ACS begins when a destroyed atherosclerotic plaque stimulates platelet aggregation and the formation of blood clots in the coronary arteries. In a subsequent stage, a blood clot clogs a vessel, reducing myocardial perfusion. Rich in platelets, it can secrete vasoconstrictors – serotonin and thromboxane A2.
- unstable angina pectoris – partial/intermittent occlusion, lack of myocardial damage;
- non-Q infarction – partial/intermittent occlusion, myocardial damage;
- Q-infarction – complete occlusion, myocardial damage.
Myocardial cells require oxygen and adenosine 5b-triphosphate (ATP) to maintain contractility and electrical stability. Since they are deprived of it, anaerobic glycogen metabolism occurs, less ATP is formed, which leads to a failure of sodium-potassium and calcium pumps and the accumulation of hydrogen and lactate ions.
Classification of acute coronary syndrome allows you to divide patients into two groups:
- Patients with chest pain lasting more than 20 minutes, which cannot be relieved by taking nitroglycerin. On the ECG – ST segment elevation, which indicates acute coronary artery occlusion. In the future, this leads to the occurrence of Q-infarction.
- Patients with chest pain lasting more than 20 minutes, which cannot be relieved by taking nitroglycerin, and patients with class III angina pectoris that first appeared without a steady ST segment elevation (depression, T change). This condition transforms into non-Q-infarction or into unstable angina.
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First of all, the diagnosis of ACS begins with a history and detailed complaints: prolonged (more than 20 minutes) intense chest pain of a pressing nature, shortness of breath, fear of death – a similar symptom complex practically does not occur in other heart pathologies.
The main purpose of the physical examination is to exclude pains of non-cardiac origin, non-ischemic heart diseases, as well as any pathologies that can potentially increase ischemia.
An electrocardiogram (ECG) at rest – is the “golden method” of diagnosing ACS, as well as a screening method for other diseases accompanied by pain.
An ECG at rest must be compared with a preliminary cardiogram and with an ECG after the disappearance of pain.
Another advantage of this method is the ease of execution – patient management is available both in the hospital, in the clinic, and in the family type outpatient clinic.
During myocardial death, heart cells die. Enzymes from cardiomyocytes enter the bloodstream and continue to circulate in it for some time. Using special tests, you can determine the concentration of these substances, assess the degree of damage, and also establish the fact of necrotic changes in the heart muscle.
Markers of necrotic changes in the myocardium are:
- Creatine phosphokinase (MV).
Echocardiography – this method is widely used to clarify the diagnosis, but is not suitable for making it, since it does not allow you to see small foci of necrosis.
Signs of ACS are:
- Pathological valve function.
- Enlarged chambers of the heart.
- Turbulent blood flow.
- Enlarged inferior vena cava.
This method is used if it is necessary to determine the exact localization of the necrotic focus. Its essence is that healthy and damaged cells have different biochemical activity. With the introduction of special reagents, the latter will accumulate selectively in either healthy or dead cells (depending on the reagent), which will accurately determine the presence of damaged areas.
Coronarography is a rather complicated, but quite informative method for the study of ACS. Its essence is the implementation of an x-ray image after the administration of a contrast agent into the coronary arteries. Coronarography allows you to determine the exact location and degree of narrowing of the affected artery.
Mandatory (standard) diagnostic measures for suspected ACS are an electrocardiogram and determination of necrosis markers. The rest are prescribed if necessary – depending on the specifics of the disease in each patient.
Emergency care for acute coronary syndrome depends on its variant and is carried out on the basis of specially developed protocols. In ACS with ST segment elevation:
- Patients hospitalized no later than 12 hours after the onset of symptoms are indicated for mechanical (percutaneous coronary intervention (PCI) or pharmacological reperfusion).
- PCI is preferred if it is produced no later than 120min. After the first call for medical help.
- If it is impossible to perform PCI for 120 minutes. Thrombolysis therapy is performed.
- In case of successful thrombolysis, the patient is sent to the center for coronary angiography for 3-24 hours. In case of ineffective thrombolysis, urgent angiography is necessary.
- Antiplatelet and anticoagulant therapy.
- Lipid-lowering therapy.
The help algorithm for ACS without ST segment elevation:
- Assessment of the clinical condition, confirmation of the diagnosis.
