Acute Cardiac Conditions


Two types of angina

Angina pectoris

Angina of effort




Acute coronary syndrome

Caused by vascular occlusive pathology

A continuum of increasingly serious pathology

Based on severity and duration of myocardial blood flow and nature of thombus

May progress to more serious forms




Low risk unstable angina

Clinical features

No CK elevation

No troponin increase




High risk unstable angina

Clinical features

No CK elevation

Increased troponins

Minor myocardial damage





Clinical features

Increased CK and troponins





Clinical features

Increased CK and troponins

ST elevation





Unstable angina and NSTEMI, white thrombus, platelets only

STEMI, 80% show red thrombus, fibrin and erythrocyte based thrombus




Management in unstable angina

Bed rest

Aspirin reduces risk of death and MI

Aspirin and clopidogrel reduces risk more

Low molecular weight heparin (e.g. enoxaparin or fondaparinux) with aspirin is better than aspirin alone

Intravenous glycoprotein inhibitors are also antiplatelet and reduce death and MI

Beta blockers, nitrates and calcium channel blockers are anti-ischaemic

Intravenous nitrates if pain persists

Gradual mobilisation

Thrombolysis is not used in unstable angina or non-NSTEMI





Management in STEMI



Acute reperfusion therapy, thrombolysis, streptokinase, TPA, tenecteplase (a recombinant fibrin specific plasminogen activator)

Primary percutaneous coronary intervention, 50% greater reduction in mortality compared to thrombolysis

Antiplatelet therapy

Anticoagulants in addition to aspirin

Beta blockers

ACE inhibitors, eg. Ramipril


Prevent complications





Complications of myocardial infarction


Dysrhythmias, e.g.

Ventricular fibrillation

Ventricular tachycardia

Atrial fibrillation

Sinus Bradycardia

Atrioventricular block

Left ventricular failure

Cardiogenic shock


Mural thrombosis

Ventricular aneurysm

Ventricular rupture

Infarct of a papillary muscle

Ischaemia from residual stenosis

Psychological / spiritual/ social







Secondary prevention after myocardial infarction


4-6 weeks for a fibrous tissue repair of infarcted muscle, therefore restrict physical activity for this time, gradual increase

Exercise programme

In smokers 5 year mortality is double in patients who continue as opposed to those that quit



Statins, risk reduced by 20% per mmol / l reduction in LDL


ACE inhibitors even if no LVF

Aspirin, reduced risk by 22%, even more with clopidogrel

Manage hypertension

Beta-blockers reduce long mortality by 25%

Treat hypothyroidism

Manage diabetes mellitus

Psychological management, denial, anxiety, depression

Sex with familiar partner is fine






Risk factors for atherosclerosis




Unknown factors account for 40% of the risk




Known risk factors are multiplicative




Age and Sex




Family history / Race












Hypercholesterolaemia and Triglycerides




Diabetes mellitus




Haemostatic factors




Physical activity




















Lack of vitamin D