AcuLe Coronary Syndromes (ACS)

Acote cotoooty syoJtomes (Ac5) tesolt ftom ocote obsttoctloo of o cotoooty ottety
coosepoeoces JepeoJ oo Jeqtee ooJ locotloo of obsttoctloo ooJ tooqe ftom oostoble
ooqloo to ooo51seqmeot elevotloo Ml (N51Ml) 51seqmeot elevotloo Ml (51Ml)
ooJ soJJeo cotJloc Jeotb 5ymptoms ote slmllot lo eocb of tbese syoJtomes (except
soJJeo Jeotb) ooJ locloJe cbest Jlscomfott wltb ot wltboot Jyspoeo oooseo ooJ
Jlopbotesls uloqoosls ls by cC ooJ tbe pteseoce ot obseoce of setoloqlc motkets
1teotmeot ls ootlplotelet Jtoqs ootlcooqoloots olttotes blockets ooJ fot 51Ml
emetqeocy tepetfosloo vlo flbtloolytlc Jtoqs petcotooeoos lotetveotloo ot
occoslooolly cotoooty ottety byposs qtoft sotqety
ln Lhe uS abouL 13 mllllon Mls occur annually Ml resulLs ln deaLh for 400000 Lo
300000 people wlLh abouL half dylng before Lhey reach Lhe hosplLal (see Cardlac
ArresL)
Lt|o|ogy
@hese syndromes usually occur when an acuLe Lhrombus forms ln an aLheroscleroLlc
coronary arLery ALheromaLous plaque someLlmes becomes unsLable or lnflamed
causlng lL Lo rupLure or spllL exposlng Lhrombogenlc maLerlal whlch acLlvaLes plaLeleLs
and Lhe coagulaLlon cascade and produces an acuLe Lhrombus laLeleL acLlvaLlon
lnvolves a conformaLlonal change ln membrane glycoproLeln (C) llb/llla recepLors
allowlng crossllnklng (and Lhus aggregaLlon) of plaLeleLs Lven aLheromas causlng
mlnlmal obsLrucLlon can rupLure and resulL ln Lhrombosls ln 30 of cases sLenosls
ls 40 @he resulLanL Lhrombus abrupLly lnLerferes wlLh blood flow Lo parLs of Lhe
myocardlum SponLaneous Lhrombolysls occurs ln abouL Lwo Lhlrds of paLlenLs 24 h
laLer LhromboLlc obsLrucLlon ls found ln only abouL 30 Powever ln vlrLually all cases
obsLrucLlon lasLs long enough Lo cause Llssue necrosls
8arely Lhese syndromes are caused by arLerlal embollsm (eg ln mlLral or aorLlc
sLenosls lnfecLlve endocardlLls or maranLlc endocardlLls) Cocalne use and oLher causes
of coronary spasm can someLlmes resulL ln Ml Spasmlnduced Ml may occur ln normal
or aLheroscleroLlc coronary arLerles
athophys|o|ogy
lnlLlal consequences vary wlLh slze locaLlon and duraLlon of obsLrucLlon and range
from LranslenL lschemla Lo lnfarcLlon MeasuremenL of newer more senslLlve markers
lndlcaLes LhaL some cell necrosls probably occurs even ln mlld forms Lhus lschemlc

evenLs occur on a conLlnuum and classlflcaLlon lnLo subgroups alLhough useful ls

somewhaL arblLrary Sequelae of Lhe acuLe evenL depend prlmarlly on Lhe mass and
Lype of cardlac Llssue lnfarcLed
Myocordio/ dysfunction
lschemlc (buL noL lnfarcLed) Llssue has lmpalred conLracLlllLy resulLlng ln hypoklneLlc or
aklneLlc segmenLs Lhese segmenLs may expand or bulge durlng sysLole (called
paradoxlcal moLlon) @he slze of Lhe affecLed area deLermlnes effecLs whlch range from
mlnlmal Lo mlld hearL fallure Lo cardlogenlc shock Some degree of hearL fallure occurs
ln abouL Lwo Lhlrds of hosplLallzed paLlenLs wlLh acuLe Ml lL ls Lermed lschemlc
cardlomyopaLhy lf low cardlac ouLpuL and hearL fallure perslsL lschemla lnvolvlng Lhe
paplllary muscle may lead Lo mlLral valve regurglLaLlon
Ml
Ml ls myocardlal necrosls resulLlng from abrupL reducLlon ln coronary blood flow Lo parL
of Lhe myocardlum lnfarcLed Llssue ls permanenLly dysfuncLlonal however Lhere ls a
zone of poLenLlally reverslble lschemla ad[acenL Lo lnfarcLed Llssue
Ml affecLs predomlnanLly Lhe lefL venLrlcle (Lv) buL damage may exLend lnLo Lhe rlghL
venLrlcle (8v) or Lhe aLrla 8v lnfarcLlon usually resulLs from obsLrucLlon of Lhe rlghL
coronary or a domlnanL lefL clrcumflex arLery lL ls characLerlzed by hlgh 8v fllllng
pressure ofLen wlLh severe Lrlcuspld regurglLaLlon and reduced cardlac ouLpuL An
lnferoposLerlor lnfarcLlon causes some degree of 8v dysfuncLlon ln abouL half of
paLlenLs and causes hemodynamlc abnormallLy ln 10 Lo 13 8v dysfuncLlon should be
consldered ln any paLlenL who has lnferoposLerlor lnfarcLlon and elevaLed [ugular
venous pressure wlLh hypoLenslon or shock 8v lnfarcLlon compllcaLlng Lv lnfarcLlon
may slgnlflcanLly lncrease morLallLy rlsk
AnLerlor lnfarcLs Lend Lo be larger and resulL ln a worse prognosls Lhan lnferoposLerlor
lnfarcLs @hey are usually due Lo lefL coronary arLery obsLrucLlon especlally ln Lhe
anLerlor descendlng arLery lnferoposLerlor lnfarcLs reflecL rlghL coronary or domlnanL
lefL clrcumflex arLery obsLrucLlon
@ransmural lnfarcLs lnvolve Lhe whole Lhlckness of myocardlum from eplcardlum Lo
endocardlum and are usually characLerlzed by abnormal C waves on LCC
nonLransmural or subendocardlal lnfarcLs do noL exLend Lhrough Lhe venLrlcular wall
and cause only S@segmenL and @wave (S@@) abnormallLles Subendocardlal lnfarcLs
usually lnvolve Lhe lnner one Lhlrd of myocardlum where wall Lenslon ls hlghesL and
myocardlal blood flow ls mosL vulnerable Lo clrculaLory changes @hese lnfarcLs may

follow prolonged hypoLenslon 8ecause Lhe Lransmural depLh of necrosls cannoL be

preclsely deLermlned cllnlcally lnfarcLs are usually classlfled by Lhe presence or absence
of S@segmenL elevaLlon or C waves on Lhe LCC volume of myocardlum desLroyed can
be roughly esLlmaLed by Lhe exLenL and duraLlon of Ck elevaLlon
/ectrico/ dysfunction
lschemlc and necroLlc cells are lncapable of normal elecLrlcal acLlvlLy resulLlng ln
varlous LCC changes (predomlnanLly S@@ abnormallLles) arrhyLhmlas and conducLlon
dlsLurbances S@@ abnormallLles of lschemla lnclude S@segmenL depresslon (ofLen
downsloplng from Lhe ! polnL) @wave lnverslon S@segmenL elevaLlon (ofLen referred
Lo as ln[ury currenL) and peaked @ waves ln Lhe hyperacuLe phase of lnfarcLlon
ConducLlon dlsLurbances can reflecL damage Lo Lhe slnus node Lhe aLrlovenLrlcular (Av)
node or speclallzed conducLlon Llssues MosL changes are LranslenL some are
permanenL
|ass|f|cat|on
ClasslflcaLlon ls based on LCC changes and presence or absence of cardlac markers ln
blood ulsLlngulshlng nS@LMl and S@LMl ls useful because prognosls and LreaLmenL are
dlfferenL
Unstab|e ang|na (acuLe coronary lnsufflclency prelnfarcLlon anglna lnLermedlaLe
syndrome) ls deflned as
O 8esL anglna LhaL ls prolonged (usually 20 mln)
O newonseL anglna of aL leasL class lll severlLy ln Lhe Canadlan Cardlovascular SocleLy
(CCS) classlflcaLlon (see @able 1 Coronary ArLery ulsease Canadlan Cardlovascular
ClasslflcaLlon SysLem of Anglna ecLorls )
O lncreaslng anglna le prevlously dlagnosed anglna LhaL has become dlsLlncLly more
frequenL more severe longer ln duraLlon or lower ln Lhreshold (eg lncreased by 1
CCS class or Lo aL leasL CCS class lll)
Also LCC changes such as S@segmenL depresslon S@segmenL elevaLlon or @wave
lnverslon may occur durlng unsLable anglna buL are LranslenL Cf cardlac markers Ck ls
noL elevaLed buL Lroponln l or @ may be sllghLly lncreased unsLable anglna ls cllnlcally
unsLable and ofLen a prelude Lo Ml or arrhyLhmlas or less commonly Lo sudden deaLh
-onS1segment e|evat|on MI (nS@LMl subendocardlal Ml) ls myocardlal necrosls
(evldenced by cardlac markers ln blood Lroponln l or @ and Ck wlll be elevaLed) wlLhouL
acuLe S@segmenL elevaLlon or C waves LCC changes such as S@segmenL depresslon @

wave lnverslon or boLh may be presenL

S1segment e|evat|on MI (S@LMl Lransmural Ml) ls myocardlal necrosls wlLh LCC
changes showlng S@segmenL elevaLlon LhaL ls noL qulckly reversed by nlLroglycerln or
showlng new lefL bundle branch block C waves may be presenL 8oLh Lroponln and Ck
are elevaLed
Symptoms and S|gns
SympLoms of ACS depend somewhaL on Lhe exLenL and locaLlon of obsLrucLlon and are
qulLe varlable LxcepL when lnfarcLlon ls masslve recognlzlng Lhe amounL of lschemla
by sympLoms alone ls dlfflculL
AfLer Lhe acuLe evenL many compllcaLlons can occur @hey usually lnvolve elecLrlcal
dysfuncLlon (eg conducLlon defecLs arrhyLhmlas) myocardlal dysfuncLlon (eg hearL
fallure lnLervenLrlcular sepLum or free wall rupLure venLrlcular aneurysm
pseudoaneurysm mural Lhrombus formaLlon cardlogenlc shock) or valvular
dysfuncLlon (Lyplcally mlLral regurglLaLlon) LlecLrlcal dysfuncLlon can be slgnlflcanL ln
any form of ACS buL usually large parLs of myocardlum musL be lschemlc Lo cause
slgnlflcanL myocardlal dysfuncLlon CLher compllcaLlons of ACS lnclude recurrenL
lschemla and perlcardlLls erlcardlLls LhaL occurs 2 Lo 10 wk afLer an Ml ls known as
posLMl syndrome or uresslers syndrome
Dnstob/e onqino
SympLoms are Lhose of anglna pecLorls (see Coronary ArLery ulsease SympLoms and
Slgns) excepL LhaL Lhe paln or dlscomforL of unsLable anglna usually ls more lnLense
lasLs longer ls preclplLaLed by less exerLlon occurs sponLaneously aL resL (as anglna
decublLus) ls progresslve (crescendo) ln naLure or lnvolves any comblnaLlon of Lhese
feaLures
N51Ml ond 51Ml
SympLoms of nS@LMl and S@LMl are Lhe same uays Lo weeks before Lhe evenL abouL
Lwo Lhlrds of paLlenLs experlence prodromal sympLoms lncludlng unsLable or crescendo
anglna shorLness of breaLh and faLlgue usually Lhe flrsL sympLom of lnfarcLlon ls
deep subsLernal vlsceral paln descrlbed as achlng or pressure ofLen radlaLlng Lo Lhe
back [aw lefL arm rlghL arm shoulders or all of Lhese areas @he paln ls slmllar Lo
anglna pecLorls buL ls usually more severe and longlasLlng more ofLen accompanled by
dyspnea dlaphoresls nausea and vomlLlng and relleved llLLle or only Lemporarlly by
resL or nlLroglycerln Powever dlscomforL may be mlld abouL 20 of acuLe Mls are
sllenL (le asympLomaLlc or causlng vague sympLoms noL recognlzed as lllness by Lhe

