mg PO stat (US: 162–325 mg PO/PR)
➕ Add a P2Y12 inhibitor: Clopidogrel 300–600 mg, Ticagrelor 180 mg, or Prasugrel 60 mg
💊 Consider Metoprolol 5–15 mg IV or 50 mg PO (if no contraindication)
⚡ If ST elevation or new LBBB → activate STEMI pathway (PCI/thrombolysis)
☎️ Consult cardiology early for ongoing pain, hypotension, LVF, or evolving ECG changes

📖 Introduction

“Acute Coronary Syndrome” (ACS) = chest pain + myocardial ischaemia ± ECG changes.
🌡️ Stable angina ≠ ACS (but unstable angina often presents acutely).
📈 ECG separates STEMI (PCI/thrombolysis benefit) from NSTEMI (no benefit from lysis).
🧪 Troponin distinguishes Unstable Angina (normal) from NSTEMI (raised).

🔎 Acute Coronary Syndromes include

🟡 Unstable angina = symptoms + ECG changes + normal troponin
🟠 NSTEMI = symptoms + ECG changes + raised troponin
🔴 STEMI = symptoms + ST elevation + raised troponin

📊 NSTEMI vs STEMI

	NSTEMI	STEMI
📉 ECG	ST depression	ST elevation
🩸 Vessel	30–40% occlusion	≈80% occlusion
⚰ Mortality	Low in-hospital, higher long-term	High in-hospital, lower at 1 yr
🧬 Clot	Platelet-rich	Fibrin-rich
💉 Thrombolysis	❌ Not indicated (may harm)	✅ Life-saving

ℹ️ About

🫀 ACS = major cause of sudden cardiac death
🚨 STEMI → needs urgent reperfusion (PCI or thrombolysis)
💊 All ACS → antiplatelets, analgesia, oxygen, nitrates, early defib readiness

⚠️ Aetiology

🟢 Most STEMIs = occlusion of a major coronary artery
📍 Outcome depends on artery involved + how proximal + myocardium at risk
⏱️ “Time = muscle” → delay to PCI worsens prognosis
🛠️ PCI = mechanical reperfusion | Thrombolysis = pharmacological reperfusion

🧬 Pathophysiology

🔓 Plaque rupture/erosion → thrombus forms
🩸 May embolise → distal ischaemia
⛔ Vessel occlusion → myocardial ischaemia/infarction

📑 Classification of MI

Not all raised troponins = plaque rupture. ⚠️ Consider Type 2 “secondary myocardial injury”.

Type	Description
1	Spontaneous MI (plaque rupture, erosion, dissection)
2	Supply–demand mismatch (anaemia, spasm, tachyarrhythmia, PE, sepsis)
3	Sudden cardiac death before biomarkers
4a/4b	PCI-related MI / stent thrombosis
5	CABG-related MI

⚠️ Risk Factors

👨 >40 yrs, 👩 >50 yrs
🧬 Family history of premature IHD
🚬 Smoking, 🍔 dyslipidaemia, 💉 diabetes, ⬆ BP hypertension

🩺 Clinical Presentation

🚨 Chest/arm/jaw pain at rest = red flag
😰 Pale, sweaty, cold peripheries
👵 Elderly/diabetics → atypical (dyspnoea, confusion, syncope, epigastric pain)
🫀 Exam: hypotension, S3, new murmurs, JVP ↑, pulmonary oedema

Summary Table — Complications of Acute Coronary Syndrome (ACS)

Category	Complication	Timing	Key Features	Management
Electrical ⚡	Ventricular arrhythmias (VT, VF)	First 24–48h	Palpitations, collapse, sudden death	Immediate DC cardioversion; IV amiodarone; ICD if persistent EF <35%
	Bradyarrhythmias, AV block	Inferior MI, early phase	Syncope, hypotension	Temporary pacing if symptomatic or high-grade block
Mechanical 💔	Papillary muscle rupture → acute MR	3–7 days post-MI	Pulmonary oedema, new pansystolic murmur	Urgent surgical repair; diuretics, inotropes, IABP bridge
	Ventricular septal rupture	3–7 days	Cardiogenic shock, new harsh systolic murmur	Urgent surgical closure; stabilise with IABP/inotropes
	Free wall rupture	First week	Sudden tamponade, collapse, PEA arrest	Emergency pericardiocentesis + surgical repair
Pump Failure ❤️	LV dysfunction → cardiogenic shock	Hours–days	Hypotension, cool peripheries, pulmonary oedema	Urgent PCI; inotropes (dobutamine), mechanical support (IABP, ECMO)
Ischaemic 🔄	Reinfarction	Early or late	Recurrent chest pain, new ECG changes	Repeat reperfusion (PCI); optimise DAPT + statins
Systemic 🌍	Pericarditis (Dressler’s syndrome)	Days–weeks	Pleuritic chest pain, pericardial rub, fever	NSAIDs ± colchicine (avoid NSAIDs early post-MI if possible)
	Bleeding	Any time	GI or intracranial haemorrhage with DAPT/anticoagulation	Stop/reverse anticoagulation if severe; consider IVC filter if VTE risk
	Renal impairment	Days	AKI from low perfusion, contrast, or nephrotoxins	Optimise fluids, avoid nephrotoxins, adjust drug doses

