Acute Coronary Syndrome Essay: Symptoms, Types, Diagnosis, And Treatment.

Types of Acute Coronary Syndrome

According to Acute coronary syndrome says that Acute coronary syndrome is a situation where suddenly there is a deprivation of blood supply to the heart muscles. The blood supply through the arteries to the heart is interrupted. This blockage may occur suddenly and completely (or) the clot may break  down (or) forms again and the whole leads to death of few cells or  any part of the heart.

Here there will be symptoms as those in the acute coronary syndrome along with the raise of segments S-T on electrocardiogram

NSTEACS (non S-T Segment elevation acute coronary syndrome):  In this situation, there will be increase in the S-T Segment but there will be decline in these segment or raises briefly, but it may be normal

Non –STEMI (non S-T Segment evaluation myocardial infections):

There will be a no ST Segment elevation but increase in serum troponin level.

UNSTABLE ANGINA:- The patients suffers from chest pain because of the coronary artery disease . It would not affect the Electrocardiogram and biomarker standards (Shrivastava et al., 2016).

Myocardial infarctions divided according to Universal:-

Type-1

The myocardial infarction occurs when the atherosclerotic plaque gets breakdown which leads  to formation of thrombus  and obstructions of blood flow via coronary artery to the heart leads to necrosis (Chapman et al., 2016).

Type-2

There will be decreased blood supply and glucose to heart muscle cells leads to myocardial infarction.

Type-3

The myocardial Ischemia gives raise to cardiac death before there are any changes in the cardiac biomarkers.

Type-4

• Myocardial infarction is associated with PCI
• Myocardial infarction corresponding to stent thrombosis

Type-5

Myocardial infarction links to CABG. NEW YORK Heart Association functional classification of Angina

Class I

Patients suffers from cardiac disease but there will be no boundaries in doing activity physically . Normal physical activity does not results in tiredness, breathlessness ,palpitations, angina pain.

Class II

Patients can do the physical activity for shorter duration and they are good at rest. casual physical activity leads to  dyspnoea, tiredness chest pain.

Class III

Patients have cardiac disease and can do physical  activity  within a certain period . They are not relaxed at rest and slighter ordinary work cause tiredness

Class IV

Patient feels more inconvenient even at rest. The sings of heart failure and angina  are also seen at rest.

Electrocardiography:

When the patients enter in to the emergency department with complaining of chest discomfort then the physician should do electrocardiography within 10 minutes . The main aim of ECG in to diagnose the ACS and also helps in risk stratification.

Myocardial Infarctions Divided According to Universal

In case of unstable angina the ECG represents ST – Segment depression, transient ST- Segment hike , T- wave inversion (or) Presence of any ST-segment deviates of minimum 0.05mv indicates ischemia and even the inversion of the T-wave is also indication of ischemia but it is of less priority and its importance will be present when it is >0.3mv. Any ECG tells us there will be 90% of myocardial infarction if there is of at least  0.1 mv raise in ST segment in any of the two adjacent leads. It is important to note that patient with no evidence of ECG changes are at minimum risk then that ECG of variations

Diagnosis

Serum or plasma cardiac troponin plays an important role in the diagnosis of myocardial infarction. Even when there are no changes in the ECG and if the cardiac troponin levels are increased it concludes myocardial injury. only cardiac troponin concentration should not be considered separately. For example, for in an unstable angina  patient if the cardiac troponin  is  within  the normal range at 12hrs are probable to  cardiovascular situation in the future . This cardiac troponin also has a vital role in directing to start the management to further treat the expected acute coronary syndrome. The Cardiac troponin which is of high sensitivity helps to know the approximation of myocardial infarction (Shah et al., 2016). High sensitive troponin test is more advanced and costly then standard troponin in testing the quantity of-

• The serum tropnin concentration is to be done in expected patient of ACS in order to plan the correct treatment and investigations.
• To diagnose myocardial infarction the serum troponin concentration should be calculated 12 hrs from the symptoms noticed.

