Acute Coronary SyndromeFaculty of Medicine University of Brawijaya
ObjectivesDefine & delineate acute coronary syndrome
Review Management GuidelinesUnstable Angina / NSTEMISTEMI
Review secondary prevention initiatives
Scope of Problem (2004 stats)CHD single leading cause of death in United States452,327 deaths in the U.S. in 2004
1,200,000 new & recurrent coronary attacks per year
38% of those who with coronary attack die within a year of having it
Annual cost > $300 billion
Expanding Risk FactorsSmokingHypertensionDiabetes MellitusDyslipidemiaLow HDL < 40Elevated LDL / TGFamily Historyevent in first degree relative >55 male/65 femaleAge-- > 45 for male/55 for femaleChronic Kidney DiseaseLack of regular physical activityObesityLack of Etoh intakeLack of diet rich in fruit, veggies, fiber
Acute Coronary Syndromes
Similar pathophysiology
Similar presentation and early management rules
STEMI requires evaluation for acute reperfusion intervention
Unstable Angina
Non-ST-Segment Elevation MI (NSTEMI)
ST-Segment Elevation MI (STEMI)
Acute Coronary SyndromeIschemic Discomfort Unstable SymptomsNo ST-segment elevation ST-segment elevationUnstable Non-QQ-Wave angina AMI AMIECGAcute ReperfusionHistory Physical Exam
Diagnosis of Acute MI STEMI / NSTEMIAt least 2 of the followingIschemic symptomsDiagnostic ECG changesSerum cardiac marker elevations
Diagnosis of AnginaTypical anginaAll three of the followingSubsternal chest discomfortOnset with exertion or emotional stressRelief with rest or nitroglycerin
Atypical angina2 of the above criteria
Noncardiac chest pain1 of the above
Diagnosis of Unstable AnginaPatients with typical angina - An episode of angina Increased in severity or durationHas onset at rest or at a low level of exertionUnrelieved by the amount of nitroglycerin or rest that had previously relieved the pain
Patients not known to have typical anginaFirst episode with usual activity or at rest within the previous two weeksProlonged pain at rest
Unstable AnginaSTEMI NSTEMINon occlusive thrombus
Non specific ECG
Normal cardiac enzymes
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis
ST depression +/- T wave inversion on ECG
Elevated cardiac enzymes
Complete thrombus occlusion
ST elevations on ECG or new LBBB
Elevated cardiac enzymes
More severe symptoms
Acute Management
Initial evaluation & stabilization
Efficient risk stratification
Focused cardiac care
EvaluationEfficient & direct history Initiate stabilization interventions
Plan for moving rapidly to indicated cardiac care
Directed Therapies are Time Sensitive! Occurs simultaneously
Chest pain suggestive of ischemia
12 lead ECGObtain initial cardiac enzymeselectrolytes, cbc lipids, bun/cr, glucose, coagsCXR
Immediate assessment within 10 MinutesEstablish diagnosisRead ECGIdentify complicationsAssess for reperfusionInitial labsand testsEmergent careHistory & PhysicalIV accessCardiac monitoringOxygenAspirinNitrates
Focused HistoryAid in diagnosis and rule out other causes
Palliative/Provocative factorsQuality of discomfortRadiationSymptoms associated with discomfortCardiac risk factorsPast medical history -especially cardiac
Reperfusion questions
Timing of presentationECG c/w STEMI Contraindication to fibrinolysisDegree of STEMI risk
Targeted PhysicalExaminationVitalsCardiovascular systemRespiratory systemAbdomenNeurological status
Recognize factors that increase riskHypotensionTachycardiaPulmonary rales, JVD, pulmonary edema,New murmurs/heart soundsDiminished peripheral pulsesSigns of stroke
ECG assessmentST Elevation or new LBBBSTEMINon-specific ECGUnstable AnginaST Depression or dynamicT wave inversionsNSTEMI
Normal or non-diagnostic EKG
ST Depression or Dynamic T wave Inversions
ST-Segment Elevation MI
New LBBBQRS > 0.12 sec ; L Axis deviationProminent S wave 1, aVL, V5-V6 with t-wave inversion
Cardiac markersTroponin ( T, I)
Very specific and more sensitive than CKRises 4-8 hours after injuryMay remain elevated for up to two weeksCan provide prognostic informationTroponin T may be elevated with renal dz, poly/dermatomyositis
CK-MB isoenzyme
Rises 4-6 hours after injury and peaks at 24 hoursRemains elevated 36-48 hoursPositive if CK/MB > 5% of total CK and 2 times normalElevation can be predictive of mortalityFalse positives with exercise, trauma, muscle dz, DM, PE
