Acute coronary syndromes

Acute coronary syndrome can manifest as heart attack or unstable angina pectoris, depending on the degree of narrowing of the arteries that supply the heart (coronary arteries) or if there is a complete obstruction.

Acute coronary syndrome is one of the most frequent diseases in the first world and one of the main causes of mortality.

How is it produced?

The heart is nourished by a series of arteries called coronary arteries that supply the heart muscle and allow it to exert its function as a heart pump, contracting and relaxing. The atherosclerosis Coronary artery disease is a slow-evolving disease in which there is a progressive narrowing of the walls of the arteries due to an accumulation of lipids (fats) and inflammatory cells (lymphocytes) forming plates.

• The coronary syndrome acute is produced by the erosion or rupture of one of these plates giving rise to the formation of a thrombus, thus causing the appearance of unstable angina or acute myocardial infarction. According to him degree of occlusion of the artery It will manifest as unstable angina or a myocardial infarction.
• The angina occurs when obstruction is incomplete, there is a decrease in blood supply which is known as ischemia and thus the coronary arteries cannot meet the cardiac oxygen demands.
• At myocardial infarction there is a complete occlusion of the artery by a clot that causes necrosis or death of the heart tissue in the area supplied by that vessel.

There are a number of risk factor's that favor the appearance of acute coronary syndrome. These factors include: s

• Sex (more common in males)
• Age (from 70 years)
• Tobacco
• diabetes
• High cholesterol
• Overweight
• Family history of coronary artery disease
• Arterial hypertension
• Sedentary lifestyle.

It is important to know them because preventive measures are the main treatment weapon to avoid this disease.

In some cases, acute coronary syndrome may be the result of a increased oxygen needs of the heart in the absence of a thrombus. This can occur in: arrhythmias, trauma, drug and certain drug use, infections or coronary artery abnormalities.

Symptoms

The key symptom in acute coronary syndrome is appearance of pain in the center of the chest and / or in the left arm. The duration of this pain is usually minutes in the case of angina and more prolonged in myocardial infarction. Other symptoms may appear such as:

• nausea and malaise
• pain in the pit of the stomach
• Feeling short of breath
• Sweating
• Dizziness

Patients may present with hypotension or hypertension and develop arrhythmias and heart failure.

Diagnosis

The diagnosis is based mainly on the symptoms that the patient presents and on a series of tests that help to confirm it.

• Conducting a electrocardiogram it is essential in all patients presenting with symptoms suggestive of acute coronary syndrome. The electrocardiographic record allows to know the degree of damage to the heart.
• Determination of markers of myocardial damage: cardiac enzymes. They are a series of substances that are eliminated into the blood when there is damage to the heart muscle (myocardium). They are measured with a blood test at regular intervals from the onset of symptoms and their elevation in the following hours allows the diagnosis of myocardial infarction to be established.
• Chest x-ray to see if there is fluid in the lungs resulting from failure of heart function
• Echocardiogram and isotopic ventriculography: They allow to assess the function of the heart and if there are areas that due to myocardial injury do not contract correctly.
• The stress test or ergometry It is the most widely used test to assess the presence of ischemia of the heart muscle. It allows to know if the chest pain is due to the obstruction of a coronary artery, especially in those patients who present a normal electrocardiogram. It consists of subjecting the patient to physical exercise on a treadmill or bicycle and detecting whether the effort causes ischemia. This is detected by the appearance of symptoms and changes in the electrocardiogram.
• The arteriography coronary also called coronary angiography or catheterization It is a test that is performed mainly in patients with significant ischemia or when the above tests are not conclusive. It consists of introducing a catheter through a vein until it reaches the heart, where a contrast is injected, which allows us to see the coronary circulation and the narrowing or obstruction of the arteries.

Treatment

Treatment will depend on the symptoms. In any patient with coronary heart disease, the treatment of cardiovascular risk factors is essential:

• Tobacco cessation.
• Control of hypertension and diabetes, if necessary with drugs.
• Follow a healthy diet low in cholesterol and fat. If necessary, drugs to lower cholesterol will be indicated
• Achieve an ideal body weight if you are overweight.
• Establish a physical exercise program appropriate to your ability.
• Avoid stress.

The objectives of the initial medical treatment are:

• stabilize the patient by restoring blood flow to the myocardium and alleviating symptoms
• prevent myocardial necrosis (death) and decrease myocardial injury
• reduce the risk of new onset and complications.

1. General measures

• Monitoring (surveillance) of the patient's vital signs (heart rate, blood pressure, oxygenation).
• Administration of oxygen.
• Ischemic pain relief with drugs.
• Bed rest until 12-24 hours after being free of symptoms.
• Use of tranquilizers and laxatives.

Morphine, nitroglycerin, and blood thinners. Drugs to decrease cardiac activity and increase coronary blood supply: beta-blockers, calcium channel blockers, and nitroglycerin.

2. Pharmacological treatment

Treatment of acute coronary syndrome includes the use of drugs to combat the ischemic process of the heart muscle such as:

• Beta-blockers
• Nitroglycerin or calcium channel blockers
• Anticoagulant therapy
• Platelet antiaggregants (acetylsalicylic acid and clopidogrel) to prevent further episodes of thrombosis
• Coronary vascularization.

3. Coronary revascularization

Some patients are candidates for coronary artery bypass grafting that involves restoring blood flow through the blocked artery. Coronary revascularization by angioplasty or surgery It is performed to improve the prognosis, symptoms, prevent new episodes and improve overall quality of life.

They can be performed by surgery (bypass) or by coronary angioplasty.

• Coronary angioplasty: A catheter is inserted into the area of ​​the coronary artery that is narrowed and dilated with a small balloon. To keep the artery open, a small metal device called a stent is placed inside it. This technique cannot always be performed.
• Bypass surgery treatment: A surgery is performed on the coronary arteries that allows the implantation of a piece of vein of oneself (generally the saphenous vein of the calf) and implant it in the coronary arteries bypassing the obstructed area. It is carried out in patients in whom angioplasty is not possible.

Prevention

Preventive measures include avoiding well-known risk factors: quitting tobacco, eating a healthy diet, exercising, losing weight if you are overweight, and controlling blood pressure, cholesterol, and diabetes.