Evaluation of the following biochemical biomarkers to find out the Acute coronary syndrome initially (Fathill et al., 2015) :-

Class 1:

Cardiac troponin shows specific role for the diagnosis of myocardial infarction. The choice after cardiac troponin is creatinkinase MB. Along with the clinical history of acute coronary syndrome, if the following are present it indicates presence of myocardial necrosis. If the cardiac troponin is greater than 99th percentile of value then it is seen once in the initial of 24hrs (Shah et al., 2016). For the two consecutive samples the creatine kinase MB should not be more than 99 percentile values.

Class IIB:

Along with the cardiac troponin the other useful marker is myoglobin and it plays role to find the myocardial necrosis within the 6hrs of the symptoms attack (Shah et al., 2016).

Class III:-

In case of, this if abnormalities are seen in Electrocardiogram treatment should be started and should not wait for biomarkers investigations.

New York Heart Association Functional Classification of Angina

Cardiac troponin I and T, CK, Myoglobin, lactate dehydrogenase and other are the biomarkers of myocardial necrosis but cardiac troponin is the  specific marker for the myocardial injury findings. Incase if cardiac troponin is not there then next preference is CK-MB.

The serum markers of myocardial damage are utilized for helping in building up the diagnosis of myocardial dead tissue. The more established markers like aspartate aminotransferase, creatine kinase, lactate dehydrogenase and soon lost their utility because of the absence of specificity and constrained sensitivities. Among the as of now accessible markers heart troponins are the most generally utilized because of their enhanced affectability specificity, proficiency and low pivot time. Contemplates have demonstrated that heart troponins ought to supplant CKMB as the indicative 'best quality level' for the analysis of the myocardial damage. The blend of myoglobin with cardiovascular troponins has additionally enhanced the exactness in the determination of intense coronary disorders.

Diagnosis of myocardial infarction depends upon the presence of biomarkers along with the symptoms. After occurrence of myocardial infarction next within 3 to 4hrs the CK-MB increases and later by 48-72 hrs, it reaches its normal level where as the cardiac toponin increases in the same way as CK-MB but maintains for up to 4-7 days for C Tnl and 10-14 days for C TnT. As the myocyte damage occurs the myoglobin raises within 1hr comes back to as usual within 12-24 hrs.

 The other variety of biomarkers are B-type natriuretic peptides , ischaemia-modified albumin, heart –type fatty-acid-binding protein, myeloperoxidase, c-reactive protein, choline, placental growth factor and growth – differentiation factor-15 their capacity for diagnosis ACS along with other traditional marker (Fathill et al., 2015).

Blood count determination (Coven et al., 2016):

To find out the status of anemia as it may leads to acute coronary syndrome.

Basic metobolic panel:

Basic metabolic information is necessary. Examination of potassium and magnesium plays vital role in acute coronary syndrome pts as below levels may lead to ventricular arrhythmias.

Chest radiography:

It is useful to identify cardiomegaly and pulmonary oedema. So that it indicates complication like ischemia.

Echocardiography:

It is used to see the movements of the walls of heart and has valuable role for acute coronary syndrome.

Myocardial perfusion imaging:

Radionuclide myocardial perfusion imaging helps to early rule out  acute myocardial infarction. It also indicates the dimensions of infarct in order to know effect of reperfusion treatment. Computed tomography coronary Angiography and CT coronary Artery Calcium scoring. It is used to find out about coronary arteries. The Coronary artery diseases are ruled out sooner so the treatment can be before they become blocked completely. It also examines about the lumen of artery including the presence of plaques.

Investigations, Treatment and Diagnosis

According to ECG findings the patients with acute coronary syndrome are classified into patients with ST-Segment raising and those with ST segment declination reperfusion therapy is necessary spontaneously for patients under the subdivision of ST- segments elevation where as fibrinolysis treatment is contraindicated for the myocardial infarction of non –ST elevation. Along with the ECG finding aside the cardiac biomarkers also plays vital role in identifying and predicting the patients of acute coronary syndrome who are at high risk and thus it helps to prevent further worst outcomes cardiac troponin helps in identifying myocardial necrosis and thus myocardial infarction.