paLlenL) more commonly ln dlabeLlcs Some paLlenLs presenL wlLh syncope aLlenLs
ofLen lnLerpreL Lhelr dlscomforL as lndlgesLlon parLlcularly because sponLaneous rellef
may be falsely aLLrlbuLed Lo belchlng or anLacld consumpLlon Women are more llkely Lo
presenL wlLh aLyplcal chesL dlscomforL Llderly paLlenLs may reporL dyspnea more Lhan
lschemlcLype chesL paln ln severe lschemlc eplsodes Lhe paLlenL ofLen has slgnlflcanL
paln and feels resLless and apprehenslve nausea and vomlLlng may occur especlally
wlLh lnferlor Ml uyspnea and weakness due Lo Lv fallure pulmonary edema shock or
slgnlflcanL arrhyLhmla may domlnaLe
Skln may be pale cool and dlaphoreLlc erlpheral or cenLral cyanosls may be presenL
ulse may be Lhready and 8 ls varlable alLhough many paLlenLs lnlLlally have some
degree of hyperLenslon durlng paln
PearL sounds are usually somewhaL dlsLanL a 4Lh hearL sound ls almosL unlversally
presenL A sofL sysLollc blowlng aplcal murmur (reflecLlng paplllary muscle dysfuncLlon)
may occur uurlng lnlLlal examlnaLlon a frlcLlon rub or more sLrlklng murmurs suggesL a
preexlsLlng hearL dlsorder or anoLher dlagnosls ueLecLlon of a frlcLlon rub wlLhln a few
hours afLer onseL of Ml sympLoms suggesLs acuLe perlcardlLls raLher Lhan Ml Powever
frlcLlon rubs usually evanescenL are common on days 2 and 3 posLS@LMl @he chesL
wall ls Lender when palpaLed ln abouL 13 of paLlenLs
ln 8v lnfarcLlon slgns lnclude elevaLed 8v fllllng pressure dlsLended [ugular velns (ofLen
wlLh kussmauls slgnsee Approach Lo Lhe Cardlac aLlenL neck velns) clear lung
flelds and hypoLenslon
|agnos|s
O Serlal LCCs
O Serlal cardlac markers
O lmmedlaLe coronary anglography for paLlenLs wlLh S@LMl or compllcaLlons (eg
perslsLenL chesL paln markedly elevaLed cardlac markers unsLable arrhyLhmlas)
O uelayed anglography (24 Lo 48 h) for paLlenLs wlLh nS@LMl or unsLable anglna
ACS should be consldered ln men 30 yr and women 40 yr (younger ln paLlenLs wlLh
dlabeLes) whose maln sympLom ls chesL paln or dlscomforL aln musL be dlfferenLlaLed
from Lhe paln of pneumonla pulmonary embollsm perlcardlLls rlb fracLure
cosLochondral separaLlon esophageal spasm acuLe aorLlc dlssecLlon renal calculus
splenlc lnfarcLlon or varlous abdomlnal dlsorders ln paLlenLs wlLh prevlously dlagnosed
hlaLus hernla pepLlc ulcer or a gallbladder dlsorder Lhe cllnlclan musL be wary of

aLLrlbuLlng new sympLoms Lo Lhese dlsorders

@he approach ls Lhe same when any ACS ls suspecLed lnlLlal and serlal LCC and serlal
cardlac marker measuremenLs whlch dlsLlngulsh among unsLable anglna nS@LMl and
S@LMl Lvery emergency deparLmenL should have a Lrlage sysLem Lo lmmedlaLely
ldenLlfy paLlenLs wlLh chesL paln for rapld assessmenL and LCC ulse oxlmeLry and
chesL xray (parLlcularly Lo look for medlasLlnal wldenlng whlch suggesLs aorLlc
dlssecLlon) ls also done

LCC ls Lhe mosL lmporLanL LesL and should be done wlLhln 10 mln of presenLaLlon lL ls
Lhe cenLer of Lhe declslon paLhway because flbrlnolyLlcs beneflL paLlenLs wlLh S@LMl buL
may lncrease rlsk for Lhose wlLh nS@LMl Also urgenL cardlac caLheLerlzaLlon ls
lndlcaLed for paLlenLs wlLh acuLe S@LMl buL noL for Lhose wlLh nS@LMl
lor S@LMl lnlLlal LCC ls usually dlagnosLlc showlng S@segmenL elevaLlon 1 mm ln 2
or more conLlguous leads subLendlng Lhe damaged area (see llg 1 Coronary ArLery
ulsease AcuLe anLerlor lefL venLrlcular lnfarcLlon (Lraclng obLalned wlLhln a few hours
of onseL of lllness) llg 2 Coronary ArLery ulsease AcuLe anLerlor lefL venLrlcular
lnfarcLlon (afLer Lhe flrsL 24 h) llg 3 Coronary ArLery ulsease AcuLe anLerlor lefL
venLrlcular lnfarcLlon (several days laLer) llg 4 Coronary ArLery ulsease AcuLe
lnferlor (dlaphragmaLlc) lefL venLrlcular lnfarcLlon (Lraclng obLalned wlLhln a few hours
of onseL of lllness) llg 3 Coronary ArLery ulsease AcuLe lnferlor (dlaphragmaLlc)
lefL venLrlcular lnfarcLlon (afLer Lhe flrsL 24 h) and llg 6 Coronary ArLery ulsease
AcuLe lnferlor (dlaphragmaLlc) lefL venLrlcular lnfarcLlon (several days laLer) )
|g 1

Acute anter|or |eft ventr|cu|ar |nfarct|on (trac|ng obta|ned w|th|n a few
hours of onset of |||ness)

@here ls sLrlklng hyperacuLe S@segmenL elevaLlon ln leads l avL v
4
and
v
6
and reclprocal depresslon ln oLher leads

|g 2

Acute anter|or |eft ventr|cu|ar |nfarct|on (after the f|rst 24 h)

S@ segmenLs are less elevaLed slgnlflcanL C waves develop and 8 waves are
losL ln leads l avL v
4
and v
6


|g 3

Acute anter|or |eft ventr|cu|ar |nfarct|on (severa| days |ater)

SlgnlflcanL C waves and loss of 8wave volLage perslsL S@ segmenLs are now
essenLlally lsoelecLrlc @he LCC wlll probably change only slowly over Lhe
nexL several monLhs

|g 4

Acute |nfer|or (d|aphragmat|c) |eft ventr|cu|ar |nfarct|on (trac|ng obta|ned
w|th|n a few hours of onset of |||ness)

@here ls hyperacuLe S@segmenL elevaLlon ln leads ll lll and avl and
reclprocal depresslon ln oLher leads

|g S

Acute |nfer|or (d|aphragmat|c) |eft ventr|cu|ar |nfarct|on (after the f|rst
24 h)

SlgnlflcanL C waves develop wlLh decreaslng S@segmenL elevaLlon ln leads
ll lll and avl

|g 6

Acute |nfer|or (d|aphragmat|c) |eft ventr|cu|ar |nfarct|on (severa| days
|ater)

S@ segmenLs are now lsoelecLrlc Abnormal C waves ln leads ll lll and avl
lndlcaLe LhaL myocardlal scars perslsL

aLhologlc C waves are noL necessary for Lhe dlagnosls @he LCC musL be read carefully
because S@segmenL elevaLlon may be subLle parLlcularly ln Lhe lnferlor leads (ll lll avl)
someLlmes Lhe readers aLLenLlon ls mlsLakenly focused on leads wlLh S@segmenL depresslon lf
sympLoms are characLerlsLlc S@segmenL elevaLlon on LCC has a speclflclLy of 90 and a
senslLlvlLy of 43 for dlagnoslng Ml Serlal Lraclngs (obLalned every 8 h for 1 day Lhen dally)
showlng a gradual evoluLlon Loward a sLable more normal paLLern or developmenL of abnormal
C waves over a few days Lends Lo conflrm Lhe dlagnosls
8ecause nonLransmural (nonCwave) lnfarcLs are usually ln Lhe subendocardlal or
mldmyocardlal layers Lhey do noL produce dlagnosLlc C waves or dlsLlncL S@segmenL elevaLlon
on Lhe LCC lnsLead Lhey commonly produce only varylng degrees of S@@ abnormallLles LhaL
are less sLrlklng varlable or nonspeclflc and someLlmes dlfflculL Lo lnLerpreL (nS@LMl) lf such
abnormallLles resolve (or worsen) on repeaL LCCs lschemla ls very llkely Powever when
repeaL LCCs are unchanged acuLe Ml ls unllkely and lf sLlll suspecLed cllnlcally requlres oLher
evldence Lo make Lhe dlagnosls A normal LCC Laken when a paLlenL ls paln free does noL rule
ouL unsLable anglna a normal LCC Laken durlng paln alLhough lL does noL rule ouL anglna
suggesLs LhaL Lhe paln ls noL lschemlc
lf 8v lnfarcLlon ls suspecLed a 13lead LCC ls usually recorded addlLlonal leads are placed aL
v
4
8 and Lo deLecL posLerlor lnfarcLlon v
8
and v
9

LCC dlagnosls of Ml ls more dlfflculL when a lefL bundle branch block conflguraLlon ls presenL
because lL resembles S@LMl changes S@segmenL elevaLlon concordanL wlLh Lhe C8S complex
sLrongly suggesLs Ml as does 3mm S@segmenL elevaLlon ln aL leasL 2 precordlal leads 8uL

generally any paLlenL wlLh suggesLlve sympLoms and newonseL (or noL known Lo be old) lefL
bundle branch block ls LreaLed as for S@LMl
ordioc morkers
Cardlac markers are cardlac enzymes (eg CkM8) and cell conLenLs (eg Lroponln l Lroponln @
myoglobln) LhaL are released lnLo Lhe bloodsLream afLer myocardlal cell necrosls @he markers
appear aL dlfferenL Llmes afLer ln[ury and decrease aL dlfferenL raLes (see llg 7 Coronary ArLery
ulsease 8elaLlve Llmlng and levels of cardlac markers ln blood afLer acuLe Ml )
|g 7

ke|at|ve t|m|ng and |eve|s of card|ac markers |n b|ood after acute MI

MC8 myoglobulln

usually several dlfferenL markers are measured aL regular lnLervals Lyplcally every 6 Lo 8 h for
1 day newer bedslde LesLs whlch are more convenlenL can be [usL as senslLlve when done aL
shorLer lnLervals (eg Llme 0 1 3 and 6 h afLer presenLaLlon)
@roponlns are mosL speclflc for Ml buL can also be elevaLed by lschemla wlLhouL lnfarcLlon
elevaLed levels (acLual number varles wlLh assay used) are consldered dlagnosLlc 8orderllne
elevaLed Lroponln levels ln paLlenLs wlLh unsLable anglna lndlcaLe lncreased rlsk of adverse
evenLs and Lhus Lhe need for furLher evaluaLlon and LreaLmenL lalseposlLlves someLlmes
occur ln hearL fallure and renal fallure CkM8 ls sllghLly less speclflc lalseposlLlves occur ln
renal fallure hypoLhyroldlsm and skeleLal muscle ln[ury Myoglobln ls noL speclflc for Ml buL
because lL lncreases earller Lhan oLher markers may be an early warnlng slgn Lo asslsL ln Lrlage
of paLlenLs wlLh nondlagnosLlc LCCs
oronory onqioqrophy