- Drug therapy: anti-ischemic drugs, anticoagulants and antiplatelet agents.
- Coronary revascularization.
Nitroglycerin is a vasodilator that reduces myocardial oxygen demand. It is administered sublingually or using a buccal spray (0,3-0,6 mg) every 5 minutes, for a total of 3 doses.
If the pain persists, the administration of intravenous nitroglycerin should be started (initial rate of 5-10 μg/min with its increase to 10 μg/min every 3 to 5 minutes until the symptoms subside).
An absolute contraindication to the use of nitroglycerin is hypotension.
Morphine is recommended after 3 doses of nitroglycerin, or when symptoms of ischemia recur during treatment. In such cases, from 1 to 5 mg of morphine sulfate can be administered intravenously every 5-30 minutes if necessary, with close monitoring of blood pressure and respiratory rate. Morphine acts as a powerful analgesic.
β-blockers inhibit β-1 adrenergic receptors in the myocardium, reduce its contractility and heart rate. In the absence of contraindications, therapy with oral forms of β-blockers should be started within the first 24 hours. For all patients, the dose should be adjusted to achieve a heart rate of 50 to 60 beats per minute.
In foreign recommendations, it was noted that in the absence of hypotension or other known contraindications, the oral administration of an angiotensin converting enzyme inhibitor (enalapril, lisinopril) or an angiotensin II receptor blocker, for patients who do not tolerate ACE inhibitors (valsartan, losartan) during the first 24 hours, significantly reduced number of deaths.
A patient with ACS is hospitalized in the intensive care unit or intensive care unit of cardiology with strict bed rest, the connection of a constant monitoring device and round-the-clock medical supervision.
The complex of therapeutic measures includes:
- Coronarolytics – nitrates intravenously until the complete disappearance of pain attacks;
- Antiplatelet agents that reduce blood viscosity – clopidogrel, aspirin;
- Anticoagulants – heparin and its analogues;
- Adrenergic blockers – propranolol, metoprolol and analogues;
- Calcium channel blockers – verapamil, amlodipine, nifedipine, cinnarizine, stugeron and others.
Drugs from the group of blockers reduce the sensitivity of arterial receptors to adrenaline and calcium, preventing the occurrence of spasm.
With treatment failure or with complete occlusion of the artery revealed by coronary angiography, endovasal surgery – stenting is urgently performed.
- A vascular probe is inserted through the vessels of the thigh into the cavity of the heart, directing it into the lumen of the affected artery, expanding it, removing the thrombus and placing a stent (spacer cylinder, inner frame), which reliably protects from narrowing of the lumen.
- First, all drugs are injected, after stabilization, they switch to their tablet form.
- After discharge, the patient should be under the supervision of a cardiologist, receive the necessary medical treatment, undergo regular examination.
Antithrombotic therapy is the cornerstone of the treatment of patients with ACS. It includes two components: antiplatelet and anticoagulant therapy.
Aspirin. It blocks the synthesis of thromboxane A2 by irreversibly inhibiting cyclooxygenase-1, thereby reducing platelet aggregation. The initial daily dose should be from 162 to 325 mg, and then reduced – from 75 to 162 mg. Used for long-term secondary prevention.
Clopidogrel is the recommended alternative for patients who cannot tolerate aspirin. It reduces platelet activation and aggregation and reduces blood viscosity. The loading dose is 600 mg, the supporting dose is 75 mg per day. Clopidogrel and aspirin therapy is recommended for almost all patients with ACS.
Unfractionated Heparin (UFH). The results of several randomized trials indicate that UFH is associated with lower mortality rates than aspirin therapy alone. But when it is prescribed, monitoring of activated partial thromboplastin time (PTT) is necessary to prevent hemorrhage.
Fondoparinux is a synthetic pentasaccharide that is an indirect inhibitor of factor XA and requires antithrombin to achieve a therapeutic effect. This drug is preferable to other anticoagulants for patients undergoing conservative therapy and in patients with an increased risk of bleeding.
In the absence of contraindications, lipid-lowering therapy with statins should be started for all patients with ACS, regardless of baseline cholesterol and LDL.