Management

Coven et al.(2016) discuss  about the treatment that:

Primarily the treatment includes:

• To stabilizethe patients situation
• Ischemic pain should clear.
• Anti thrombotic treatment

The primary objective for healthcare experts in the administration of intense myocardial infarction (MI) is to analyze the condition in an extremely fast way. When in doubt, the primary treatment for intense MI is coordinated toward reclamation of perfusion at the earliest opportunity to rescue however much of the risked myocardium as could be expected. This might be expert through medicinal or mechanical means, for example, percutaneous coronary mediation (PCI), or coronary supply route sidestep join (CABG) surgery. Despite the fact that the underlying treatment of the diverse sorts of intense coronary disorder (ACS) may have all the earmarks of being comparative, it is vital to recognize whether the patient is having a ST-rise MI (STEMI) or a non–STEMI (NSTEMI), in light of the fact that complete treatments contrast between these two sorts of MI. Specific contemplations and contrasts include the desperation of treatment and the level of proof in regards to various pharmacologic choices (Rienstra et al., 2013).

Prepared pre-hospital workforce can give life-sparing intercessions if the patient creates heart failure. The way to enhanced survival is the accessibility of early defibrillation. Roughly 1 in each 300 patients with trunk torment transported to the crisis division by private vehicle goes into heart failure on the way.

Anti ischemic treatment consist of:

Nitrates and Beta blockers

Anti thrombotic treatments

Aspirin, clopidogrel, prasugrel, tricogrelor, Glycoptotein IIb / IIIa receptor agonist.

Anticoagulant  treatment:

Un-fractioned heparin, low molecular weight of heparin, factor invasive approach (Rienstra et al., 2013).

Treatment plan:

To make the patients situation firm so it contains morphine for relieving pain, oxygen, nitro glycerin intravenously, aspirin sublingually 162 to 325 mg, clopidogrel  300-600mg. High risk NSTEMI Acute coronary syndrome patients should consist absolute treatment. The aim is revascularization. Intermediate risk patients of NSTEMI should be considered for further investigations to find out their status. Low risk patients of NSTEMI acute coronary syndrome consist of basic treatment and clopidrogel is advantageous (D’Ascenzo et al., 2014).

Electrocardiography

Finding out for any presence of arrhythmias in first 48hrs and treat it and also observe for any negative situations like changes in electrolytes, hypoxemia etc and make right pathway. Nitrates are non indicated if there is hypotension. Antiplatelet and antithrombotic treatments are contraindicated with bleeding diosordres. Cardiogenic patients are treated with percutaneous coronary intervention (D’Ascenzo et al., 2014). Due to incomplete reperfusion there may be ischaemia again so CABG has less complication comparatively.

Pharmocologiic anti ischaemic therapy:

Using of nitrates relieves the symptoms by betterment of blood circulation but doesn’t favours mortality.

Beta blockers:

Advisable for most of the patients except under various conditions like asthma, bradycardia , hypotension. It reduces mortality and worsens cardiovascular situations. The drug preferred is 2-5mg metropolol every 5minutes intravenously later orally 25-100mg two times daily (Reinstra et al., 2013).

Aspirin:-

Aspirin helps in mortality and morbidity. It will not favorite platelet function. If allergic then clopidogrel suggested (Halvorsen et al., 2014).

Clopidogrel:

It prevents platelet function. The investigations enables that loading of 600mg is more useful then 300mg. It should not be given for at least 5days before CABG.

Prasugrel:

It has same effect has clopidogrel. It will be more advantageous in stopping the myocardial infarction to occur again. It is most effective for PCI interventions to prevent thrombus formation. In case of unstable angina, myocardial infarction without ST segment elevation the prasugrel has  more deaths compared to clopidogrel.