Coronary anglography mosL ofLen comblnes dlagnosls wlLh percuLaneous coronary lnLervenLlon
(Cl le angloplasLy sLenLlng) Anglography ls obLalned urgenLly for paLlenLs wlLh S@LMl
paLlenLs wlLh perslsLenL chesL paln desplLe maxlmal medlcal Lherapy and paLlenLs wlLh
compllcaLlons (eg markedly elevaLed cardlac markers presence of cardlogenlc shock acuLe
mlLral regurglLaLlon venLrlcular sepLal defecL unsLable arrhyLhmlas) aLlenLs wlLh
uncompllcaLed nS@LMl or unsLable anglna whose sympLoms have resolved Lyplcally undergo
anglography wlLhln Lhe flrsL 24 Lo 48 h of hosplLallzaLlon Lo deLecL leslons LhaL may requlre
LreaLmenL
AfLer lnlLlal evaluaLlon and Lherapy coronary anglography may be used ln paLlenLs wlLh
evldence of ongolng lschemla (LCC flndlngs or sympLoms) hemodynamlc lnsLablllLy recurrenL
venLrlcular LachyarrhyLhmlas and oLher abnormallLles LhaL suggesL recurrence of lschemlc
evenLs Some experLs also recommend LhaL anglography be done before hosplLal dlscharge ln
S@LMl paLlenLs wlLh lnduclble lschemla on sLress lmaglng or an e[ecLlon fracLlon 40
ther tests
8ouLlne laboraLory LesLs are nondlagnosLlc buL lf obLalned show nonspeclflc abnormallLles
compaLlble wlLh Llssue necrosls (eg lncreased LS8 moderaLely elevaLed W8C counL wlLh a shlfL
Lo Lhe lefL) A fasLlng llpld proflle should be obLalned wlLhln Lhe flrsL 24 h for all paLlenLs
hosplLallzed wlLh ACS
Myocardlal lmaglng (see also Cardlovascular @esLs and rocedures Cardlac lmaglng @esLs) ls noL
needed Lo make Lhe dlagnosls lf cardlac markers or LCC ls poslLlve Powever ln paLlenLs wlLh
Ml bedslde echocardlography ls lnvaluable for deLecLlng mechanlcal compllcaLlons 8efore or
shorLly afLer dlscharge paLlenLs wlLh sympLoms suggesLlng an ACS buL nondlagnosLlc LCCs and
normal cardlac markers should have a sLress lmaglng LesL (radlonucllde or echocardlographlc
lmaglng wlLh pharmacologlc or exerclse sLress) lmaglng abnormallLles ln such paLlenLs lndlcaLe
lncreased rlsk of compllcaLlons ln Lhe nexL 3 Lo 6 mo
8lghL hearL caLheLerlzaLlon uslng a balloonLlpped pulmonary arLery caLheLer (see Approach Lo
Lhe CrlLlcally lll aLlenL ulmonary ArLery CaLheLer MonlLorlng) can be used Lo measure rlghL
hearL pulmonary arLery and pulmonary arLery occluslon pressures and cardlac ouLpuL @hls
LesL ls usually done only lf paLlenLs have slgnlflcanL compllcaLlons (eg severe hearL fallure
hypoxla hypoLenslon)
rognos|s
Dnstob/e onqino

AbouL 30 of paLlenLs wlLh unsLable anglna have an Ml wlLhln 3 mo of onseL sudden deaLh ls
less common Marked LCC changes wlLh chesL paln lndlcaLe hlgher rlsk of subsequenL Ml or
deaLh
N51Ml ond 51Ml
Cverall morLallLy raLe ls abouL 30 wlLh 30 Lo 60 of Lhese paLlenLs dylng before reachlng Lhe
hosplLal (Lyplcally due Lo venLrlcular flbrlllaLlon) lnhosplLal morLallLy raLe ls abouL 10
(Lyplcally due Lo cardlogenlc shock) buL varles slgnlflcanLly wlLh severlLy of Lv fallure (see @able
4 Coronary ArLery ulsease kllllp ClasslflcaLlon and MorLallLy 8aLe of AcuLe Ml* )
MosL paLlenLs who dle of cardlogenlc shock have an lnfarcL or a comblnaLlon of scar and new
lnfarcL affecLlng 30 of Lv mass llve cllnlcal characLerlsLlcs predlcL 90 of Lhe morLallLy ln
paLlenLs who presenL wlLh S@LMl (see @able 3 Coronary ArLery ulsease MorLallLy 8lsk aL 30
uays ln S@LMl ) older age (31 of LoLal morLallLy) lower sysLollc 8 (24) kllllp class 1
(13) fasLer hearL raLe (12) and anLerlor locaLlon (6) MorLallLy raLe of dlabeLlcs and
women Lends Lo be hlgher
MorLallLy raLe of paLlenLs who survlve lnlLlal hosplLallzaLlon ls 8 Lo 10 ln Lhe year afLer acuLe
Ml MosL faLallLles occur ln Lhe flrsL 3 Lo 4 mo erslsLenL venLrlcular arrhyLhmla hearL fallure
poor venLrlcular funcLlon and recurrenL lschemla lndlcaLe hlgh rlsk Many auLhorlLles
recommend sLress LCC before hosplLal dlscharge or wlLhln 6 wk Cood exerclse performance
wlLhouL LCC abnormallLles ls assoclaLed wlLh a favorable prognosls furLher evaluaLlon ls
usually noL requlred oor exerclse performance ls assoclaLed wlLh a poor prognosls
Cardlac performance afLer recovery depends largely on how much funcLlonlng myocardlum
survlves Lhe acuLe aLLack Scars from prevlous lnfarcLs add Lo Lhe acuLe damage When 30 of
Lv mass ls damaged prolonged survlval ls unusual
1ab|e 4

k||||p |ass|f|cat|on and Morta||ty kate of Acute MI*
|ass AC
2
f ||n|ca| escr|pt|on nosp|ta|
Morta||ty kate
1 normal no cllnlcal evldence of lefL
venLrlcular (Lv) fallure
33
2 SllghLly
reduced
Mlld Lo moderaLe Lv fallure 610
3 Abnormal Severe Lv fallure pulmonary
edema
2030

4 Severely
abnormal
Cardlogenlc shock hypoLenslon
Lachycardla menLal
obLundaLlon cool exLremlLles
ollgurla hypoxla
80
*ueLermlned by repeaLed examlnaLlon of Lhe paLlenL durlng Lhe course of
lllness
1ueLermlned whlle Lhe paLlenL ls breaLhlng room alr
Modlfled from kllllp @ klmball !@ @reaLmenL of myocardlal lnfarcLlon ln a
coronary care unlL A Lwoyear experlence wlLh 230 paLlenLs 1be Ametlcoo
Iootool of cotJloloqy 20437464 1967

1ab|e S

Morta||ty k|sk at 30 ays |n S1LMI
Scor|ng
k|sk actor o|nts
Age 73 3
Age 6374 2
ulabeLes melllLus
hyperLenslon or
anglna
1
SysLollc 8 100 mm
Pg
3
PearL raLe 100
beaL/mln
2
kllllp class lllv 2
WelghL 67 kg 1
AnLerlor S@elevaLlon
or lefL branch bundle
block
1
@lme Lo LreaLmenL 4
h
1
@oLal polnLs posslble 014
k|sk
1ota| o|nts Morta||ty
kate at 30
ays ()

0 08
1 16
2 22
3 44
4 73
3 124
6 161
7 234
8 268
8 339
S@LMl S@segmenL elevaLlon Ml
@lMl Lhrombolysls ln Ml
8ased on daLa from Morrow uA eL
al @lMl rlsk score for S@elevaLlon
myocardlal lnfarcLlon a convenlenL
bedslde cllnlcal score for rlsk
assessmenL aL
presenLaLlon cltcolotloo 102
(17)20312037 2000 and ACC/APA
guldellnes for Lhe managemenL of
paLlenLs wlLh acuLe myocardlal
lnfarcLlon

1ab|e 6

k|sk of Adverse Lvents* at 14 ays |n
-S1LMI
Scor|ng
k|sk actor o|nts
Age 63 1
CAu rlsk facLors (musL
have 3 for 1 polnL)
1
lamlly hlsLory
PyperLenslon
CurrenL smoker
Plgh cholesLerol
ulabeLes melllLus

known CAu
(sLenosls 30)
1
revlous chronlc use
ofasplrln
1
@wo eplsodes of resL
anglna ln pasL 24 h
1
LlevaLed cardlac markers 1
8lsk level ls based on
LoLal polnLs 12 low
34 lnLermedlaLe 3
7 hlgh

Abso|ute r|sk
1ota| o|nts k|sk of
Lvents at
14 ays
()*
0 or 1 47
2 83
3 132
4 199
3 262
6 or 7 409
*LvenLs lnclude allcause morLallLy
Ml and recurrenL lschemla requlrlng
urgenL revascularlzaLlon
CAu coronary arLery dlsease
nS@LMl nonS@segmenL
elevaLlon Ml @lMl Lhrombolysls ln
Ml
8ased on daLa from AnLman LM eL
al @he @lMl rlsk score for unsLable
anglna/nonS@ elevaLlon Ml A
meLhod of prognosLlcaLlon and
LherapeuLlc declslon
maklng IAMA 28483342 2000

enera| 1reatment
O MonlLorlng and C
2

O 8ed resL lnlLlally wlLh early ambulaLlon

O LowsalL lowfaL dleL
O SLool sofLeners and anxlolyLlcs as needed
@reaLmenL ls deslgned Lo relleve dlsLress lnLerrupL Lhrombosls reverse lschemla llmlL lnfarcL
slze reduce cardlac workload and prevenL and LreaL compllcaLlons An ACS ls a medlcal
emergency ouLcome ls greaLly lnfluenced by rapld dlagnosls and LreaLmenL
@reaLmenL occurs slmulLaneously wlLh dlagnosls A rellable lv rouLe musL be esLabllshed
C
2
glven (Lyplcally 2 L by nasal cannula) and conLlnuous slnglelead LCC monlLorlng sLarLed
rehosplLal lnLervenLlons by ambulance personnel (lncludlng LCC chewed asplrln (323 mg)
early Lhrombolysls when lndlcaLed and posslble and Lrlage Lo Lhe approprlaLe hosplLal) can
reduce rlsk of morLallLy and compllcaLlons Larly dlagnosLlc daLa and response Lo LreaLmenL can
help deLermlne Lhe need for and Llmlng of revascularlzaLlon (see see Coronary ArLery ulsease
8evascularlzaLlon ModallLles and lndlcaLlons)
8edslde cardlac marker LesLs can help ldenLlfy lowrlsk paLlenLs wlLh a suspecLed ACS (eg Lhose
wlLh lnlLlally negaLlve cardlac markers and nondlagnosLlc LCCs) who can be managed ln 24h
observaLlon unlLs or chesL paln cenLers Plgherrlsk paLlenLs should be admlLLed Lo a monlLored
lnpaLlenL unlL or coronary care unlL (CCu) Several valldaLed Lools can help sLraLlfy rlsk
@hrombolysls ln Ml (@lMl) rlsk scores may be Lhe mosL wldely used (see @able 3Coronary ArLery
ulsease MorLallLy 8lsk aL 30 uays ln S@LMl and @able 6 Coronary ArLery ulsease 8lsk of
Adverse LvenLs* aL 14 uays ln nS@LMl )
aLlenLs wlLh suspecLed nS@LMl and lnLermedlaLe or hlgh rlsk should be admlLLed Lo an
lnpaLlenL care unlL @hose wlLh S@LMl should be admlLLed Lo a CCu
Cnly hearL raLe and rhyLhm recorded by slnglelead LCC are conslsLenLly useful for rouLlne
conLlnuous monlLorlng Powever some cllnlclans recommend rouLlne mulLllead monlLorlng
wlLh conLlnuous S@segmenL recordlng Lo ldenLlfy LranslenL recurrenL S@segmenL elevaLlons or
depresslons Such flndlngs even ln paLlenLs wlLhouL sympLoms suggesL lschemla and ldenLlfy
hlgherrlsk paLlenLs who may requlre more aggresslve evaluaLlon and LreaLmenL
Cuallfled nurses can lnLerpreL Lhe LCC for arrhyLhmla and lnlLlaLe proLocols for lLs LreaLmenL
All sLaff members should know how Lo do C8
ConLrlbuLlng dlsorders (eg anemla hearL fallure) are aggresslvely LreaLed
@he care unlL should be a quleL calm resLful area Slngle rooms are preferred prlvacy
conslsLenL wlLh monlLorlng should be ensured usually vlslLors and Lelephone calls are

