ACUTE CORONARY SYNDROME

Spectrum of ACS

Characteristics of patients with NSTE-ACS at HIGH acute, thrombotic risk for rapid progression

to MI or death that should undergo coronary angiography within 48 hrs

- recurrent resting pain

- dynamic ST-segment changes

- elevated TnI, TnT, or CK-MB levels

- haemodynamic instability within the observation period

- major arrhythmias

- early post-MI unstable angina

- diabetes mellitus

Antiplatelet treatment

Aspirin: all pts, 162-325 mg initially followed by 10-100 mg daily thereafter

ADP receptor antagonist (clopidogrel, Plavix®): all pts, unless anticipated need for urgent CABG or within 5 days of electively scheduled CABG; loading dose 300 mg followed by 75 mg qd up to 1 year

GP IIb/IIIa inhibitors (abciximab, ReoPro®; tirofiban, Aggrastat®; eptifibatid, Integrilin®) : all pts with anticipated PCI, iv infusion

BETA BLOCKADE

No clear preferred agent

All patients: low to intermediate risk patients with angina and all high risk patients

CHOLESTEROL TREATMENT

All patients

Potent, high-dose statin (goal LDL-C level < 70 mg/dL)

Ezetimibe: all patients unable to achieve LDL-C level < 70 mg/dL while taking a potent, high-dose statin

To convert LDL-C to mmol/l multiply by 0.02586

CIGARETTE SMOKING CESSATION: long-term behavioral support

DIABETES MANAGEMENT: HbA1c<7%

DIET: to achieve optimal BMI

EXERCISE: aerobic exercise 4-5 times per week for >30 min.

Antiplatelet and Anticoagulation TherapyClass III Recommendations

Intravenous thrombolytic therapy in patients without acute ST-segment

elevation

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment DeniedTreatment Delayed is Treatment Denied

“At this time of day at this hospital, how can I most safely and quickly open the patient’s artery with the best flow and

keep the artery open?”

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

Absolute Contraindications

• Any prior intracranial hemorrhage

• Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

• Known malignant intracranial neoplasm (primary or metastatic)

• Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours

NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

Absolute Contraindications

• Suspected aortic dissection

• Active bleeding or bleeding diathesis (excluding menses)

• Significant closed-head or facial trauma within 3 months

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

• History of chronic, severe, poorly controlled hypertension

• Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg)

• History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications

• Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks)

RelativeContraindications

Primary PCI for STEMI:Primary PCI for STEMI:General ConsiderationsGeneral Considerations

Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB

PCI of infarct artery within 12 hours of symptom onset

Balloon inflation within 90 minutes of presentation

Skilled personnel available (individual performs > 75 procedures per year)

Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)

Cardiac surgical backup available

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Primary PCI for STEMI:Primary PCI for STEMI:Specific ConsiderationsSpecific Considerations

Medical contact–to-balloon or door-to-balloon should be within 90 minutes.

PCI preferred if > 3 hours from symptom onset.

Primary PCI should be performed in patients with severe congestive heart failure (CHF) and/or pulmonary edema (Killip class 3) and onset of symptoms within 12 hours.

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FUTURE PERSPECTIVE

- ALL patients should be transferred primarily to high volume PCI centers

- No more AMI to small hospitals

Adjunctive measures

- ASA- Heparin i.v. and LMWH

- Beta-blockers - ACE-inhibitors

Secondary Prevention and Long Term Management

• Assess tobacco use.

• Strongly encourage patient and family to stop smoking and to avoid secondhand smoke.

• Provide counseling, pharmacological therapy (including nicotine replacement and bupropion), and formal smoking cessation programs as appropriate.

Smoking Goal: Complete Cessation

Goals Recommendations

Secondary Prevention and Long Term Management

If blood pressure is 120/80 mm Hg or greater:

• Initiate lifestyle modification (weight control, physical activity, alcohol moderation, moderate sodium restriction, and emphasis on fruits, vegetables, and low-fat dairy products) in all patients.

If blood pressure is 140/90 mm Hg or greater or 130/80 mm Hg or greater for individuals with chronic kidney disease or diabetes:

• Add blood pressure-reducing medications, emphasizing the use of beta-blockers and inhibitors of the renin-angiotensin-aldosterone system.