Prognosis with Troponin
Risk Stratification UA or NSTEMI- Evaluate for Invasive vs. conservative treatment- Directed medical therapyBased on initialEvaluation, ECG, andCardiac markers- Assess for reperfusion- Select & implement reperfusion therapy- Directed medical therapySTEMI Patient?YESNO
Cardiac Care Goals
Decrease amount of myocardial necrosisPreserve LV functionPrevent major adverse cardiac events Treat life threatening complications
STEMI cardiac care STEP 1: AssessmentTime since onset of symptoms90 min for PCI / 12 hours for fibrinolysis
Is this high risk STEMI?KILLIP classificationIf higher risk may manage with more invasive rx
Determine if fibrinolysis candidateMeets criteria with no contraindications
Determine if PCI candidateBased on availability and time to balloon rx
Fibrinolysis indicationsST segment elevation >1mm in two contiguous leadsNew LBBBSymptoms consistent with ischemiaSymptom onset less than 12 hrs prior to presentation
Absolute contraindications for fibrinolysis therapy in patients with acute STEMI
Any prior ICH (intracerebral hemorrhage)Known structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastatic)Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hoursSuspected aortic dissectionActive bleeding or bleeding diathesis (excluding menses)Significant closed-head or facial trauma within 3 months
Relative contraindications for fibrinolysis therapy in patients with acute STEMI History of chronic, severe, poorly controlled hypertensionSevere uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindicationsTraumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)Recent (within 2-4 weeks) internal bleedingNoncompressible vascular puncturesFor streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to these agentsPregnancyActive peptic ulcerCurrent use of anticoagulants: the higher the INR, the higher the risk of bleeding
STEMI cardiac careSTEP 2: Determine preferred reperfusion strategy Fibrinolysis preferred if: 90mindoor to balloon minus door to needle > 1hrDoor to needle goal 3 hrHigh risk STEMIKillup 3 or higherSTEMI dx in doubt
Comparing outcomes
Comparing outcomes
Medical Therapy
Morphine (class I, level C)AnalgesiaReduce pain/anxietydecrease sympathetic tone, systemic vascular resistance and oxygen demandCareful with hypotension, hypovolemia, respiratory depression
Oxygen (2-4 liters/minute) (class I, level C)Up to 70% of ACS patient demonstrate hypoxemiaMay limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation
Nitroglycerin (class I, level B)Analgesiatitrate infusion to keep patient pain freeDilates coronary vesselsincrease blood flowReduces systemic vascular resistance and preloadCareful with recent ED (erectile dysfunction) meds, hypotension, bradycardia, tachycardia, RV infarction
Aspirin (160-325mg chewed & swallowed) (class I, level A)Irreversible inhibition of platelet aggregationStabilize plaque and arrest thrombusReduce mortality in patients with STEMICareful with active gastrointestinal bleeding, hypersensitivity, bleeding disorders
Beta-Blockers (class I, level A)14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMIApproximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptomsBe aware of contraindications (CHF, Heart block, Hypotension)Reassess for therapy as contraindications resolve
ACE-Inhibitors / ARB (class I, level A)Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotensionStart in first 24 hoursARB as substitute for patients unable to use ACE-I
Heparin (class I, level C to class IIa, level C)LMWH or UFH (max 4000u bolus, 1000u/hr)Indirect inhibitor of thrombin less supporting evidence of benefit in era of reperfusionAdjunct to surgical revascularization and thrombolytic / PCI reperfusion24-48 hours of treatmentCoordinate with PCI team (UFH preferred)Used in combo with aspirin and/or other platelet inhibitorsChanging from one to the other not recommended
Additional medication therapyClopidodrel (class I, level B)Irreversible inhibition of platelet aggregationUsed in support of cath / PCI intervention or if unable to take aspirin3 to 12 month duration depending on scenario
