Problem 27 Management of acute coronary syndrome

The pain has been present for 2 hours, is a retrosternal ‘heaviness’ graded at 6 out of 10 and radiates to both arms. It began while the patient was sitting watching television. He has not made specific attempts to relieve the pain and does not think changes in posture or inspiration alter the intensity. The only accompanying symptom is mild dyspnoea but this is much less prominent than the pain. On questioning, the man says he experienced a similar discomfort while walking quickly uphill a week ago, but it had resolved after a few minutes of rest.

The patient has never been diagnosed with, or been investigated for, coronary artery disease.

He has a 20 pack-year smoking history and quit about 20 years ago. He also has hypertension. He has been tested for hypercholesterolaemia and diabetes and not been diagnosed with either of these conditions.

Current medication is perindopril 10 mg daily for hypertension.

The patient is mildly hypertensive at 150/90 mmHg in both arms, has a regular heart rate of 90/min, oxygen saturation of 96% on room air, two heart sounds with no murmur, gallop or rub, non-elevated JVP and a clear chest to auscultation.

Q.5

What is the most important initial investigation and what would you look for in it?

Figure 27.1

You interpret the ECG (Figure 27.1), and your consultant asks you your opinion.

You institute urgent therapy, as per guidelines. Five minutes after administration of the GTN the chest pain has improved but not resolved, and he is given 10 mg IV morphine which results in complete resolution. He is admitted to the coronary care unit for continuous ECG monitoring.

Thirty minutes later the troponin-I comes back at 1.8 µg/L (normal range <0.04 µg/L).

The day after presentation the patient is taken to the cardiac catheterization laboratory where a coronary angiogram is performed (Figure 27.2). It shows a severe stenosis of the left anterior descending coronary artery and this is treated with percutaneous coronary intervention (PCI) with the use of a bare metal stent. A left ventriculogram is also performed and shows normal left ventricular systolic function. No heparin is required after a PCI, so the heparin infusion is stopped.

Figure 27.2

The day after the PCI (48 hours after admission), the patient is asymptomatic, has no abnormalities on cardiovascular examination and ECG monitoring has shown no arrhythmias.

He is discharged the day after the PCI, with no complications. You see him in clinic after 6 weeks, and he is actively participating in the cardiac rehabilitation programme at your hospital. You advise him that he is doing well, and to continue his current medications.

Answers

A.1

• The duration of the pain.

• The severity and nature of the pain.

• The location of the pain and whether it radiates from the chest.

• What he was doing when the pain began.

• What, if any, attempts the patient has made to relieve the pain and whether they have been effective.

Whether inspiration or changes in posture change the severity of the pain.

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