Acute Coronary Syndrome especially NSTEMI is a very often missed diagnosis in ICU patients. The presentation addresses Emergenc

1. Acute Coronary Syndrome
Non ST Elevation MI
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP
Department of Critical Care Medicine
King Saud Medical City
Riyadh Saudi Arabia

2. Disclosures
We are not
promotional speakers
for any company but
we do accept the
breakfast in our
presentations
(just for fun)
A very special man is here to see U doctor!!

3. Session Objectives



Utilize both clinical evaluation and risk scoring in
selecting the appropriate initial management
strategy for patients with UA/NSTEMI
Identify potential updates to current UA/NSTEMI
critical pathways based on the latest ACC/AHA
UA/NSTEMI guidelines and recent UA/NSTEMI
clinical trial results
Evaluate current approaches to discharge
planning and follow-up, and modify them as
necessary to promote adherence to medical and
rehabilitative therapies

4. Deaths from ACS
others
23%
ACS
48%
Hypertension
5%
CHF
5%
Atherosclerosis
2%
0.5%
0.5%
Stroke
17%

5. Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI†
STEMI
1.24 million
.33 million
Admissions per year
Admissions per year
Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171.
*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

6. Ischemic Heart Disease Evaluation
Based on the patient’s
•
•
•
History / Physical exam
Electrocardiogram
Biochemical markers
Patients are categorized into 2 groups


Non Cardiac Chest Pain
Pain cardiac in origin
USA/NSTEMI/STEMI

7. Spectrum of Coronary Syndromes
Risk Factors + Hypertension
Endothelial Dysfunction
Atherosclerosis
IHD/Angina Pectoris
Myocardial Ischemia
Chronic
Coronary
Syndromes
Coronary Thrombosis
Myocardial Infarction
Acute
Coronary
Syndromes
Arrhythmia & Loss of Muscle
Remodeling
Ventricular Dilation
Congestive Heart Failure
Endstage Heart Disease
Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.

8. Acute Coronary Syndrome

Definition
The term ACS refers to a spectrum of
presentations caused by myocardial
ischemia that includes



Unstable Angina
Non ST elevation myocardial infarction
ST elevation myocardial infarction

9. Diagnosis





Diagnosis requires a rise and/or fall in serum
levels (preferably troponin) together with:
Evidence of Myocardial Ischaemia
Defined clinically by patient history
ECG (new ST-T wave changes, new left bundle
branch block or evolving pathological Q waves)
Imaging evidence of new regional wall motion
abnormality.

10. Acute Coronary Syndromes
Pathophysiology
 The
embracing term reflects the
common pathophysiology of
 Plaque
disruption
 Intravascular thrombosis
 Impaired myocardial blood supply

11. STEMI
Result of complete
epicardial occlusion
following plaque
disruption & leads to
propagation of
thrombus & epicardial
vasoconstriction
NSTEMI
Incomplete &
transient epicardial
occlusion with
platelet-rich &
phasic distal
embolisation

12. Pathophysiology

13. Summary of events & outcome

14. Acute ST Elevation MI

15. Normal ECG

16. Acute Coronary Syndrome
Clinical Diagnosis
MONA
Morphine
Oxygen
NTG
Aspirin
Blood Tests:
Troponin at 12 hours after
onset of pain, U&E, cholesterol,
FBC, coagulation
Admission or subsequent ECG

17. High Risk ECG changes:
(2 or more contiguous leads)
ST depression > 1mm
T inversion > 1mm
Transient BBB
Minor/ transient ST elevation
NO
High Risk Clinical
features:
Ongoing rest pain.
Haemodynamic instability.
Arrythmias
Troponin Elevated?
NO
Low Risk Patient
Discharge
Able to exercise ?
YES
NO
Consider
investigations:
Perfusion scan
Angiography
Cardiology
Referral
ETT
ETT Normal
ETT Inconclusive

18. High Risk ECG changes:
(2 or more contiguous leads)
ST depression > 1mm
T inversion > 1mm
Transient BBB
Minor/ transient ST elevation
High Risk
UnStable
Ongoing pain
ECG changes
GPIIbIIIa
Urgent cath.
pre-morbidity
suitability for
revasc.
1.
2.
3.
4.
5.
High Risk Clinical
features:
Ongoing rest pain.
Haemodynamic instability.
Arrythmias
Troponin
Elevated
High Risk
LMWH
Clopidogrel 300 stat, 75mg OD
Aspirin 75 mg OD
Beta Blockers: (metopr)25 mg tds
Hyperglycaemic control DIGAMI
protocol, if RBS > 10 mmol
6. Morphine and / or IV nitrates if
continuing pain, titrate to pain and
blood pressure.
High Risk
Stable
Cardiac Cath.
pre-morbid
state and
suitability
for revasc.