Vorapaxer:-

It is proved that it decreases the cardiovascular events to perform again but has to be taken in combination of aspirin or clopidogrel (Held et al., 2014).

Abciximab,Eptifibatlde and Tiroflabn:-

These are one of the Glycoprotein IIb/IIa receptor antagonists. It prevents the platelet aggregation. The studies shown that, if eptifibatide is used earlier, it leads to the risk for bleeding.  In acute coronary syndrome patients in whom PCI and catheterization are suggested in those cases the  tirofiban and eptfibatide are advisable.         

 Intermediate  and high risk patients of ST segment depression, hike serum troponin levels, diabetes milletus will react in a positive way to glycoprotein IIb/IIIa inhibitor. For unstable angina condition when this antagonist are used along with aspirin then it leads to be standard antiplatelet treatment.

Pharmacologic Anti coagulation therapy :

• Factor xa inhibitors: It was found that decreasing the dose of rivaroxaban from5mg to 2.5mg twicedaily leading to declination of deaths and bleeding after acute coronary syndrome.
• Unfractioned heparin:- studies shown that when heparin and aspirin are used together there is deccelaration of 33percent deaths of unstable angina when compared with aspirin alone (Valgimigli et al., 2015).
• Low molecular weight heparin:- It may be in upperhand compared to unfractioned heparin in decreasing cardiovascular outcomes.

Acute coronary syndrome is treated earlier then there are positive effects thus there is decrease in the mortality but comparatively morbidity was declined more and chances of reoccurrence of infarction was reduced. In the same way cardiac rehabilitation started earlier, there was decrease in the both mortality and morbidity. As physiological responses shows positive the quality of life is improved and shows long lasting effects (Spinler & Denus, 2016). 

Diagnosis

Coronary Interventions:- In case of unstable angina there are no other associated diseases or any contraindications then there is indication of revascularization  hence there will be decreased mortality rate.

THROMBOLYSIS:- As there are no evidence advantages of prehospital thrombolysis. So it is not advisable and PCI is other choice for thrombolysis for STEMI.

It was being found out the effectiveness of giving antihypertensive drugs for the earlier cardiovascular situations. Here randomized controlled trials are taken to find out comparison between taking the medicines and without treatment. Drugs are given within 24hrs from the acute cardio vascular incidence 65 randomized controlled trials are taken  and it was subdivided into four division that consist of  Ac inhibitors , beta blockers, calcium channel blockers and nitrates (Reinstra et al., 2013). It was observed that initially for 2 days there was mortality decreased to a great level and later no advantages whereas the AC inhibitors for first two days no changes and deduction in mortality after 10 days. There is no effect on mortality of the remaining drugs.   

The following are the effectiveness of early treatment of acute coronary syndrome:-

McCaul et al (2014) investigated about the effect on mortality and morbidity of thrombolysis for STEMI comparing  between pre hospital and in hospital. Randomised controlled trials of three are taken and consist of 538 patients. Hence, concluded that pre-hospital thrombolysis therapy shows decline in death rate and disability. Further research is needed.

Hemkens et al (2016) deals about the advantages and disadvantages of colchine drug on the cardiovascular disease. Randomised controlled trials of 39 are done for six months. It declares that there is unclear about its impact on mortality but reduces to a certain extent, the dangers for cardiovascular risk. Further investigations are necessary.

Vale et al (2014) evaluates about the mortality, pros and cons of about intake of satins for acute coronary syndrome. Randomized control trials are taken. There is a comparison between treatments containing statins and without statin therapy is taken at the initial 14 days from attack of acute coronary syndrome. The report says that there is no descending in mortality, myocardial infarction, revascularization, heart-failure for 1 month or 4 months continuation, but it represented the chances of attack of unstable angina within 4months after onset was declined.