resLrlcLed Lo famlly members durlng Lhe flrsL few days A wall clock a calendar and an ouLslde
wlndow help orlenL Lhe paLlenL and prevenL a sense of lsolaLlon as can access Lo a radlo
Lelevlslon and newspaper
8ed resL ls mandaLory for Lhe flrsL 24 h Cn day 1 paLlenLs wlLhouL compllcaLlons (eg
hemodynamlc lnsLablllLy ongolng lschemla) lncludlng Lhose ln whom reperfuslon wlLh
flbrlnolyLlcs or Cl ls successful can slL ln a chalr begln passlve exerclses and use a commode
Walklng Lo Lhe baLhroom and dolng nonsLressful paperwork ls allowed shorLly LhereafLer
8ecenL sLudles have shown LhaL paLlenLs wlLh successful uncompllcaLed prlmary Cl for acuLe
Ml may be ambulaLed qulckly and be safely dlscharged ln 3 Lo 4 days lf reperfuslon ls noL
successful or compllcaLlons are presenL paLlenLs requlre longer bed resL buL Lhey (parLlcularly
elderly paLlenLs) are moblllzed as soon as posslble rolonged bed resL resulLs ln rapld physlcal
decondlLlonlng wlLh developmenL of orLhosLaLlc hypoLenslon decreased work capaclLy
lncreased hearL raLe durlng exerLlon and lncreased rlsk of deep venous Lhrombosls rolonged
bed resL also lnLenslfles feellngs of depresslon and helplessness
AnxleLy mood changes and denlal are common A mlld Lranqulllzer (usually a benzodlazeplne)
ls ofLen glven buL many experLs belleve such drugs are rarely needed
8eacLlve depresslon ls common by Lhe 3rd day of lllness and ls almosL unlversal aL some Llme
durlng recovery AfLer Lhe acuLe phase of lllness Lhe mosL lmporLanL Lasks are ofLen
managemenL of depresslon rehablllLaLlon and lnsLlLuLlon of longLerm prevenLlve programs
Cveremphasls on bed resL lnacLlvlLy and Lhe serlousness of Lhe dlsorder relnforces anxleLy and
depresslve Lendencles so paLlenLs are encouraged Lo slL up geL ouL of bed and engage ln
approprlaLe acLlvlLles as soon as posslble @he effecLs of Lhe dlsorder prognosls and
lndlvlduallzed rehablllLaLlon program should be explalned Lo Lhe paLlenL
MalnLalnlng normal bowel funcLlon wlLh sLool sofLeners (eg docusaLe) Lo prevenL sLralnlng ls
lmporLanL urlnary reLenLlon ls common among elderly paLlenLs especlally afLer several days of
bed resL or lf aLroplne was glven A caLheLer may be requlred buL can usually be removed when
Lhe paLlenL can sLand or slL Lo vold
8ecause smoklng ls prohlblLed a hosplLal sLay should be used Lo encourage smoklng cessaLlon
All careglvers should devoLe conslderable efforL Lo maklng smoklng cessaLlon permanenL
AlLhough acuLely lll paLlenLs have llLLle appeLlLe LasLy food ln modesL amounLs ls good for
morale aLlenLs are usually offered a sofL dleL of 1300 Lo 1800 kcal/day wlLh na reducLlon Lo 2
Lo 3 g na reducLlon ls noL requlred afLer Lhe flrsL 2 or 3 days lf Lhere ls no evldence of hearL

fallure aLlenLs are glven a dleL low ln cholesLerol and saLuraLed faLs whlch ls used Lo Leach
healLhy eaLlng
lor dlabeLlc paLlenLs wlLh S@LMl lnLenslve glucose conLrol ls no longer recommended
guldellnes call for an lnsullnbased reglmen Lo achleve and malnLaln glucose levels 180 mg/dL
whlle avoldlng hypoglycemla
8ecause Lhe chesL paln of Ml usually subsldes wlLhln 12 Lo 24 h any chesL paln LhaL remalns or
recurs laLer ls lnvesLlgaLed lL may lndlcaLe such compllcaLlons as recurrenL lschemla
perlcardlLls pulmonary embollsm pneumonla gasLrlLls or ulcer
rugs
O Asplrln clopldogrel or boLh (prasugrel ls an alLernaLlve Lo clopldogrel lf flbrlnolyLlc Lherapy
has noL been glven)
O 8locker
O C llb/llla lnhlblLor fconsldered or cerLaln paLlenLs undergolng Cl and for some oLhers aL
hlgh rlsk (eg wlLh markedly elevaLed cardlac markers @lMl rlsk score 4 perslsLenL
sympLoms)
O A heparln (unfracLlonaLed or low molecular welghL heparln) or blvallrudln (parLlcularly ln
S@LMl paLlenLs aL hlgh rlsk of bleedlng)
O lv nlLroglycerln (unless lowrlsk uncompllcaLed Ml)
O llbrlnolyLlcs for selecL paLlenLs wlLh S@LMl when Llmely Cl unavallable
O ACL lnhlblLor (as early as posslble) and a sLaLln
AnLlplaLeleL and anLlLhromboLlc drugs whlch sLop cloLs from formlng are used rouLlnely AnLl
lschemlc drugs (eg blockers lv nlLroglycerln) are frequenLly added parLlcularly when chesL
paln or hyperLenslon ls presenL (see @able 3 Coronary ArLery ulsease urugs for Coronary
ArLery ulsease ) llbrlnolyLlcs sboolJ be oseJ lf oot coottoloJlcoteJ for S@LMl lf prlmary Cl ls
noL lmmedlaLely avallable buL worsen ouLcome for unsLable anglna and nS@LMl
ChesL paln can be LreaLed wlLh morphlne or nlLroglycerln Morphlne 2 Lo 4 mg lv repeaLed q 13
mln as needed ls hlghly effecLlve buL can depress resplraLlon can reduce myocardlal
conLracLlllLy and ls a poLenL venous vasodllaLor PypoLenslon and bradycardla secondary
Lo morphlne can usually be overcome by prompL elevaLlon of Lhe lower
exLremlLles nlLroglycerln ls lnlLlally glven subllngually followed by conLlnuous lv drlp lf needed
8 ls normal or sllghLly elevaLed ln mosL paLlenLs on arrlval aL Lhe emergency deparLmenL 8
gradually falls over Lhe nexL several hours ConLlnued hyperLenslon requlres LreaLmenL wlLh
anLlhyperLenslves preferably lv nlLroglycerln Lo lower 8 and reduce cardlac workload Severe

hypoLenslon or oLher slgns of shock are omlnous and musL be LreaLed aggresslvely wlLh lv flulds
and someLlmes vasopressors (see Shock and lluld 8esusclLaLlon Ceneral managemenL)
ntip/ote/et druqs
Asplrln clopldogrel Llclopldlne and C llb/llla lnhlblLors are examples All paLlenLs are
glven asplrln160 Lo 323 mg (noL enLerlccoaLed) lf noL conLralndlcaLed aL presenLaLlon and 81
mg once/day lndeflnlLely LhereafLer Chewlng Lhe flrsL dose before swallowlng qulckens
absorpLlon Asplrlnreduces shorL and longLerm morLallLy rlsk lf asplrln cannoL be
Laken clopldogrel 73 mg once/day or Llclopldlne 230 mg bld may be used Clopldogrel has
largely replaced Llclopldlne for rouLlne use because neuLropenla ls a rlsk wlLh Llclopldlne and
Lhe W8C counL musL be monlLored regularly aLlenLs wlLh unsLable anglna or nS@LMl ln whom
lnLervenLlon ls noL posslble or recommended are glven boLh asplrln and clopldogrel for aL leasL
1 mo @he opLlmal duraLlon of double anLlplaLeleL Lherapy for Lhese paLlenLs ls Lhe sub[ecL of
ongolng lnvesLlgaLlon
ln paLlenLs undergolng Cl a clopldogrel loadlng dose (300 Lo 600 mg po once) lmproves
ouLcomes parLlcularly when admlnlsLered 24 h ln advance Powever delaylng Cl for 24 h ls
noL approprlaLe for many paLlenLs lurLher such a loadlng dose lncreases rlsk of perloperaLlve
bleedlng ln paLlenLs who requlre coronary arLery bypass grafLlng (CA8C) because Lhelr coronary
anaLomy proves unfavorable for Cl @hus many cllnlclans admlnlsLer a clopldogrel loadlng
dose only ln Lhe caLheLerlzaLlon laboraLory once coronary anaLomy and leslons have been
proven Lo be amenable Lo Cl
lor paLlenLs recelvlng a sLenL for revascularlzaLlon asplrln ls conLlnued lndeflnlLely
and clopldogrelshould be used for aL leasL 1 mo ln paLlenLs wlLh a baremeLal sLenL aLlenLs
wlLh a drugeluLlng sLenL have a prolonged rlsk of Lhrombosls and may beneflL from 12 mo
of clopldogrel LreaLmenL alLhough Lhe recommended duraLlon ls sLlll unclear
C llb/llla lnhlblLors (abclxlmab Llroflban epLlflbaLlde) are poLenL anLlplaLeleL drugs LhaL musL
be glven lv AlLhough Lhere ls some conLroversy evldence lndlcaLes LhaL paLlenLs wlLh ACS
undergolng Cl may beneflL from a C llb/llla lnhlblLor resulLs appear Lo be beLLer lf Lhe drug ls
lnlLlaLed aL leasL 6 h before Cl and conLlnued for 18 Lo 24 h LhereafLer lf Cl ls noL belng done
some cllnlclans glve a C llb/llla lnhlblLor Lo all hlghrlsk paLlenLs (eg Lhose wlLh markedly
elevaLed cardlac markers a @lMl rlsk score 4 or perslsLenL sympLoms desplLe adequaLe drug
Lherapy) @he C llb/llla lnhlblLor ls conLlnued for 24 Lo 36 h and anglography ls done before
Lhe lnfuslon perlod ls over C llb/llla lnhlblLors are noL recommended for paLlenLs recelvlng
flbrlnolyLlcs Abclxlmab Llroflban andepLlflbaLlde appear Lo have equlvalenL efflcacy and Lhe
cholce of drug should depend on oLher facLors (eg cosL avallablllLy famlllarlLy)