Streptokinase – 1,5 million, I/O OD for 30-60 min;
- Alteplase – 15 mg IV bolus, 0,75 mg/kg body weight for 30 minutes, then 0,5 mg/kg for 60 minutes .; total dose should not exceed 100 mg;
- Tenectoplase – a bolus in/in the introduction of the drug depends on the weight of the patient: 30 mg with a mass of less than 60 kg; 35 mg per 60-69 kg; 40 mg per 70-79 kg; 45 mg per 80-89 kg; 50 mg per weight more than 90 kg.
Acute coronary syndrome: emergency care, treatment, recommendations
The term “acute coronary syndrome” refers to a very life-threatening emergency. In this case, the blood flow through one of the arteries that feed the heart decreases so much that a larger or smaller portion of the myocardium either ceases to perform its function normally or dies completely.
The diagnosis is valid only during the first days of the development of this condition, while doctors differentiate – a person has unstable angina or it is the beginning of myocardial infarction.
At the same time (while the diagnosis is being carried out), cardiologists take all possible measures to restore the patency of the damaged artery.
Acute coronary syndrome requires emergency care. If we are talking about myocardial infarction, then only during the first (from the onset of initial symptoms) 90 minutes it is still possible to introduce a drug that will dissolve a blood clot in the artery that feeds the heart.
After 90 minutes, doctors can only help the body in every way to reduce the area of the dying area, maintain basic vital functions and try to avoid complications. Therefore, a sudden pain in the heart that develops when it does not go away within a few minutes of rest, even if this symptom first appears, requires an immediate emergency call.
Do not be afraid to seem like an alarmist and seek medical help, because with every minute irreversible changes in the myocardium accumulate.
Next, we will consider what symptoms, in addition to heart pain, you need to pay attention to, what needs to be done before the ambulance arrives. We will also tell about who is more likely to develop acute coronary syndrome.
Unstable angina pectoris is a condition in which, against the background of physical exertion or rest, pain behind the sternum appears, which has a pressing, burning or compressive character. Such pain radiates to the jaw, left arm, left shoulder blade. It can also manifest in abdominal pain, nausea.
Unstable angina pectoris is said when these symptoms or:
- only occurred (that is, before a person performed loads without heartaches, shortness of breath or discomfort in the abdomen);
- began to occur at a lower load;
- become stronger or last longer;
- began to appear alone.
At the heart of unstable angina pectoris is a narrowing or spasm of the lumen of a larger or smaller artery that feeds, respectively, a larger or smaller portion of the myocardium.
Moreover, this narrowing should be more than 50% of the diameter of the artery in this area, or the obstruction in the blood path (it is almost always an atherosclerotic plaque) is not fixed, but fluctuates with the blood flow, more or less blocking the artery.
Acute coronary syndrome without ST segment elevation is either unstable angina or a heart attack without elevation of this segment. At the stage prior to hospitalization in a cardiology hospital, these 2 conditions do not differentiate – there are no necessary conditions and equipment for this. If an ST segment elevation is visible on the cardiogram, the diagnosis of Acute myocardial infarction can be made.
The treatment of acute coronary syndrome depends on what the type of the disease will be – with or without ST elevation.
If the formation of a deep (“infarction”) Q wave is already immediately visible on the ECG, the diagnosis is “Q-myocardial infarction”, and not acute coronary syndrome.
This suggests that a large branch of the coronary artery is affected, and the focus of the dying myocardium is quite large (large focal myocardial infarction).
Such a disease occurs with complete blockage of a large branch of the coronary artery with a dense thrombotic mass.
An alarm must be raised if you or your relative makes the following complaints:
- Pain behind the sternum, the spread of which is shown with a fist, not a finger (that is, a large area hurts). The pain is burning, baking, strong. Not necessarily defined on the left, but can be localized in the middle or on the right side of the sternum. Gives to the left side of the body: half of the lower jaw, arm, shoulder, neck, back. Its intensity does not change depending on the position of the body, but several attacks of such pain, between which there are several practically painless “gaps”, can be observed (this is characteristic of a syndrome with an ST segment elevation).
It is not removed by nitroglycerin or similar drugs. Fear joins the pain, sweat appears on the body, there may be nausea or vomiting.
- Shortness of breath, which is often accompanied by a feeling of lack of air. If this symptom develops as a sign of pulmonary edema, then suffocation increases, a cough appears, pink frothy sputum may cough.
