Arrhythmias, recurrent angina, heart failure and pericarditis after acute coronary syndrome
THE CONTEXT
Acute coronary syndrome may be complicated by rhythm disturbances, recurrent ischaemia, acute heart failure and post-infarction pericarditis.
Common arrhythmias
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Common arrhythmias include ventricular fibrillation, ventricular tachycardia, accelerated idioventricular rhythm, ventricular ectopics and atrial fibrillation.
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Sinus bradycardia is particularly associated with inferior myocardial infarction. Atrioventricular block is another common rhythm disturbance.
Recurrent angina and revascularisation
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Recurrent angina at rest or on minimal exertion after acute coronary syndrome indicates high risk and warrants consideration of prompt coronary angiography with a view to revascularisation.
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Dynamic ECG changes with ongoing pain warrant consideration of intravenous glycoprotein IIb/IIIa receptor antagonists.
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Resistant pain or marked haemodynamic changes warrant consideration of intra-aortic balloon counterpulsation and emergency coronary revascularisation.
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Post-infarct angina occurs in up to 50% of patients treated with thrombolysis. Residual stenosis in the infarct-related vessel can cause angina when viable myocardium remains downstream.
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After successful thrombolysis, all patients should be considered for early coronary angiography within the first 24 hours, with a view to coronary revascularisation.
Acute heart failure
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Acute heart failure usually reflects extensive myocardial damage and carries a poor prognosis.
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Other complications of myocardial infarction are more likely when acute heart failure is present.
Post-infarction pericarditis
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Pericarditis occurs following infarction and is particularly common on the second and third days.
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Patients may describe a different pain at the same site. It is positional and tends to worsen, or occur only, on inspiration; a pericardial rub may be audible.
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Opiate-based analgesia should be used.
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Non-steroidal and steroidal anti-inflammatory drugs should be avoided where possible during early recovery because they may increase the risk of aneurysm formation and myocardial rupture.