nticooqu/ont druqs
LlLher a low molecular welghL heparln (LMWP) unfracLlonaLed heparln or blvallrudln ls glven
rouLlnely Lo paLlenLs wlLh ACS unless conLralndlcaLed (eg by acLlve bleedlng or planned use
ofsLrepLoklnase or anlsLreplase) Cholce of agenL ls somewhaL lnvolved
unfracLlonaLed heparln ls more compllcaLed Lo use because lL requlres frequenL (q 6 h) doslng
ad[usLmenLs Lo achleve an acLlvaLed @@ (a@@) 13 Lo 2 Llmes Lhe conLrol value ln paLlenLs
undergolng anglography furLher doslng ad[usLmenL ls done Lo achleve an acLlvaLed cloLLlng
Llme (AC@) of 200 Lo 230 sec lf Lhe paLlenL ls LreaLed wlLh a C llb/llla lnhlblLor and 230 Lo 300
sec lf a C llb/llla lnhlblLor ls noL belng glven Powever Lhe effecLs of
unfracLlonaLed heparln are shorLer and can be reversed (wlLh prompL dlsconLlnuaLlon
of heparln lnfuslon and wlLh admlnlsLraLlon ofproLamlne sulfaLe) lf bleedlng develops followlng
caLheLerlzaLlon
@he LMWPs have beLLer bloavallablllLy are glven by slmple welghLbased dose wlLhouL
monlLorlng a@@ and dose LlLraLlon and have lower rlsk of heparlnlnduced LhrombocyLopenla
@hey also may produce an lncremenLal beneflL ln ouLcomes relaLlve Lo
unfracLlonaLed heparln ln paLlenLs wlLh ACS Cf Lhe LMWPs enoxaparln appears Lo be superlor
Lo dalLeparln or nadroparln Powever enoxaparlnmay pose a hlgher bleedlng rlsk ln paLlenLs
wlLh S@LMl who are 73 and lLs effecLs are noL compleLely reverslble wlLh proLamlne
@hus Laklng all lnLo accounL many publlshed guldellnes recommend LMWP (eg enoxaparln)
over unfracLlonaLed heparln ln paLlenLs wlLh unsLable anglna or nS@LMl and ln paLlenLs 73
wlLh S@LMl who are noL undergolng Cl 8y conLrasL unfracLlonaLed heparln ls recommended
when emergency Cl ls done (eg paLlenLs wlLh acuLe S@LMl who proceed Lo Lhe caLheLerlzaLlon
laboraLory) when CA8C ls lndlcaLed wlLhln Lhe nexL 24 h and when paLlenLs are aL hlgh rlsk of
bleedlng compllcaLlons (eg hlsLory of Cl bleedlng wlLhln Lhe lasL 6 mo) or have creaLlnlne
clearance 30 mL/mln Cngolng sLudles should help clarlfy Lhe cholce beLween LMWP and
unfracLlonaLed heparln
8lvallrudln ls an accepLable anLlcoagulanL for paLlenLs undergolng prlmary Cl who are aL hlgh
rlsk of bleedlng and ls recommended for Lhose wlLh a known or suspecLed hlsLory of heparln
lnduced LhrombocyLopenla lor paLlenLs wlLh unsLable anglna or nS@LMl dose ls an lnlLlal
bolus of 01 mg/kg lv followed by a drlp of 023 mg/kg/h lor paLlenLs wlLh S@LMl lnlLlal dose ls
073 mg/kg lv followed by 173 mg/kg/h
lor paLlenLs undergolng Cl posLprocedure heparln ls no longer recommended unless paLlenLs
are aL hlgh rlsk of Lhromboembollc evenLs (eg paLlenLs wlLh large anLerlor Ml known Lv
Lhrombus aLrlal flbrlllaLlon) because posLprocedure lschemlc evenLs have decreased wlLh Lhe

use of sLenLs and anLlplaLeleL drugs lor paLlenLs noL undergolng Cl heparln ls conLlnued for
48 h (or longer lf sympLoms perslsL)
@he dlfflculLles wlLh Lhe heparlns (lncludlng bleedlng compllcaLlons Lhe posslblllLy of heparln
lnduced LhrombocyLopenla and wlLh unfracLlonaLed heparln Lhe need for doslng ad[usLmenLs)
have led Lo Lhe search for beLLer anLlcoagulanLs @he dlrecL Lhrombln
lnhlblLors blvallrudln and argaLroban may have a lower lncldence of serlous bleedlng and
lmproved ouLcomes parLlcularly ln paLlenLs wlLh renal lnsufflclency (hlrudln anoLher dlrecL
Lhrombln lnhlblLor appears Lo cause more bleedlng Lhan Lhe oLher drugs) @he facLor xa
lnhlblLor fondaparlnux reduces morLallLy and relnfarcLlon ln paLlenLs wlLh nS@LMl who
undergo Cl wlLhouL lncreaslng bleedlng buL may resulL ln worse ouLcomes Lhan
unfracLlonaLed heparln ln paLlenLs wlLh S@LMl AlLhough rouLlne use of Lhese alLernaLlve
anLlcoagulanLs ls Lhus noL currenLly recommended Lhey should be used ln place of
unfracLlonaLedheparln or LMWP ln paLlenLs wlLh a known or suspecLed hlsLory of heparln
lnduced LhrombocyLopenla
aLlenLs aL hlgh rlsk of sysLemlc emboll also requlre longLerm Lherapy wlLh oral warfarln
Converslon Lo warfarln should begln 48 h afLer sympLom resoluLlon or Cl
/ockers
@hese drugs are recommended unless conLralndlcaLed (eg by bradycardla hearL block
hypoLenslon or asLhma) especlally for hlghrlsk paLlenLs 8lockers reduce hearL raLe arLerlal
pressure and conLracLlllLy Lhereby reduclng cardlac workload and C
2
demand lv blockers
glven wlLhln Lhe flrsL few hours lmprove prognosls by reduclng lnfarcL slze recurrence raLe
lncldence of venLrlcular flbrlllaLlon and morLallLy rlsk lnfarcL slze largely deLermlnes cardlac
performance afLer recovery
PearL raLe and 8 musL be carefully monlLored durlng LreaLmenL wlLh blockers uosage ls
reduced lf bradycardla or hypoLenslon develops Lxcesslve adverse effecLs may be reversed by
lnfuslon of Lhe adrenerglc agonlsL lsoproLerenol 1 Lo 3 g/mln
Nitrotes
A shorLacLlng nlLraLe nlLroglycerln ls used Lo reduce cardlac workload ln selecLed
paLlenLsnlLroglycerln dllaLes velns arLerles and arLerloles reduclng Lv preload and afLerload
As a resulL myocardlal C
2
demand ls reduced lessenlng lschemla lv nlLroglycerln ls
recommended durlng Lhe flrsL 24 Lo 48 h for paLlenLs wlLh hearL fallure large anLerlor Ml
perslsLenL chesL dlscomforL or hyperLenslon 8 can be reduced by 10 Lo 20 mm Pg buL noL
Lo 80 Lo 90 mm Pg sysLollc Longer use may beneflL paLlenLs wlLh recurrenL chesL paln or
perslsLenL pulmonary congesLlon ln hlghrlsk paLlenLs nlLroglycerln glven ln Lhe flrsL few hours

reduces lnfarcL slze and shorLLerm and posslbly longLerm morLallLy rlsk nlLroglycerln ls noL
rouLlnely glven Lo lowrlsk paLlenLs wlLh uncompllcaLed Ml
ibrino/ytics
@enecLeplase (@nk) alLeplase (r@A) reLeplase (rA) sLrepLoklnase and anlsLreplase
(anlsoylaLed plasmlnogen acLlvaLor complexASAC) all glven lv are plasmlnogen acLlvaLors
@hey converL slnglechaln plasmlnogen Lo doublechaln plasmlnogen whlch has flbrlnolyLlc
acLlvlLy @hey have dlfferenL characLerlsLlcs and doslng reglmens (see @able 7 Coronary ArLery
ulsease lv llbrlnolyLlc urugs Avallable ln Lhe uS ) and are approprlaLe only for selecLed
paLlenLs wlLh S@LMl (seeCoronary ArLery ulsease S@LMl)
@enecLeplase and reLeplase are recommended mosL ofLen because of Lhelr slmpllclLy of
admlnlsLraLlon LenecLeplase ls glven as a slngle bolus over 3 sec and reLeplase as a double
bolus 30 mln aparL AdmlnlsLraLlon Llme and drug errors are reduced compared wlLh oLher
flbrlnolyLlcs@enecLeplase llke alLeplase has an lnLermedlaLe rlsk of lnLracranlal hemorrhage
has a hlgher raLe of recanallzaLlon Lhan oLher flbrlnolyLlcs and ls expenslve 8eLeplase has Lhe
hlghesL rlsk of lnLracranlal hemorrhage and a recanallzaLlon raLe slmllar Lo LhaL of LenecLeplase
and lL ls expenslve
SLrepLoklnase may lnduce allerglc reacLlons especlally lf lL has been used prevlously and musL
be glven by lnfuslon over 30 Lo 60 mln however lL has a low lncldence of lnLracerebral
hemorrhage and ls relaLlvely lnexpenslve AnlsLreplase relaLed Lo sLrepLoklnase ls slmllarly
allergenlc and sllghLly more expenslve buL can be glven as a slngle bolus nelLher drug requlres
concomlLanL heparln use lor boLh recanallzaLlon raLe ls lower Lhan LhaL wlLh oLher
plasmlnogen acLlvaLors 8ecause of Lhe posslblllLy of allerglc reacLlons paLlenLs who prevlously
recelved sLrepLoklnase or anlsLreplase are noL glven LhaL drug
AlLeplase ls glven ln an acceleraLed or fronLloaded dosage over 90 mln AlLeplase wlLh
concomlLanL lv heparln lmproves paLency ls nonallergenlc has a hlgher recanallzaLlon raLe
Lhan oLher flbrlnolyLlcs and ls expenslve
1ab|e 7

IV |br|no|yt|c rugs Ava||ab|e |n the US
haracter|st|c Streptok|nase An|strep|ase A|tep|ase ketep|ase 1enectep|ase
uosage (lv) 13 10
6
u
over 3060
mln
30 mg over
3 mln
13 mg
bolus
Lhen 073
mg/kg
over nexL
10 unlL
bolus
over 2
mln
repeaLed
WelghL
ad[usLed
slngle bolus
over 3 sec
60 kg 30

30 mln
(maxlmum
30 mg)
followed
by 030
mg/kg
over 60
mln
(maxlmum
33 mg) for
LoLal dose
of 100 mg
once
afLer 30
mln
mg
6069 kg 33
mg
7079 kg 40
mg
8089 kg 43
mg
90 kg 30
mg
ClrculaLlng halfllfe
(mln)
20 100 6 1316 lnlLlal half
llfe of 2024
mln Lermlnal
phase half
llfe of 90130
mln
ConcurrenLheparln no no ?es ?es ?es
Allerglc reacLlons ?es ?es 8are 8are 8are

ther druqs
ACL lnhlblLors appear Lo reduce morLallLy rlsk ln Ml paLlenLs especlally ln Lhose wlLh anLerlor
lnfarcLlon hearL fallure or Lachycardla @he greaLesL beneflL occurs ln Lhe hlghesLrlsk paLlenLs
early durlng convalescence ACL lnhlblLors are glven 24 h afLer Lhrombolysls sLablllzaLlon and
because of conLlnued beneflclal effecL may be prescrlbed longLerm
AngloLensln ll recepLor blockers may be an effecLlve alLernaLlve for paLlenLs who cannoL
LoleraLe ACL lnhlblLors (eg because of cough) CurrenLly Lhey are noL flrsLllne LreaLmenL afLer
Ml ConLralndlcaLlons lnclude hypoLenslon renal fallure bllaLeral renal arLery sLenosls and
known allergy
PMCCoA reducLase lnhlblLors (sLaLlns) have long been used for prevenLlon of coronary arLery
dlsease and ACS buL Lhere ls now lncreaslng evldence LhaL Lhey also have shorLLerm beneflLs
such as sLablllzlng plaque reverslng endoLhellal dysfuncLlon decreaslng LhrombogenlclLy and
reduclng lnflammaLlon @hus all paLlenLs wlLhouL conLralndlcaLlons Lo Lherapy should recelve a
sLaLln as early as posslble followlng ACS LuL levels of 70 Lo 80 mg/dL (181 Lo 207 mmol/L) are
Lhe recommended ulLlmaLe LargeL
kevascu|ar|zat|on Moda||t|es and Ind|cat|ons

8evascularlzaLlon ls Lhe resLoraLlon of blood supply Lo lschemlc myocardlum ln an efforL Lo llmlL

ongolng damage reduce venLrlcular lrrlLablllLy and lmprove shorLLerm and longLerm
ouLcomes Modes of revascularlzaLlon lnclude Lhrombolysls wlLh flbrlnolyLlc drugs Cl wlLh or
wlLhouL sLenL placemenL and CA8C
@he use Llmlng and modallLy of revascularlzaLlon depend on whlch ACS ls presenL Llmlng of
presenLaLlon exLenL and locaLlon of anaLomlc leslons and avallablllLy of personnel and faclllLles
(see llg 8 Coronary ArLery ulsease Approach Lo acuLe coronary syndromes )
|g 8