Blood pressure control:Goal: < 140/90 mm Hg or <130/80 mm Hg if chronic kidney disease or diabetes

Goals Recommendations

Secondary Prevention and Long Term Management

• Assess risk, preferably with exercise test, to guide

prescription.

• Encourage minimum of 30 to 60 minutes of activity,

preferably daily but at least 3 or 4 times weekly (walking,

jogging, cycling, or other aerobic activity) supplemented by

an increase in daily lifestyle activities (e.g., walking breaks

at work, gardening, household work).

• Cardiac rehabilitation programs are recommended for

patients with STEMI.

Physical activity:Minimum goal:30 minutes 3 to 4 days per week;Optimal daily

Goals Recommendations

Secondary Prevention and Long Term Management

• Start dietary therapy in all patients (< 7% of total calories as saturated fat and < 200 mg/d cholesterol). Promote physical activity and weight management. Encourage increased consumption of omega-3 fatty acids.

• Assess fasting lipid profile in all patients, preferably within 24 hours of STEMI. Add drug therapy according to the following guide:

Lipid management:(TG less than 200 mg/dL)Primary goal:LDL-C << than 100 mg/dL

Goals Recommendations

LDL-C < 100 mg/dL (baseline or on treatment):Statins should be used to lower LDL-C.

LDL-C ≥ 100 mg/dL (baseline or ontreatment):

Intensify LDL-C–lowering therapy with drug treatment, giving preference to statins.

Secondary Prevention and Long Term Management

If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:Emphasize weight management and physical activity. Advise smoking cessation.

If TG is 200 to 499 mg/dL: After LDL-C–lowering therapy, consider adding fibrate or niacin.

If TG is ≥ 500 mg/dL: Consider fibrate or niacin before LDL-C–lowering therapy.Consider omega-3 fatty acids as adjunct for high TG.

Lipid management:(TG 200 mg/dL or greater)Primary goal:Non–HDL-C << 130 mg/dL

Goals Recommendations

Secondary Prevention and Long Term Management

Goals Recommendations

Calculate BMI and measure waist circumference as part of evaluation. Monitor response of BMI and waist circumference to therapy.

Start weight management and physical activity as appropriate. Desirable BMI range is 18.5 to 24.9 kg/m2.

If waist circumference is ≥ 35 inches in women or ≥ 40 inches in men, initiate lifestyle changes and treatment strategies for metabolic syndrome.

Weight management:Goal:BMI 18.5 to 24.9 kg/m2

Waist circumference:Women: < 35 in.Men: < 40 in.

Secondary Prevention and Long Term Management

Goals Recommendations

Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose, as indicated by HbA1c.

Treatment of other risk factors (e.g., physical activity, weight management, blood pressure, and cholesterol management).

Diabetes management: Goal: HbA1c < 7%

Secondary Prevention and Long Term Management

Goals Recommendations

• In the absence of contraindications, start aspirin

75 to 162 mg/d and continue indefinitely.

• If aspirin is contraindicated, consider clopidogrel

75 mg/day or warfarin.

• Manage warfarin to INR 2.5 to 3.5 in post-

STEMI patients when clinically indicated or for

those not able to take aspirin or clopidogrel.

Antiplatelet agents/ anticoagulants

Secondary Prevention and Long Term Management

Goals Recommendations

ACE inhibitors in all patients indefinitely; start early in stable, high-risk patients (ant. MI, previous MI, Killip class ≥ 2 [S3 gallop, rales, radiographic CHF], LVEF < 0.40).

Angiotensin receptor blockers in patients who are intolerant of ACE inhibitors and with either clinical or radiological signs of heart failure or LVEF < 0.40.

Aldosterone blockade in patients without significant renal dysfunction or hyperkalemia who are already receiving therapeutic doses of an ACE inhibitor, have LVEF ≤ 0.40, and have either diabetes or heart failure.

Renin-Angiotensin-Aldosterone System Blockers

Secondary Prevention and Long Term Management

Goals Recommendations

Start in all patients. Continue indefinitely. Observe usual contraindications. Beta-

Blockers