Acute Coronary Syndrome Treatments

Objectives of treatment

• To reduce progression to MI and relief of ischemic pain.

• Choice of a management strategy, i.e, an early invasive strategy (with angiography and intent for revascularization with PCI or CABG versus a conservative strategy with medical therapy.

• Initiation of antithrombotic therapy (including Antiplatelets and anticoagulant therapies) to prevent further thrombosis of or embolism from an ulcerated plaque.

1. Intensified medical therapy in ICU including:

• I.V. infusion Nitroglycerin and can be increased to a level at which chest pain is abolished, Then transdermal or oral long acting nitrates.
• Beta-blockers.
• Statin.
• Antiplatelets, aspirin , clopidogrel or ticlopidine.
• Low molecular weight heparin e.g. Enoxaparin .

NB: the majority of patients improve with such treatment. If do not diminish within 24 to 48 h of treatment coronary angiography should be performed. Percutaneous transluminal coronary angioplasty (PTCA) can be performed with surgical standby.

2. Early coronary revascularization therapy: coronary angioplasty (PTCA) or CABG.

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So, Types of Angina are:

1. Stable angina: (Effort, atherosclerotic, typical angina, classic): The pain is commonly induced by exercise, emotion……etc. It is due to atherosclerosis. Pain is induced by effort and disappears with rest.

 2. Variant angina: (Prinzmetal’s angina, α-receptor–mediated vasoconst-riction): the coronary artery undergoes severe spasm due to overactivity of α1 receptors. May or may not be associated with atherosclerosis. The patient develops pain at rest. - contraindicated with beta blockers   3. Unstable angina: (accelerated angina =preinfarction syndrome ): Any type of angina that developed recent changes in the character, duration, or frequency of pain. The patient must be hospitalized.

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ACS: Therapy

TIME = MYOCARDIUM

Reperfusion strategies

• The definitive therapy for STEMI
  1. Reduces infarct size
  2. Preserves left ventricular function
  3. Reduces mortality
• Fibrinolysis (thrombolysis); taken in first 6hr
• PTCA (percutaneous transluminal coronary angiography)
• CABG (coronary artery bypass grafting)

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Therapy process:

*I. Prehospital management: Before transfer to CCU.

1. Pain relief in Morphine MI: Morphine 2-4 mg l.V. to be repeated every 5 min. sublingual nitroglycerin. - contraindicated in Inferior MI
2. Aspirin: Chewed 160-325 tablets reduce mortality, and acts rapidly as anti platelet. ///// Clopidogreil 300 mg.
3. l.V. B-Blockers: reduces also mortality. Metoprolol 5 mg/5 min. for 3 doses followed by I 00 mg orally/day.
4. Low molecular weight heparin e.g enoxparin I mg/kg s.c.
5. Oxygen: used in doses sufficient to avoid hypoxemia.

II. CCU management is aimed at the following:

1. Restoration of the balance between the oxygen supply and demand to prevent further ischemia by recanalization.
2. Pain relief
3. Prevention and treatment of complications. It include the followings:
   • Recanalization therapy
   • Unfractionated heparin
   • Antiplatelets
   • nitrates & nitrites
   • Beta-blockers
   • ACEIs
   • Antiarrhythmics
   • Lipid-lowering therapy

III. Post-infraction management:

1. Long term therapy with Antiplatelets (aspirin, clopidgril) reduces risk of recurrent infraction and stroke.

2. ACEIs is inhibitors or ARBs reduce risk of heart failure and can prevent the adverse myocardial remodeling after MI.

3. B-Blockers for at least 2 years after infraction reduce risk of sudden death.

4. Modification of risk factors:

   • Statin to reduce LDLc < 1 OOmg
   • Regular exercise & weight reduction.
   • Stop smoking.
   • Control D.M. and hypertension.

5. Treadmill ECG and coronary angiography to detect areas of silent, reversible ischemia to be corrected by PTCA.

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Y ?????? •Treatment of complications : e.g

Cardiogenic shock → give dobutamine i.v.i

Arrhythmia → give lidocaine i.v.