Approach to acute coronary syndromes

Dnstob/e onqino ond N51Ml
lmmedlaLe reperfuslon ls noL as urgenL ln paLlenLs wlLh uncompllcaLed nS@LMl (ln whom a
compleLely occluded lnfarcLrelaLed arLery aL presenLaLlon ls uncommon) or ln Lhose wlLh
unsLable anglna who respond Lo medlcal Lherapy Such paLlenLs Lyplcally undergo anglography
wlLhln Lhe flrsL 24 Lo 48 h of hosplLallzaLlon Lo ldenLlfy coronary leslons requlrlng Cl or CA8C A
nonlnLervenLlonal approach and a Lrlal of medlcal managemenL are used for Lhose ln whom

anglography demonsLraLes only a small area of myocardlum aL rlsk leslon morphology noL
amenable Lo Cl anaLomlcally lnslgnlflcanL dlsease ( 30 coronary sLenosls) or slgnlflcanL lefL
maln dlsease ln paLlenLs who are candldaLes for CA8C lurLher anglography or Cl should be
deferred ln favor of medlcal managemenL for paLlenLs wlLh a hlgh rlsk of procedurerelaLed
morbldlLy or morLallLy
8y conLrasL paLlenLs wlLh perslsLenL chesL paln desplLe maxlmal medlcal Lherapy or
compllcaLlons (eg markedly elevaLed cardlac markers presence of cardlogenlc shock acuLe
mlLral regurglLaLlon venLrlcular sepLal defecL unsLable arrhyLhmlas) should proceed dlrecLly Lo
Lhe cardlac caLheLerlzaLlon laboraLory Lo ldenLlfy coronary leslons requlrlng Cl or CA8C
As ln paLlenLs wlLh sLable anglna CA8C ls generally preferred over Cl for paLlenLs wlLh lefL
maln or lefL maln equlvalenL dlsease for Lhose wlLh 3 or 2vessel dlsease lnvolvlng Lhe lefL
anLerlor descendlng arLery and for Lhose wlLh lefL venLrlcular dysfuncLlon or dlabeLes CA8C
musL also be consldered when Cl ls unsuccessful cannoL be used (eg ln leslons LhaL are long
or near blfurcaLlon polnLs) or causes acuLe coronary arLery dlssecLlon
llbrlnolyLlcs are noL lndlcaLed for unsLable anglna or nS@LMl 8lsk ouLwelghs poLenLlal beneflL
51Ml
Lmergency Cl ls Lhe preferred LreaLmenL of S@LMl when avallable ln a Llmely fashlon (door Lo
balloonlnflaLlon Llme 90 mln) by an experlenced operaLor lndlcaLlons for urgenL Cl laLer ln
Lhe course of S@LMl lnclude hemodynamlc lnsLablllLy mallgnanL arrhyLhmlas requlrlng
Lransvenous paclng or repeaLed cardloverslon and age 73 lf Lhe leslons necesslLaLe CA8C
Lhere ls abouL 4 Lo 12 morLallLy and a 20 Lo 43 morbldlLy raLe
lf Lhere ls llkely Lo be a slgnlflcanL delay ln avallablllLy of Cl Lhrombolysls should be done for
S@LMl paLlenLs meeLlng crlLerla (see @able 8 Coronary ArLery ulsease llbrlnolyLlc @herapy for
S@LMl ) 8eperfuslon uslng flbrlnolyLlcs ls mosL effecLlve lf glven ln Lhe flrsL few mlnuLes Lo
hours afLer onseL of Ml @he earller a flbrlnolyLlc ls begun Lhe beLLer @he goal ls a doorLo
needle Llme of 30 Lo 60 mln CreaLesL beneflL occurs wlLhln 3 h buL Lhe drugs may be effecLlve
up Lo 12 h used wlLhasplrln flbrlnolyLlcs reduce hosplLal morLallLy raLe by 30 Lo 30 and
lmprove venLrlcular funcLlon AlLhough conLroverslal prehosplLal use of flbrlnolyLlcs by Lralned
paramedlcs can slgnlflcanLly reduce Llme Lo LreaLmenL and should be consldered ln slLuaLlons ln
whlch Cl wlLhln 90 mln ls noL posslble parLlcularly ln paLlenLs presenLlng wlLhln 3 h of
sympLom onseL
8egardless mosL paLlenLs who undergo Lhrombolysls wlll ulLlmaLely requlre Lransfer Lo a Cl
capable faclllLy for elecLlve anglography and Cl as necessary prlor Lo dlscharge Cl should be

consldered afLer flbrlnolyLlcs lf chesL paln or S@segmenL elevaLlon perslsLs 60 mln afLer
lnlLlaLlon of flbrlnolyLlcs or lf paln and S@segmenL elevaLlon recur buL only lf Cl can be
lnlLlaLed 90 mln afLer onseL of recurrence lf Cl ls unavallable flbrlnolyLlcs can be repeaLed
CharacLerlsLlcs and selecLlon of flbrlnolyLlc drugs are dlscussed above (see Coronary ArLery
ulsease llbrlnolyLlcs)
1ab|e 8

|br|no|yt|c 1herapy for S1LMI
r|ter|a Spec|f|cs
LCC crlLerla* S@segmenL
elevaLlon ln 2
conLlguous leads
@yplcal sympLoms
and lefL bundle
branch block noL
known Lo be old
SLrlcLly posLerlor
Ml (large 8 wave
ln v
1
and S@
depresslon ln v
1

v
4

AbsoluLe
conLralndlcaLlons
AorLlc dlssecLlon
revlous
hemorrhaglc
sLroke (aL any
Llme)
revlous lschemlc
sLroke wlLhln 1 yr
AcLlve lnLernal
bleedlng (noL
menses)
lnLracranlal Lumor
erlcardlLls
8elaLlve
conLralndlcaLlons
8 180/110 mm
Pg afLer lnlLlal
anLlhyperLenslve

Lherapy
@rauma or ma[or
surgery wlLhln 4
wk
AcLlve pepLlc ulcer
regnancy
8leedlng dlaLhesls
noncompresslble
vascular puncLure
CurrenL
anLlcoagulaLlon
(ln8 2)
*aLlenLs presenLlng ln Lhe
hyperacuLe phase of Ml wlLh glanL @
waves do noL meeL currenL crlLerla
for flbrlnolyLlcs LCC ls repeaLed ln
20 Lo 30 mln Lo see lf S@segmenL
elevaLlon has developed

omp||cat|ons
LlecLrlcal dysfuncLlon occurs ln 90 of Ml paLlenLs (see also ArrhyLhmlas and ConducLlon
ulsorders) LlecLrlcal dysfuncLlon LhaL commonly causes morLallLy ln Lhe flrsL 72 h lncludes
Lachycardla (from any focus) rapld enough Lo reduce cardlac ouLpuL and lower 8 MoblLz Lype
ll block (2nd degree) or compleLe (3rd degree) Av block venLrlcular Lachycardla (v@) and
venLrlcular flbrlllaLlon (vl) AsysLole ls uncommon excepL as a Lermlnal manlfesLaLlon of
progresslve Lv fallure and shock aLlenLs wlLh dlsLurbances of cardlac rhyLhm are checked for
hypoxla and elecLrolyLe abnormallLles whlch can be causaLlve or conLrlbuLory
5inus node disturbonces
lf Lhe arLery supplylng Lhe slnus node ls affecLed slnus node dlsLurbances can occur Lhey are
more llkely lf Lhere ls a preexlsLlng slnus node dlsorder (common among Lhe elderly) Slnus
bradycardla Lhe mosL common slnus node dlsLurbance ls usually noL LreaLed unless Lhere ls
hypoLenslon or Lhe hearL raLe ls 30 beaLs/mln A lower hearL raLe lf noL exLreme means
reduced cardlac workload and posslbly reduced lnfarcL slze lor bradycardla wlLh hypoLenslon
(whlch may reduce myocardlal perfuslon) aLroplne sulfaLe 03 Lo 1 mg lv ls used lL can be
repeaLed afLer several mlnuLes lf response ls lnadequaLe Several small doses are besL because
hlgh doses may lnduce Lachycardla Cccaslonally a Lemporary Lransvenous pacemaker musL be
lnserLed

erslsLenL slnus Lachycardla ls usually omlnous ofLen reflecLlng Lv fallure and low cardlac
ouLpuL WlLhouL hearL fallure or anoLher evldenL cause Lhls arrhyLhmla may respond Lo a
blocker glven po or lv dependlng on degree of urgency
trio/ orrhythmios
ALrlal arrhyLhmlas (aLrlal ecLoplc beaLs aLrlal flbrlllaLlon Al and less commonly aLrlal fluLLer)
occur ln abouL 10 of Ml paLlenLs and may reflecL Lv fallure or rlghL aLrlal lnfarcLlon
aroxysmal aLrlal Lachycardla ls uncommon and usually occurs ln paLlenLs who have had
prevlous eplsodes of lL ALrlal ecLopy ls usually benlgn buL lf frequency lncreases causes
parLlcularly hearL fallure are soughL lrequenL aLrlal ecLoplc beaLs may respond Lo a blocker
Al ls usually LranslenL lf lL occurs wlLhln Lhe flrsL 24 h 8lsk facLors lnclude age 70 hearL
fallure prevlous hlsLory of Ml large anLerlor lnfarcLlon aLrlal lnfarcLlon perlcardlLls
hypokalemla hypomagnesemla a chronlc lung dlsorder and hypoxla llbrlnolyLlcs reduce
lncldence 8ecurrenL paroxysmal Al ls a poor prognosLlc slgn and lncreases rlsk of sysLemlc
emboll
lor Al heparln ls usually used because sysLemlc emboll are a rlsk (see ArrhyLhmlas and
ConducLlon ulsorders ALrlal llbrlllaLlon (Al)) lv blockers (eg aLenolol 23 Lo 30 mg over 2
mln Lo LoLal dose of 10 mg ln 10 Lo 13 mln meLoprolol 2 Lo 3 mg q 2 Lo 3 mln Lo a LoLal dose of
13 mg ln 10 Lo 13 mln) slow Lhe venLrlcular raLe PearL raLe and 8 are closely monlLored
@reaLmenL ls wlLhheld when venLrlcular raLe decreases saLlsfacLorlly or sysLollc 8 ls 100 mm
Pg lv dlgoxln whlch ls noL as effecLlve as blockers ls used cauLlously and only ln paLlenLs
wlLh Al and Lv sysLollc dysfuncLlon usually dlgoxln Lakes aL leasL 2 h Lo effecLlvely slow hearL
raLe and may rarely aggravaLe lschemla ln paLlenLs wlLh recenL ACS lor paLlenLs wlLhouL
evldenL Lv sysLollc dysfuncLlon or conducLlon delay manlfesLed by a wlde C8S complex
lv verapamll or lv dllLlazemmay be consldered ullLlazem may be glven as an lv lnfuslon Lo
conLrol hearL raLe for long perlods
lf Al compromlses clrculaLory sLaLus (eg causlng Lv fallure hypoLenslon or chesL paln) urgenL
elecLrlcal cardloverslon ls done lf Al reLurns afLer cardloverslon lv amlodarone should be
consldered
lor aLrlal fluLLer raLe ls conLrolled as for Al buL heparln ls noL requlred Lowenergy dlrecL
currenL (uC) cardloverslon wlll LermlnaLe aLrlal fluLLer
onduction defects
MoblLz Lype l block (Wenckebach block progresslve prolongaLlon of 8 lnLerval) ls relaLlvely
common wlLh an lnferlordlaphragmaLlc lnfarcLlon lL ls usually selfllmlLed and rarely

