Acute coronary syndromes

Unstable angina & NSTEMI

same tx for both. MONABASH + PCTA within 24h. Aspirin + clopidogrel = DAPT (dual antiplatelet therapy), and is a key part.

PCTA = PCI. Percutaneous transluminal coronary angioplasty, Percutaneous coronary intervention.


  • Monitor
  • Oxygen supplementation if SaO2<90%
  • Nitroglycerin (sublingual) for pain
  • Antiplatelet (aspirin + clopidogrel)
  • Beta-blockers (BBs) — reduce oxygen demand in heart
  • Anticoagulation e.g. UFH, enoxaparin, fondaparinux
  • Statins (High-dose)


  • stabilize & MONABASH.
  • Reperfusion = PCTA if <90 min, tPA if >120 min eg. IV alteplase. Has to be <12h since symptoms began
  • + IV furosemide if severe pulmonary edema
  • + IV atropine if unstable sinus bradycardia
  • + IV morphine if persistent pain (severe)
  • +IV NTG if severe pain/ HTN/ HF
  • Avoid these
    • BBs if hypotension, bradycardia or heart failure
    • IV NTG if hypotension, or RV infarct, or severe aortic stenosis
    • Furosemide if hypotension

So, if STEMI with hypotension, MOAASHA –> monitor, O2, antiplatelet, anticoagulation, statin-high-dose, atropine

Post-MI Complications

RV failureRCA occlusionacuteno blood to lungs –> clear lungs
kussmaul’s sign
hypkinetic RV
Papillary muscle ruptureRCA occlusion0-5 days laterMR (mitral regurgitation) –> pulmonary edema & new holosytolic murmur at apex“flail” leaflet of MV
Interventricular septum ruptureLAD (apical septum)/ RCA (basal septum) occlusion0-5 days latersimilar to “VSD” –> holosytolic murmur @LSB “new” more (L–>R shunt) blood to lungs –> pulmonary edemaL–>R shunt
↑O2 from RA to RV
Free wall ruptureLAD occlusion<5 days — 2 wks
most (50%) <5 days later (0-5 days)
chest pain, tamponade (shock, distant heart sounds)pericardial effusion with tamponade
LV aneurysmLAD occlusionupto several months later (0-months)subacute heart failure. Stable anginathin & dyskinetic wall

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