Acute Coronary Syndromes 1-3 (2024).pdf

WEEK 9 MPharm Programme Acute Coronary Syndromes 1 Dr G Boachie-Ansah [email protected] Dale 113 ext. 2617 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORON...

WEEK 9 MPharm Programme Acute Coronary Syndromes 1 Dr G Boachie-Ansah [email protected] Dale 113 ext. 2617 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Aetiology, Clinical features & Management Slide 2 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 OUTLINE OF LECTURES Definitions Aetiology & Pathogenesis Clinical features Clinical management & therapeutics Slide 3 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Learning Outcomes At the end of the lectures on Acute Coronary Syndromes, you should be able to: Define & describe the 3 major clinical subtypes of acute coronary syndromes Describe the causes, underlying coronary pathology, major clinical features & diagnosis of acute coronary syndromes Give an account of the non-pharmacological & pharmacological management of ACS Give an account of mechanisms of action of the major classes of drugs used in the management of ACS Describe the consensus care pathways for ACS Slide 4 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Definitions, Aetiology & Distinctive Clinical Features Slide 5 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Definitions ACS encompass a spectrum of acute myocardial ischaemic states All result from acute plaque rupture in the wall of an epicardial coronary artery  an abrupt reduction in, or stoppage of, blood flow to a region of the heart 3 clinical subtypes Unstable Angina (UA) Non-ST segment Elevation Myocardial Infarction (NSTEMI) ST-segment Elevation Myocardial Infarction (STEMI) Slide 6 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Aetiology & Pathogenesis usually occur as a complication of advanced atherosclerotic coronary artery disease triggered by atheromatous plaque disruption (rupture/ fissure/ erosion)  coronary thrombosis  formation of intravascular thrombus or clot Incomplete and/or transient / intermittent occlusion of the culprit artery  UA or NSTEMI Complete and sustained occlusion of the culprit artery  STEMI Slide 7 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Pathogenesis of ACS Slide 8 of 76 MPharm PHA222 Acute Coronary Syndromes  ACUTE CORONARY SYNDROMES WEEK 9 Aetiology & Pathogenesis (cont’d) UA & NSTEMI are closely related conditions: similar pathophysiological origins – incomplete and/or transient / intermittent occlusion of an epicardial coronary artery similar clinical presentation differences in duration & severity of ischaemia / symptoms STEMI lies at the most severe end of ASC spectrum: complete and sustained occlusion of an epicardial coronary artery (by fibrin-rich thrombus) Slide 9 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Pathogenesis of STE- & NSTE-ACS Slide 10 of 76 MPharm PHA222 Acute Coronary Syndromes  Clinical Subtypes of ACS WEEK 9 Unstable Angina (UA) usually characterised by acceleration in frequency or severity of chest pain new-onset severe anginal pain prolonged anginal chest pain that abruptly occurs at rest due to unstable plaque rupture & thrombosis  incomplete or transient / intermittent occlusion of an epicardial coronary artery no enzymatic evidence of myocardial cell death/necrosis presence of an active prothrombotic surface at site of plaque rupture  increased risk of MI Slide 11 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Clinical Subtypes of ACS Non-ST segment Elevation Myocardial Infarction (NSTEMI) due to unstable plaque rupture & thrombosis  significant partial and/or intermittent occlusion of an epicardial coronary artery +ve enzymatic evidence of myocardial cell necrosis presence of persistent prothrombotic surface at site of plaque rupture   risk for recurrent ischaemic episodes Slide 12 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Clinical Subtypes of ACS ST-segment Elevation Myocardial Infarction (STEMI) due to unstable plaque rupture & thrombosis  complete occlusion of an epicardial coronary artery persistent, complete occlusion of the epicardial coronary artery  sustained myocardial ischaemia  transmural myocardial cell necrosis (infarction) ischaemia-induced electrical instability  abnormal cardiac rhythms and  risk of sudden cardiac death Slide 13 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Acute Myocardial Infarction (STEMI & NSTEMI) Pathophysiology Temporal characteristics cell necrosis begins within 20-40 min of occlusion subendocardium === ===> epicardium significant necrosis at 2-3 hours rate as a function of residual flow & collateral BF gives rise to 2 phases: phase of ischaemia (reversible injury) phase of infarction (irreversible injury) Slide 14 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Acute Myocardial Infarction Temporal characteristics Slide 15 of 76 MPharm PHA222 Acute Coronary Syndromes  Acute Coronary Syndromes WEEK 9 Clinical features (signs & symptoms) Pain & apprehension Haemodynamic breathlessness, hypotension, dizziness, syncope due to acute LV failure & abnormal cardiac rhythms Serial ECG changes ST-segment changes – depression or elevation T-wave abnormalities, e.g. inversion, biphasic, hyperacute pathological Q wave development Slide 16 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACS – Characteristics of the Chest Pain Slide 17 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACS – Characteristic Serial ECG Changes Slide 18 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACS – Characteristic Serial ECG Changes Slide 19 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Typical Serial ECG Changes in ACS Serial ECG changes in STEMI ST-segment elevation (persistent) Pathological Q wave development Slide 20 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Typical Serial ECG Changes in ACS Serial ECG changes in UA/NSTEMI ST-segment depression (or transient elevation) T wave abnormalities, e.g. inversion Often persistent in NSTEMI Usually transient in UA Slide 21 of 76 MPharm PHA222 Acute Coronary Syndromes  Acute Coronary Syndromes WEEK 9 Clinical features (signs & symptoms) Pain & apprehension Haemodynamic Serial ECG changes Serial Cardiac Biomarker changes serum levels of myoglobin, CK-MB & troponin (I / T) biomarkers of myocardial cell necrosis / infarction Slide 22 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 AMI – Serial Enzyme Changes Slide 23 of 76 MPharm PHA222 Acute Coronary Syndromes  AMI – Serial Enzyme Changes WEEK 9 Slide 24 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Slide 25 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 MPharm Programme Acute Coronary Syndromes 2 Dr G Boachie-Ansah [email protected] Dale 113 ext. 2617 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Diagnosis of ACS Primary steps Confirm or rule out ACS secondary to obstructive CAD Risk stratification – determine patient’s 6-month risk of adverse cardiovascular events (UA/NSTEMI) Diagnostic approach Thorough clinical assessment Clinical presentation, medical history & physical examination ECG changes Serial cardiac biomarker changes Risk assessment scores (e.g. TIMI, GRACE scores) Slide 27 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACS – Algorithm for Evaluation of Patients Presenting with Suggestive Chest Pain Slide 28 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 Acute Myocardial Infarction The Fourth Universal Diagnostic Criteria Acute myocardial injury Elevated cardiac troponin values (≥ 99th percentile of URL) Rise and/or fall of cardiac troponin values Plus at least ONE of the following Symptoms of myocardial ischaemia New ischaemic ECG changes (ST/T wave changes or LBBB) Development of pathological Q waves on ECG Imaging evidence of new loss of viable myocardium or regional wall motion abnormality Angiographic or autopsy evidence of coronary thrombus Slide 29 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Clinical Management Slide 30 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Principles of Clinical Management Immediate / Initial Management Aims relieve ongoing ischaemia & ischaemic pain prevent potentially fatal clinical outcomes inhibit / prevent any ongoing coronary thrombosis prevent the recurrence of adverse ischaemic events Strategies Analgesic & anti-ischaemic therapy Slide 31 of 76 MPharm PHA222 Acute Coronary Syndromes WEEK 9 ACUTE CORONARY SYNDROMES Principles of Clinical Management Immediate Management Aspirin 300 mg PO Stat (if intolerant, clopidogrel) Supplemental O2 (only if SaO2