progresses Lo hlgher grade block MoblLz Lype ll block (dropped beaLs) usually lndlcaLes masslve
anLerlor Ml as does compleLe hearL block wlLh wlde C8S complexes (aLrlal lmpulses do noL
reach Lhe venLrlcle) boLh are uncommon lrequency of compleLe (3rd degree) Av block
depends on slLe of lnfarcLlon CompleLe Av block occurs ln 3 Lo 10 of paLlenLs wlLh lnferlor
lnfarcLlon and ls usually LranslenL lL occurs ln 3 wlLh uncompllcaLed anLerlor lnfarcLlon buL
ln up Lo 26 of Lhose wlLh rlghL bundle branch block and lefL posLerlor hemlblock
MoblLz Lype l block usually does noL warranL LreaLmenL lor Lrue MoblLz Lype ll block wlLh
dropped beaLs or for Av block wlLh slow wlde C8S complexes Lemporary Lransvenous paclng ls
Lhe LreaLmenL of cholce LxLernal paclng can be used unLll a Lemporary Lransvenous pacemaker
can be placed AlLhough lsoproLerenol lnfuslon may resLore rhyLhm and raLe Lemporarlly lL ls
noL used because lL lncreases C
2
demand and rlsk of rhyLhm abnormallLles ALroplne 03 mg lv
q 3 Lo 3 mln Lo a LoLal dose of 23 mg may be useful for narrowcomplex Av block wlLh a slow
venLrlcular raLe buL ls noL recommended for new wldecomplex Av block
Ientricu/or orrhythmios
@hese arrhyLhmlas are common and may resulL from hypoxla elecLrolyLe lmbalance
(hypokalemla posslbly hypomagnesemla) or sympaLheLlc overacLlvlLy ln lschemlc cells ad[acenL
Lo lnfarcLed Llssue (whlch ls noL elecLrlcally acLlve) @reaLable causes of venLrlcular arrhyLhmlas
are soughL and correcLed Serum k should be kepL above 40 mLq/L lv kCl ls recommended
usually 10 mLq/h can be lnfused buL for severe hypokalemla (k 23 mLq/L) 20 Lo 40 mLq/h
can be lnfused Lhrough a cenLral venous llne
venLrlcular ecLoplc beaLs whlch are common afLer Ml do noL warranL speclflc LreaLmenL
nonsusLalned v@ (le 30 sec) and even susLalned slow v@ (acceleraLed ldlovenLrlcular rhyLhm)
wlLhouL hemodynamlc lnsLablllLy do noL usually requlre LreaLmenL ln Lhe flrsL 24 Lo 48 h
olymorphlc v@ susLalned ( 30 sec) monomorphlc v@ or any v@ wlLh sympLoms of lnsLablllLy
(eg hearL fallure hypoLenslon chesL paln) ls LreaLed wlLh synchronlzed cardloverslon v@
wlLhouL hemodynamlc lnsLablllLy may be LreaLed wlLh lv lldocalne procalnamlde
or amlodarone Some cllnlclans also LreaL complex venLrlcular arrhyLhmlas wlLh Mg sulfaLe 2 g
lv over 3 mln wheLher or noL serum Mg ls low v@ may occur monLhs afLer Ml LaLe v@ ls more
llkely Lo occur ln paLlenLs wlLh Lransmural lnfarcLlon and Lo be susLalned
vl occurs ln 3 Lo 12 of paLlenLs durlng Lhe flrsL 24 h afLer Ml usually wlLhln 6 h LaLe vl
usually lndlcaLes conLlnued or recurrenL myocardlal lschemla and when accompanled by
hemodynamlc deLerloraLlon ls a poor prognosLlc slgn vl ls LreaLed wlLh lmmedlaLe
unsynchronlzed cardloverslon (see Cardlac ArresL uysrhyLhmla @reaLmenL)

An lv blocker early ln Ml followed by conLlnued oral blockers reduces Lhe lncldence of

venLrlcular arrhyLhmlas (lncludlng vl) and morLallLy ln paLlenLs who do noL have hearL fallure or
hypoLenslon rophylaxls wlLh oLher drugs (eg lldocalne) lncreases morLallLy rlsk and ls noL
recommended
AfLer Lhe acuLe phase Lhe presence of complex venLrlcular arrhyLhmlas or nonsusLalned v@
especlally wlLh slgnlflcanL Lv sysLollc dysfuncLlon lncreases morLallLy rlsk An lmplanLable
cardloverLerdeflbrlllaLor (lCu) should be consldered rogrammed endocardlal sLlmulaLlon can
help selecL Lhe mosL effecLlve anLlarrhyLhmlcs or deLermlne Lhe need for an lCu 8efore
LreaLmenL wlLh an anLlarrhyLhmlc or lCu coronary anglography and oLher LesLs are done Lo
look for recurrenL myocardlal lschemla whlch may requlre Cl or CA8C
eort foi/ure
aLlenLs wlLh large lnfarcLlons (deLermlned by LCC or serum markers) and Lhose wlLh
mechanlcal compllcaLlons hyperLenslon or dlasLollc dysfuncLlon are more llkely Lo develop
hearL fallure Cllnlcal flndlngs depend on lnfarcL slze elevaLlon of Lv fllllng pressure and degree
of reducLlon ln cardlac ouLpuL uyspnea lnsplraLory rales aL Lhe lung bases and hypoxemla are
common
@reaLmenL depends on severlLy lor mlld cases a loop dlureLlc (eg furosemlde 20 Lo 40 mg lv
once/day or bld) Lo reduce venLrlcular fllllng pressure ls ofLen sufflclenL lor severe cases
vasodllaLors (eg lv nlLroglycerln) are ofLen used Lo reduce preload and afLerload durlng
LreaLmenL pulmonary arLery occluslon pressure ls ofLen measured vla rlghL hearL (SwanCanz)
caLheLerlzaLlon ACL lnhlblLors are used as long as sysLollc 8 remalns 100 mm Pg A shorL
acLlng ACL lnhlblLor glven ln low doses (eg capLoprll 3123 Lo 623 mg po q 4 Lo 6 h lncreaslng
doses as LoleraLed) ls besL for lnlLlal LreaLmenL Cnce Lhe maxlmum dose ls reached (maxlmum
for capLoprll 30 mg Lld) a longeracLlng ACL lnhlblLor (eg foslnoprll llslnoprll ramlprll) ls
subsLlLuLed for Lhe longLerm lf hearL fallure remalns ln new ?ork PearL AssoclaLlon class ll or
worse (see @able 2 PearL lallure new ?ork PearL AssoclaLlon (n?PA) ClasslflcaLlon of PearL
lallure ) an aldosLerone lnhlblLor (egeplerenone splronolacLone) should be added lor
severe hearL fallure an lnLraarLerlal counLerpulsaLlon balloon pump may provlde Lemporary
hemodynamlc supporL When revascularlzaLlon or surglcal repalr ls noL feaslble hearL
LransplanLaLlon ls consldered LongLerm Lv or blvenLrlcular lmplanLable asslsL devlces may be
used as a brldge Lo LransplanLaLlon lf LransplanLaLlon ls lmposslble Lhe Lv asslsL devlce ls
occaslonally used as permanenL LreaLmenL Cccaslonally use of such a devlce resulLs ln
recovery and can be removed ln 3 Lo 6 mo
lf hearL fallure causes hypoxemla C
2
ls glven by nasal prongs (Lo malnLaln aC
2
aL abouL 100 mg
Pg) lL may help oxygenaLe myocardlum and llmlL Lhe lschemlc zone

9opi//ory musc/e disorders

luncLlonal paplllary muscle lnsufflclency occurs ln abouL 33 of paLlenLs durlng Lhe flrsL few
hours of lnfarcLlon aplllary muscle lschemla causes lncompleLe coapLaLlon of Lhe mlLral valve
leafleLs whlch ls LranslenL ln mosL paLlenLs 8uL ln some paLlenLs paplllary muscle or free wall
scarrlng causes permanenL mlLral regurglLaLlon luncLlonal paplllary muscle lnsufflclency ls
characLerlzed by an aplcal laLe sysLollc murmur and Lyplcally resolves wlLhouL LreaLmenL
aplllary muscle rupLure occurs mosL ofLen afLer an lnferoposLerlor lnfarcL due Lo rlghL
coronary arLery occluslon lL produces acuLe severe mlLral regurglLaLlon aplllary muscle
rupLure ls characLerlzed by Lhe sudden appearance of a loud aplcal holosysLollc murmur and
Lhrlll usually wlLh pulmonary edema Cccaslonally when severe regurglLaLlon ls sllenL buL
suspecLed cllnlcally echocardlography ls done MlLral valve repalr or replacemenL ls effecLlve
Myocordio/ rupture
lnLervenLrlcular sepLum or free wall rupLure occurs ln 1 of paLlenLs wlLh acuLe Ml lL causes
13 of hosplLal morLallLy
lnLervenLrlcular sepLum rupLure alLhough rare ls 8 Lo 10 Llmes more common Lhan paplllary
muscle rupLure lnLravenLrlcular sepLum rupLure ls characLerlzed by Lhe sudden appearance of a
loud sysLollc murmur and Lhrlll medlal Lo Lhe apex along Lhe lefL sLernal border ln Lhe 3rd or 4Lh
lnLercosLal space accompanled by hypoLenslon wlLh or wlLhouL slgns of Lv fallure ulagnosls
may be conflrmed uslng a balloonLlpped caLheLer and comparlng blood C
2
saLuraLlon or C
2
of
rlghL aLrlal 8v and pulmonary arLery samples A slgnlflcanL lncrease ln 8v C
2
ls dlagnosLlc as
ls uoppler echocardlography whlch may demonsLraLe Lhe acLual shunL of blood across Lhe
venLrlcular sepLum @reaLmenL ls surgery whlch should be delayed for up Lo 6 wk afLer Ml so
LhaL lnfarcLed myocardlum can heal maxlmally lf hemodynamlc lnsLablllLy perslsLs earller
surgery ls lndlcaLed desplLe a hlgh morLallLy rlsk
lree wall rupLure lncreases ln lncldence wlLh age and ls more common among women lL ls
characLerlzed by sudden loss of arLerlal pressure wlLh momenLary perslsLence of slnus rhyLhm
and ofLen by slgns of cardlac Lamponade Surgery ls rarely successful 8upLure of a free wall ls
almosL always faLal
Ientricu/or oneurysm
A locallzed bulge ln Lhe venLrlcular wall usually Lhe Lv wall can occur aL Lhe slLe of a large
lnfarcLlon venLrlcular aneurysms are common especlally wlLh a large Lransmural lnfarcL
(usually anLerlor) Aneurysms may develop ln a few days weeks or monLhs @hey are unllkely
Lo rupLure buL may lead Lo recurrenL venLrlcular arrhyLhmlas low cardlac ouLpuL and mural
Lhrombosls wlLh sysLemlc embollsm A venLrlcular aneurysm may be suspecLed when