Glycoprotein IIb/IIIa inhibitors (class IIa, level B)Inhibition of platelet aggregation at final common pathwayIn support of PCI intervention as early as possible prior to PCI
STEMI care CCUMonitor for complications: recurrent ischemia, cardiogenic shock, ICH, arrhythmias
Review guidelines for specific management of complications & other specific clinical scenariosPCI after fibrinolysis, emergent CABG, etc
Decision making for risk stratification at hospital discharge and/or need for CABG
Unstable angina/NSTEMI cardiac careEvaluate for conservative vs. invasive therapy based upon:Risk of actual ACSTIMI risk scoreACS risk categories per AHA guidelines
LowIntermediateHigh
Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome
AssessmentFindings indicating HIGH likelihood of ACSFindings indicating INTERMEDIATE likelihood of ACS in absence of high-likelihood findingsFindings indicating LOW likelihood of ACS in absence of high- or intermediate-likelihood findingsHistoryChest or left arm pain or discomfort as chief symptomReproduction of previous documented anginaKnown history of coronary artery disease, including myocardial infarctionChest or left arm pain or discomfort as chief symptomAge > 50 yearsProbable ischemic symptomsRecent cocaine usePhysical examinationNew transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or ralesExtracardiac vascular diseaseChest discomfort reproduced by palpationECGNew or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptomsFixed Q wavesAbnormal ST segments or T waves not documented to be newT-wave flattening or inversion of T waves in leads with dominant R wavesNormal ECGSerum cardiac markersElevated cardiac troponin T or I, or elevated CK-MBNormal Normal
TIMI Risk ScorePredicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days
ACS risk criteriaLow Risk ACS
No intermediate or high risk factors
10 minutes rest pain, now resolved
T-wave inversion > 2mm
Slightly elevated cardiac markers
High Risk ACS
Elevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery
Low riskHigh riskConservative therapyInvasive therapyChest Pain centerIntermediate risk
Invasive therapy option UA/NSTEMICoronary angiography and revascularization within 12 to 48 hours after presentation to EDFor high risk ACS (class I, level A)MONA + Anticoagulant (UFH)Clopidogrel20% reduction death/MI/Stroke CURE trial1 month minimum duration and possibly up to 9 monthsGlycoprotein IIb/IIIa inhibitors
Conservative Therapy for UA/NSTEMIEarly revascularization or PCI not plannedMONA + Anticoagulant (LMWH or UFH)ClopidogrelGlycoprotein IIb/IIIa inhibitorsOnly in certain circumstances (planning PCI, elevated TnI/T)Surveillence in hospitalSerial ECGsSerial Markers
Secondary PreventionDiseaseHipertension, DM, Dyslipidemia
Behavioralsmoking, diet, physical activity, weight
Cognitive Education, cardiac rehab program
Secondary Preventiondisease managementBlood PressureGoals < 140/90 or 500; consider omega-3 fatty acids
DiabetesA1c < 7%
Secondary preventionbehavioral interventionSmoking cessationCessation-class, medications, counseling
Physical ActivityGoal 30 - 60 minutes dailyRisk assessment prior to initiation
DietDASH diet, fiber, omega-3 fatty acids
Thinking outside the box
Secondary preventioncognitivePatient educationIn-hospital discharge outpatient clinic/rehab
Monitor psychosocial impactDepression/anxiety assessment & treatmentSocial support system
Medication Checklist after ACSAntiplatelet agentAspirin and/or Clopidorgrel
Lipid lowering agentStatinFibrate / Niacin / Omega-3
Antihypertensive agentBeta blockerACE-I/ARBAldactone (as appropriate)
Prevention newsFrom 1994 to 2004 the death rate from coronary heart disease declined33%...
But the actual number of deaths declined only18%Getting better with treatment
But more patients developing disease need for primary prevention focus
SummaryACS includes UA, NSTEMI, and STEMI
Management guideline focusImmediate assessment/intervention (MONA+BAH)Risk stratification (UA/NSTEMI vs. STEMI)RAPID reperfusion for STEMI (PCI vs. Thrombolytics)Conservative vs Invasive therapy for UA/NSTEMI
Aggressive attention to secondary prevention initiatives for ACS patients Beta blocker, ASA, ACE-I, Statin
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