- Rhythm disturbances, which are felt as interruptions in the work of the heart, chest discomfort, sudden jolts of the heart against the ribs, pauses between heart contractions. As a result of such irregular contractions, in the worst case, loss of consciousness occurs very quickly, at best – headache, dizziness develops.
- Pain can be felt in the upper abdomen and may be accompanied by loosening of the stool, nausea, and vomiting, which does not bring relief. It is also accompanied by fear, sometimes – a feeling of heart palpitations, irregular heartbeat, shortness of breath.
- In some cases, acute coronary syndrome may begin with loss of consciousness.
- There is a variant of the course of acute coronary syndrome, manifested by dizziness, vomiting, nausea, in rare cases – focal symptoms (asymmetry of the face, paralysis, paresis, impaired swallowing, and so on).
The intensified or frequent pains behind the sternum should also alert, for which a person knows that his angina pectoris, increased shortness of breath and fatigue are manifested. A few days or weeks after this, 2/3 of people develop acute coronary syndrome.
A particularly high risk of developing acute cardiac syndrome in such people:
- overweight persons;
- alcohol abusers;
- lovers of salty dishes;
- leading a sedentary lifestyle;
- coffee lovers;
- having a lipid metabolism disorder (for example, high cholesterol, LDL or VLDL in a blood test for a lipid profile);
- with an established diagnosis of atherosclerosis;
- with a diagnosis of unstable angina pectoris;
- if atherosclerotic plaques are identified in one of the coronary (which nourish the heart) arteries;
- who have already suffered myocardial infarction;
- chocolate lovers.
Assistance should be started at home. In this case, the first action should be an ambulance call. Further, the algorithm is as follows:
- It is necessary to lay the person on the bed, on the back, but at the same time the head and shoulders should be raised, making an angle of 30-40 degrees with the body.
- Clothes and a belt must be unfastened so that a person’s breathing does not constrain anything.
- If there are no signs of pulmonary edema, give the person 2–3 tablets of aspirin (“Aspekarda”, “Aspeter”, “Cardiomagnyl”, “Aspirin-Cardio”) or “Clopidogrel” (that is 160-325 mg of aspirin). They need to be chewed. This increases the likelihood of dissolution of the thrombus, which (by itself, or layered on an atherosclerotic plaque) blocked the lumen of one of the arteries that feed the heart.
- Open the windows or windows (if necessary, the person needs to be covered): this way the patient will receive more oxygen.
- If the blood pressure is more than 90/60 mm Hg, give the person 1 tablet of nitroglycerin under the tongue (this drug dilates the vessels that feed the heart). Repeatedly give nitroglycerin can be given 2 more times, with an interval of 5-10 minutes. Even if after a 1-3-fold administration, the person feels better, the pain has passed, you can’t refuse hospitalization in any case!
- If before that a person was taking drugs from the group of beta-blockers (Anaprilin, Metoprolol, Atenolol, Corvitol, Bisoprolol), after aspirin he needs to give 1 tablet of this drug. It will reduce myocardial oxygen demand, allowing it to recover. Note! A beta-blocker can be given if blood pressure is greater than 110/70 mmHg, and the pulse is more than 60 beats per minute.
- If a person takes antiarrhythmic drugs (for example, Arrhythmil or Cordaron), and he feels a rhythm disturbance, you need to take this pill. In parallel, the patient himself should begin to cough deeply and severely before the arrival of the ambulance.
- All the time before the arrival of the ambulance you need to be close to the person, watching his condition. If the patient is conscious and feels a sense of fear, panic, he needs to be reassured, but not soldered by the valerian motherwort (resuscitation may be necessary, and a full stomach can only interfere), but soothe in words.
- With seizures, a person nearby should help ensure airway patency. To do this, taking the corners of the lower jaw and the area under the chin, move the lower jaw so that the lower teeth are in front of the upper ones. From this position, artificial respiration of the mouth to nose can be made if spontaneous breathing is lost.
- If the person has stopped breathing, check the pulse on the neck (on both sides of the Adam’s apple), and if there is no pulse, start resuscitation: 30 direct pressure on the lower part of the sternum (so that the bone moves down), then 2 breaths into the nose or mouth. In this case, the lower jaw should be held by the area under the chin so that the lower teeth are in front of the upper ones.