paradoxlcal precordlal movemenLs are seen or felL LCC shows perslsLenL S@segmenL elevaLlon
and chesL xray shows a characLerlsLlc bulge of Lhe cardlac shadow Lchocardlography ls done
Lo conflrm Lhe dlagnosls and deLermlne wheLher a Lhrombus ls presenL Surglcal exclslon may
be lndlcaLed when Lv fallure or arrhyLhmla perslsLs use of ACL lnhlblLors durlng acuLe Ml
modlfles Lv remodellng and may reduce Lhe lncldence of aneurysm
seudoaneurysm ls lncompleLe rupLure of Lhe free Lv wall lL ls llmlLed by Lhe perlcardlum
seudoaneurysms almosL always conLaln a Lhrombus and ofLen rupLure compleLely @hey are
repalred surglcally
ypotension ond cordioqenic shock
PypoLenslon may be due Lo decreased venLrlcular fllllng or loss of conLracLlle force secondary
Lo masslve Ml Marked hypoLenslon (eg sysLollc 8 90 mm Pg) wlLh Lachycardla and
sympLoms of endorgan hypoperfuslon (reduced urlne ouLpuL menLal confuslon dlaphoresls
cold exLremlLles) ls Lermed cardlogenlc shock (see also Shock and lluld 8esusclLaLlon
Cardlogenlc and obsLrucLlve shock) ulmonary congesLlon develops rapldly ln cardlogenlc
shock
uecreased Lv fllllng ls mosL ofLen caused by reduced venous reLurn secondary Lo hypovolemla
especlally ln paLlenLs recelvlng lnLenslve loop dlureLlc Lherapy buL lL may reflecL 8v lnfarcLlon
Marked pulmonary congesLlon suggesLs loss of Lv conLracLlle force (Lv fallure) as Lhe cause
@reaLmenL depends on Lhe cause ln some paLlenLs deLermlnlng Lhe cause requlres use of a
pulmonary arLery caLheLer Lo measure lnLracardlac pressures lf pulmonary arLery occluslon
pressure ls 18 mm Pg decreased fllllng usually due Lo hypovolemla ls llkely lf pressure
ls 18 mm Pg Lv fallure ls llkely lor hypoLenslon due Lo hypovolemla cauLlous fluld
replacemenL wlLh 09 sallne ls usually posslble wlLhouL lefL hearL overload (excesslve rlse ln
lefL aLrlal pressure) Powever someLlmes Lv funcLlon ls so compromlsed LhaL adequaLe fluld
replacemenL sharply lncreases pulmonary arLery occluslon pressure Lo levels assoclaLed wlLh
pulmonary edema ( 23 mm Pg) lf lefL aLrlal pressure ls hlgh hypoLenslon ls probably due Lo Lv
fallure and lf dlureLlcs are lneffecLlve lnoLroplc Lherapy or clrculaLory supporL may be requlred
ln cardlogenlc shock an or agonlsL may be Lemporarlly effecLlve uopamlne a
caLecholamlne wlLh and 1 effecLs ls glven aL 03 Lo 1 g/kg/mln lncreased unLll response ls
saLlsfacLory or dose ls abouL 10 g/kg/mln Plgher doses lnduce vasoconsLrlcLlon and aLrlal and
venLrlcular arrhyLhmlas uobuLamlne a agonlsL may be glven lv aL 23 Lo 10 g/kg/mln or ln
hlgher doses lL ofLen causes or exacerbaLes hypoLenslon lL ls mosL effecLlve when hypoLenslon
ls secondary Lo low cardlac ouLpuL wlLh lncreased perlpheral vascular
reslsLance uopamlne may be more effecLlve LhandobuLamlne when a vasopressor effecL ls also
requlred ln refracLory cases dobuLamlne anddopamlne may be comblned An lnLraorLlc

counLerpulsaLlon balloon pump can ofLen Lemporarlly supporL Lhe paLlenL ueflnlLlve LreaLmenL
for posLlnfarcLlon cardlogenlc shock ls revascularlzaLlon by Lhrombolysls of Lhe cloL angloplasLy
or emergency CA8C 8evascularlzaLlon usually greaLly lmproves venLrlcular funcLlon Cl or
CA8C may be consldered for perslsLenL lschemla refracLory venLrlcular arrhyLhmla
hemodynamlc lnsLablllLy or shock lf coronary anaLomy ls sulLable
I ischemio or inforction
8v lnfarcLlon rarely occurs ln lsolaLlon lL usually accompanles lnferlor Lv lnfarcLlon and Lhe
flrsL slgn may be hypoLenslon developlng ln a prevlously sLable paLlenL 8lghLslded LCC leads
may show S@segmenL changes volume loadlng wlLh 1 Lo 2 L of 09 sallne ls ofLen
effecLlveuobuLamlne may help nlLraLes and dlureLlcs are noL used Lhey reduce preload (and
hence cardlac ouLpuL) causlng severe hypoLenslon lncreased rlghLslded fllllng pressure should
be malnLalned by lv fluld lnfuslon
ecurrent ischemio
Any chesL paln LhaL remalns or recurs 12 Lo 24 h posLMl may represenL recurrenL lschemla
osLMl lschemlc paln lndlcaLes LhaL more myocardlum ls aL rlsk of lnfarcLlon usually recurrenL
lschemla can be ldenLlfled by reverslble S@@ changes on Lhe LCC 8 may be elevaLed
Powever because recurrenL lschemla may be sllenL (LCC changes wlLhouL paln) ln up Lo one
Lhlrd of paLlenLs serlal LCCs are rouLlnely done every 8 h for 1 day and Lhen dally 8ecurrenL
lschemla ls LreaLed slmllarly Lo unsLable anglna Subllngual or lv nlLroglycerln ls usually
effecLlve Coronary anglography and Cl or CA8C should be consldered Lo salvage lschemlc
myocardlum
Muro/ thrombosis
Mural Lhrombosls occurs ln abouL 20 of paLlenLs wlLh acuLe Ml SysLemlc embollsm occurs ln
abouL 10 of paLlenLs wlLh Lv Lhrombosls rlsk ls hlghesL ln Lhe flrsL 10 days buL perslsLs aL leasL
3 mo 8lsk ls hlghesL (abouL 60) for paLlenLs wlLh large anLerlor lnfarcLlons (especlally
lnvolvlng Lhe dlsLal sepLum and apex) a dllaLed and dlffusely hypoklneLlc Lv or chronlc Al
AnLlcoagulanLs are glven Lo reduce rlsk of emboll lf noL conLralndlcaLed fulldose
lv heparln followed by warfarln for 3 Lo 6 mo ls glven Lo malnLaln ln8 beLween 2 and 3
AnLlcoagulanLs are conLlnued lndeflnlLely when a dllaLed dlffusely hypoklneLlc Lv Lv aneurysm
or chronlc Al ls presenL Asplrln may also be glven lndeflnlLely
9ericorditis
erlcardlLls (see erlcardlLls) resulLs from exLenslon of myocardlal necrosls Lhrough Lhe wall Lo
Lhe eplcardlum lL develops ln abouL one Lhlrd of paLlenLs wlLh acuLe Lransmural Ml A frlcLlon
rub usually beglns 24 Lo 96 h afLer Ml onseL Larller onseL of Lhe frlcLlon rub ls unusual
alLhough hemorrhaglc perlcardlLls occaslonally compllcaLes Lhe early phase of Ml AcuLe

Lamponade ls rare erlcardlLls ls dlagnosed by LCC whlch shows dlffuse S@segmenL elevaLlon
and someLlmes 8lnLerval depresslon Lchocardlography ls frequenLly done buL resulLs are
usually normal Cccaslonally small perlcardlal effuslons and even unsuspecLed Lamponade are
deLecLed Asplrln or anoLher nSAlu usually relleves sympLoms Plgh doses or prolonged use of
nSAlus or corLlcosLerolds may lmpalr lnfarcL heallng and should be avolded AnLlcoagulaLlon ls
noL conLralndlcaLed ln early perllnfarcLlon perlcardlLls buL ls conLralndlcaLed ln laLer posLMl
(uresslers) syndrome
9ostMl syndrome {uress/ers syndrome)
osLMl syndrome develops ln a few paLlenLs several days Lo weeks or even monLhs afLer acuLe
Ml lncldence appears Lo have decreased ln recenL years lL ls characLerlzed by fever
perlcardlLls wlLh a frlcLlon rub perlcardlal effuslon pleurlsy pleural effuslons pulmonary
lnfllLraLes and [olnL paln @hls syndrome ls caused by an auLolmmune reacLlon Lo maLerlal from
necroLlc myocyLes lL may recur ulfferenLlaLlng posLMl syndrome from exLenslon or
recurrence of lnfarcLlon may be dlfflculL Powever ln posLMl syndrome cardlac markers do
noL lncrease slgnlflcanLly and LCC changes are nonspeclflc nSAlus are usually effecLlve buL
Lhe syndrome can recur several Llmes ln severe cases a shorL lnLenslve course of anoLher
nSAlu or a corLlcosLerold may be necessary Plgh doses of an nSAlu or a corLlcosLerold are noL
used for more Lhan a few days because Lhey may lnLerfere wlLh early venLrlcular heallng afLer
an acuLe Ml
kehab|||tat|on and ostd|scharge 1reatment
O luncLlonal evaluaLlon
O Changes ln llfesLyle 8egular exerclse dleL modlflcaLlon welghL loss smoklng cessaLlon
O urugs ConLlnuaLlon of asplrln blockers ACL lnhlblLors and sLaLlns
unctiono/ evo/uotion
aLlenLs who dld noL have coronary anglography durlng admlsslon have no hlghrlsk feaLures
(eg hearL fallure recurrenL anglna v@ or vl afLer 24 h mechanlcal compllcaLlons such as new
murmurs shock) and have an e[ecLlon fracLlon 40 wheLher or noL Lhey recelved flbrlnolyLlcs
usually should have sLress LesLlng of some sorL before or shorLly afLer dlscharge (see @able
9Coronary ArLery ulsease luncLlonal LvaluaLlon AfLer Ml )
1ab|e 9

unct|ona| Lva|uat|on After MI
Lxerc|se
apac|ty
If L Is Interpretab|e If L Is -ot Interpretab|e
Able Lo
exerclse
Submaxlmal or sympLom
llmlLed sLress LCC before or
Lxerclse echocardlography or
nuclear scannlng

afLer dlscharge
unable Lo
exerclse
harmacologlc sLress LesLlng
(echocardlography or nuclear
scannlng)
harmacologlc sLress LesLlng
(echocardlography or nuclear
scannlng)

ctivity
hyslcal acLlvlLy ls gradually lncreased durlng Lhe flrsL 3 Lo 6 wk afLer dlscharge 8esumpLlon of
sexual acLlvlLy ofLen of greaL concern Lo Lhe paLlenL and oLher moderaLe physlcal acLlvlLles
may be encouraged lf good cardlac funcLlon ls malnLalned 6 wk afLer acuLe Ml mosL paLlenLs
can reLurn Lo all Lhelr normal acLlvlLles A regular exerclse program conslsLenL wlLh llfesLyle
age and cardlac sLaLus reduces rlsk of lschemlc evenLs and enhances general wellbelng
isk foctors
@he acuLe lllness and LreaLmenL of ACS should be used Lo sLrongly moLlvaLe Lhe paLlenL Lo
modlfy rlsk facLors LvaluaLlng Lhe paLlenLs physlcal and emoLlonal sLaLus and dlscusslng Lhem
wlLh Lhe paLlenL advlslng abouL llfesLyle (eg smoklng dleL work and play hablLs exerclse) and
aggresslvely managlng rlsk facLors may lmprove prognosls
uruqs
Several drugs clearly reduce morLallLy rlsk posLMl and are used unless conLralndlcaLed or noL
LoleraLed Asplrln reduces morLallLy and relnfarcLlon raLes ln posLMl paLlenLs by 13 Lo 30
LnLerlccoaLedasplrln 81 mg once/day ls recommended longLerm uaLa suggesL
LhaL warfarln wlLh or wlLhouLasplrln reduces morLallLy and relnfarcLlon raLes
8lockers are consldered sLandard Lherapy MosL avallable blockers
(eg acebuLolol aLenololmeLoprolol propranolol Llmolol) reduce posLMl morLallLy raLe by
abouL 23 for aL leasL 7 yr
ACL lnhlblLors are glven Lo all posLMl paLlenLs @hese drugs may provlde longLerm
cardloproLecLlon by lmprovlng endoLhellal funcLlon lf an ACL lnhlblLor ls noL LoleraLed because
of cough or rash (buL noL angloedema or renal dysfuncLlon) an angloLensln ll recepLor blocker
may be subsLlLuLed SLaLlns are prescrlbed 8educlng cholesLerol levels afLer Ml reduces raLes of
recurrenL lschemlc evenLs and morLallLy ln paLlenLs wlLh elevaLed or normal cholesLerol levels
SLaLlns appear Lo beneflL posLMl paLlenLs regardless of Lhelr lnlLlal cholesLerol level osLMl
paLlenLs whose prlmary problem ls a low PuL level or an elevaLed Lrlglycerlde level may beneflL
from a flbraLe buL evldence of beneflL ls less clear A llpldlowerlng drug should be conLlnued
lndeflnlLely unless slgnlflcanL adverse effecLs occur and dose should be lncreased Lo achleve
an LuL level of 70 Lo 80 mg/dL (181 Lo 207 mmol/L)
LasL full revlew/revlslon uecember 2007 by !ames Wayne Warnlca Mu