Castellons et al (2014) evaluates about the NSTEMI patients treating with heparin and with no treatment. Here, un-fractioned or low fractioned heparin is used. Randomised controlled trials are taken. The results concludes that there is variation on mortality, revasularization between two groups but there will be descended in the reoccur of myocardial infarction when treated with heparin.

Biochemical Markers of Myocardial Necrosis

According to Fanning et al (2016) there are two types of approaches for dealing with the unstable angina and non-ST elevation myocardial infarction one is invasive and other is conservative treatment. The author examines the advantages and disadvantages. Eight randomized controlled trials are taken. There is no satisfaction in deduction in mortality in both cases but the risk for myocardial infarction, recurrent angina, rehospitalisation were decreased in case of invasive treatment then conservative. These all are seen for 6-12 months follow up.

A study shows the objective is to dig whether CABG is better or stents in reducing the cardiac events of acute coronary syndrome patients. Randomised controlled trials of CABG and PTCA are considered. There are nine studies of which four are number vessels diseased and five is of only one artery diseased. It was noticed that cardiac events were decreased when compared with PTCA but there is no variation in the mortality risks (Valgimigli et al., 2015).  

The Effects Of Cardiac Rehabilitation On Acute Coronary Syndrome 

To know about the effect of cardiac rehabilitation in elderly patients after the attack of acute coronary syndrome. An age group of 65years and older of 548 patients is considered. For this exercises that are related to walking are used and found out how it effects on various measurements related to metabolic and anticipation. Then measurements are noticed before the start of the program and also next to 3months. It was identified that was positive improvement in all those variables statistically. Therefore it was decided that cardiac rehabilitation has reduced mortality and morbidity.

Barquero et al., 2016, rules out about the returning back to their work after cardiac rehabilitation. Patients of 60 years are taken into count and they had percutaneous coronary intervention for acute coronary syndrome and are subjected to cardiac rehabilitation for three weeks. Questionnaires are used to know about the data and to find out the reasons of going or not back to work. Total of 69 patients only 58 were moved back to work. Overall 115 days were late to work and the reason for not going back to work is left ventricular ejection fraction. Thus there is appositive impact on their life style.

Generally the patients of acute coronary syndrome undergoing cardiac rehabilitation have an improvement of endothelial proginator cells but some of them may not respond. Cesari et al studies to know about the features of patient who doesn’t gain of having endothelial progenitor. They were exposed to cardiac rehabilitation for four weeks. Before and after the programme, the endothelial regeneration cells, Creactive protein, NT-ProBNP measures are noted by nephelometric and immune-metric method. Cardiopulmonary test was performed by patients. The results represents that there is improvement in the endothelial regeneration cells in few patients, HDL cholesterol and there is reduced C reactive protein and NT-ProBNP, waist circumference, triglycerides.

Optimal Timing of Sample Acquisition

Contractor et al (2011) focuses that cardiac rehabilitation assists in bringing back the patient to normal physical, social, psychological function. Meta analysis 48 randomised trials were done to correlate with the exercise based and usual treatment. It was found that there is reduction in 20 percent overall mortality and 26 percent of cardiac mortality. The patients during their exercise performance the ECG is also evaluated for the safety purpose .

The following study by Lawler et al (2011) examines about the impact of cardiac rehabilitation on cardiovascular events and also to know about the plan of cardiac rehabilitation programme that influences the uses of cardiac rehabilitation. Rndomized controlled trials are done on the post myocardial infarction patients. Here exercise based rehabilitation is done.The advantages are decrease in the mortality rate, reinfarction is also reduced, overall mortality was declined. The factors which are dangers to cardiovascular are smoking ,hypertension, cholesterol over body weight are also decended. Therefore concluded that even the cardiac rehabilitation of shorter duration  given longlasting effects.

Conclusion:-

Acute coronary syndrome is treated earlier then there are positive effects thus there are decreased mortality and morbidity and even recurrence of infarction is decreased. In the same way as cardiac rehabilitation is started earlier there is decrease in mortality and morbidity, good physiological changes in the body thus quality of life is enhanced.

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