- Find ECG films and medications the patient is taking to show them to healthcare providers. They will not need this in the first place, but it will be necessary.
Medical care for acute coronary syndrome begins with simultaneous actions:
- providing vital functions. To do this, oxygen is supplied: if breathing is independent, then through the nasal cannulas, if there is no breathing, then tracheal intubation and artificial ventilation are performed. If blood pressure is critically low, special drugs begin to be injected into the vein, which will increase it;
- parallel registration of an electrocardiogram. They look at it whether there is an ST rise or not. If there is a rise, then if there is no possibility of a quick delivery of the patient to a specialized cardiological hospital (provided that the team left is sufficiently staffed), they may begin to carry out thrombolysis (dissolution of the thrombus) in an out-of-hospital environment. In the absence of ST elevation, when it is likely that the thrombus that has clogged the artery is “fresh”, which can be dissolved, the patient is taken to a cardiological or multidisciplinary hospital, where there is a resuscitation unit.
- eliminate pain. To do this, inject narcotic or non-narcotic painkillers;
- in parallel, with the help of rapid tests (strips where a drop of blood drips, and they show a negative result or a positive one), the level of troponins, markers of myocardial necrosis, is determined. Normally, the level of troponins should be negative.
- if there are no signs of bleeding, anticoagulants are administered under the skin: Clexane, Heparin, Fraxiparin, or others;
- if necessary, “Nitroglycerin” or “Isoket” is administered intravenously;
- Intravenous beta-blockers may also be initiated to reduce myocardial oxygen demand.
Algorithm 15 “Acute coronary syndrome”
A history of risk factors or clinical signs of coronary heart disease. The appearance for the first time or a change in the usual anginal pain.
With unstable angina, the first appearance of frequent or severe anginal attacks (or their equivalents), worsening of the course of previously existing angina, the resumption or appearance of angina in the first 14 days of myocardial infarction. Especially dangerous is the occurrence of anginal pain alone at first.
- With myocardial infarction, anginal status, less commonly, other options for the onset of the disease: asthmatic (cardiac asthma, pulmonary edema), arrhythmic (fainting, sudden death, MAC syndrome), cerebrovascular (acute neurological symptoms), abdominal (epigastric pain, nausea, vomiting) malosymptomatic (weakness, vague sensations in the chest).
- In the first hours of the disease, changes in the ECG may be absent or undefined, in some cases, ST segment polio is recorded in two or more adjacent leads or acute (presumably acute) blockade of the left bundle branch block with the formation of a pathological Q wave in the future.
- A few hours after the onset of the disease, positive biochemical markers of myocardial necrosis (in particular, a positive troponin test).
With unstable angina pectoris in most cases – with cardialgia, extracardiac pain, rarely with pulmonary embolism, acute diseases of the abdominal organs (pancreatitis, etc.).
With myocardial infarction in most cases with unstable angina pectoris, cardialgia. extracardial pains, pulmonary embolism, acute diseases of the abdominal organs (primarily pancreatitis), sometimes with exfoliating aortic aneurysm, spontaneous pneumothorax.
- To provide emergency care (especially in the first hours of the disease or with complications), peripheral vein catheterization is indicated; readiness for cardiopulmonary resuscitation should be ensured.
- If there are additional indications (persistent or recurring anginal pain, arterial hypertension) and provided monitoring of hemodynamics and heart rate are possible, doctors of specialized cardiological emergency teams can start treatment with intravenous administration of β-blockers: propranolol (1 mg every 3 times —5 minutes until the clinical effect is achieved, but not more than 6–8 mg) or metoprolol (5 mg again after 5–10 minutes until the effect, but not more than 15 mg).
- To perform an invasive intervention (balloon dilatation, stenting) hospitalize patients taking into account the minimum transportation time.
- For thrombolytic therapy for myocardial infarction with ST segment elevation (in the first 6, and in case of recurrent pain – up to 12 hours from the onset of the disease)
- contact the advisory center of the GMDSS to include the patient in the register;
- Obtain patient informed consent
- evaluate contraindications;
- enter a thrombolytic drug in accordance with the instructions for its use.