Teaching Commentary 🧠

Complications of ACS follow a predictable timeline: - Minutes–hours: arrhythmias, shock. - Days: mechanical rupture syndromes. - Weeks: pericarditis, Dressler’s. Careful monitoring in CCU is essential, and early recognition saves lives. Always think in categories (electrical, mechanical, pump, systemic) for exams and clinical safety.

🧪 Investigations

ECG: 🚦 Always repeat with new pain
Troponin T/I: 🧬 high-sensitivity rules MI in/out
Echo: wall motion, LV function
Other labs: FBC, U&E, lipids, glucose
Consider CT aorta/PE if atypical

💊 Secondary Prevention

🛡 Beta-blockers (unless contraindicated)
💊 High-dose statin (Atorvastatin 80 mg)
💊 ACEi/ARB (start once stable)
🌀 Eplerenone (if post-MI LVSD/HF)
💊 PPI if high GI bleed risk on DAPT

📚 Reference

SIGN 148: Acute Coronary Syndrome (2016)

Cases — Acute Coronary Syndrome (ACS) & Complications

Case 1 — NSTEMI with CKD 🧪: A 68-year-old man with diabetes and CKD stage 4 presents with chest pain at rest and troponin rise. ECG: ST depression in V4–V6. Diagnosis: NSTEMI. Issue: Contrast-induced nephropathy risk during angiography. Management: Aspirin + clopidogrel, fondaparinux; hydrate before angiography; minimise contrast load.
Case 2 — STEMI with Cardiogenic Shock ❤️: A 60-year-old woman presents with acute chest pain and hypotension (BP 75/40). ECG: anterior STEMI. Echo: severe LV systolic dysfunction. Diagnosis: STEMI complicated by cardiogenic shock. Management: Immediate PCI (preferred) or thrombolysis; cautious fluids; inotropes (dobutamine); consider IABP or mechanical support.
Case 3 — ACS with Bleeding Risk 🩸: A 75-year-old man with a recent peptic ulcer bleed presents with NSTEMI. Troponin elevated, ECG: dynamic T-wave inversion. Issue: Antiplatelet therapy vs high GI bleed risk. Management: Aspirin essential; add PPI; weigh DAPT vs bleeding risk; liaise with gastro + cardiology; angiography with careful anticoagulation strategy.
Case 4 — Post-MI Arrhythmia ⚡: A 58-year-old man 2 days after inferior STEMI develops sudden palpitations and collapse. ECG: sustained VT. Diagnosis: Ventricular tachycardia complicating acute MI. Management: Immediate DC cardioversion if unstable; amiodarone IV if stable; secondary prevention with ICD if EF remains low.
Case 5 — Mechanical Complication (Papillary Muscle Rupture) 💔: A 70-year-old woman, 5 days post-MI, develops acute pulmonary oedema and a new pansystolic murmur. Echo: flail mitral leaflet with severe MR. Diagnosis: Papillary muscle rupture causing acute severe MR post-MI. Management: Urgent surgical repair/replacement; stabilise with diuretics, inotropes, and possible IABP as bridge.

Teaching Commentary 🧠

ACS complications can be divided into: - Early electrical → arrhythmias (VT, VF, AV block). - Mechanical → papillary muscle rupture, ventricular septal rupture, free wall rupture. - Pump failure → cardiogenic shock, LV dysfunction. - Other issues → bleeding risk (dual antiplatelets + anticoagulation), renal impairment, contrast nephropathy. Management is always: ABCDE, oxygen if hypoxic, antiplatelets, anticoagulation, reperfusion (PCI/thrombolysis for STEMI), risk stratification for NSTEMI. Complications highlight why close monitoring in CCU is essential during the first days post-ACS.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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