Classification and clinical significance
The term ACS includes variants of unstable angina and myocardial infarction. The introduction of this term is justified by similar clinical manifestations and basic treatment principles, which helps accelerate pre-hospital and in-hospital care.
Clinical forms are divided into two categories:
- ST-segment elevation: corresponds to the development of transmural myocardial infarction.
- Non-ST-segment elevation: implies unstable angina or small focal subendocardial infarction. The diagnosis is confirmed by blood necrosis markers — troponins T and I, as well as creatine kinase.
Pain management and hemodynamics
Relief of pain and associated stress at the initial stage is critically important. To achieve this, the following are used:
- Neuroleptanalgesia (a combination of an opioid analgesic with a neuroleptic, e.g., fentanyl plus droperidol).
- Opioid analgesics (morphine and analogues).
- Inhalation anesthesia using a non-opioid analgesic — nitrous oxide.
To control rhythm and hemodynamics, the following are prescribed:
- Lidocaine (class IB) — the drug of choice for ventricular extrasystoles, eliminating them without depressing myocardial contractility.
- Nitroglycerin (intravenous) — provides hemodynamic unloading and serves as prevention of acute heart failure.
Antithrombotic and thrombolytic therapy
Pathogenetic treatment starts in the first hours to prevent thrombus formation:
- Antiplatelet agents: acetylsalicylic acid, as well as P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor).
- Direct anticoagulants: heparin (especially in ST elevation), nadroparin calcium, rivaroxaban, dabigatran etexilate. Subsequently, indirect anticoagulants are prescribed to replace direct ones (acenocoumarol, warfarin).
Thrombolytic therapy (fibrinolytics — streptokinase, alteplase) has a strict indication: it is performed exclusively in STEMI (ST-segment elevation acute coronary syndrome) to dissolve fresh thrombi and achieve reperfusion.
Briefly: answers to topical questions
What is the mechanism of action of alteplase during thrombolytic therapy?
- Alteplase (alteplase) is a recombinant tissue plasminogen activator that acts predominantly within the thrombus structure. The drug activates plasminogen already bound to fibrin strands, providing fibrin-specific activation and localized action.
"ABCD": Aspirin and antiplatelets, Ball-relief/painkillers (opioids/nitrous oxide), Casodilators (nitroglycerin), Deparin (Heparin) and lidocaine.
Class and exam questions
How does ST-elevation ACS differ from the non-elevation form?
The ST-elevation form indicates transmural myocardial infarction and allows for thrombolytic therapy. The non-elevation form implies unstable angina or small focal infarction, confirmed by troponins and creatine kinase.
What medications are used for pain relief in acute coronary syndrome?
Neuroleptanalgesia (fentanyl combined with droperidol), opioid analgesics (morphine), and the inhalation non-opioid anesthetic nitrous oxide are used.
In what cases is thrombolytic therapy prescribed?
Fibrinolytics (e.g., alteplase or streptokinase) are indicated exclusively for patients with ST-segment elevation acute coronary syndrome to dissolve blood clots.
Which antiarrhythmic drug is chosen for ventricular extrasystoles in the acute period?
Lidocaine (class IB) is the drug of choice because it effectively eliminates extrasystoles without depressing myocardial contractility.
What else to study on this topic
- Differential diagnosis of non-ST-elevation ACS using myocardial necrosis markers
- Mechanisms of action of antiplatelet agents and P2Y12 receptor inhibitors
- Comparative characteristics of direct and indirect anticoagulants in the acute period
- Indications and limitations for the use of fibrinolytics in reperfusion therapy
- The role of neuroleptanalgesia and inhalation anesthetics in reducing cardiac stress
- Features of symptomatic therapy depending on individual manifestations
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