19. What is UA/NSTEMI Patients Risk
of inpatient Cardiac Mortality and
ischemic events?

20. Variables Used in the TIMI Risk Score
•
Age ≥ 65 years =1 point
•
At least 3 risk factors for CAD =1 point
•
Prior coronary stenosis of ≥ 50% =1 point
•
ST-segment deviation on ECG presentation =1 point
•
At least 2 anginal events in prior 24 hours =1 point
•
Use of aspirin in prior 7 days =1 point
•
Elevated serum cardiac biomarkers =1 point
The TIMI risk score is determined by the sum of the presence of the above 7 variables at
admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more
remained relatively insensitive to missing information and remained a significant predictor
of events. Antman EM, et al. JAMA 2000;284:835–42.
TIMI = Thrombolysis in Myocardial Infarction.

21. TIMI Risk Score
TIMI
Risk
Score
All-Cause Mortality, New or Recurrent MI, or Severe
Recurrent Ischemia Requiring Urgent
Revascularization Through 14 Days After
Randomization %
0-1
4.7
2
8.3
3
13.2
4
19.9
5
26.2
6-7
40.9
Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American
Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.

22. GRACE Risk Score
Variable
Odds ratio
Older age
1.7 per 10 y
Killip class
2.0 per class
Systolic BP
1.4 per 20 mm Hg ↑
ST-segment deviation
2.4
Cardiac arrest during presentation
4.3
Serum creatinine level
1.2 per 1-mg/dL ↑
Positive initial cardiac biomarkers
1.6
Heart rate
1.3 per 30-beat/min
↑
The sum of scores is applied to a reference monogram to determine the corresponding all-cause
mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRACE
clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157.
GRACE = Global Registry of Acute Coronary Events.

23. Why R U Confusing us?

24. UA/NSTEMI Hospital Care
Let’s Start with the Basics! Assuming the
NSTEMI has been our diagnosis

25. ACC/AHA Guidelines
ACS Treatment Overview: UA/NSTEMI
Diagnosis of UA or NSTEMI is likely or definite
Aspirin or clopidogrel
(if patient is aspirin intolerant)
Initial conservative
management
Initial invasive
management
Medical
therapy
Evaluation of LV
Function in pt
with ischemia
aIf
Diagnostic
angiography
PCI or CABGa
Long-term medical management:
Clopidogrel, aspirin, β-blocker, ACEI,
statin
possible, clopidogrel should be withheld for 5-7 days prior to the procedure.
Anderson JL, et al. Circulation. 2007;116:803-877.

26. Selection of Initial Treatment
Wright RS et al. Circ 2011;123;2022-2060.

27. Early Treatment
Class I Indications




Bed rest with continuous ECG Monitoring
O2 therapy if saturation <90%, respiratory
distress, or other high-risk features for
hypoxemia
SL NTG 0.4 mg q5min x3 then assessment of
need for IV NTG
IV NTG indicated first 48 hours for treatment of
persistent ischemia, CHF or HTN; should not
preclude Rx with beta-blockers or ACE
Wright RS et al. Circ 2011;123;2022-2060.

28. Early Treatment
Class I Indications


Oral Beta-Blocker in first 24 hours for pt who do not
have
 Signs of CHF
 Low out-put state
 Increased risk of cardiogenic shock
 Contraindication to Beta blockers/heart block/COPD
If Beta-Blockers are contraindicated a
nondihydropyridine calcium channel blocker may be used
if no LV dysfunction
Wright RS et al. Circ 2011;123;2022-2060.

29. Early Treatment (Cont.)
ACE inhibitor within 24 hours with pulmonary congestion or
LVEF < 40% in the absence of hypotension or
contraindication
 Because of the increased risk of mortality, reinfarction, HTN,
CHF, and myocardial rupture NSAIDS except for ASA should
be discontinued at presentation
Class II indications:
 It is reasonable to admin O2 to all UA/NSTEMI pts in first 6
hours. IIa
 Morphine (1-5 mg IV) remains Class I for STEMI although
may increase adverse events in UA/NSTEMI (1,2)
 It is reasonable to administer morphine sulfate IV if there
is uncontrolled ischemic Chest Pain despite NTG. IIa

1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.
2. Meine T el al. Am Heart J 2005;149:1043- 9

30. Rx for all NSTEMI
Early Hospital Care
2011 Focused update Antiplatelet therapy


ASA should be administered to USA/NSTEMI as
soon as possible after hospital presentation and
continued indefinitely (LOE A)
Clopidogrel (loading dose followed by
maintenance dose) should be administered to
USA/NSTEMI patients who are unable to take
ASA because of hypersensitivity or major
gastrointestinal intolerance (LOE B)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

31. Look who is sleeping

32. Conservative Rx
Hospital Care
2011 Focused update Antiplatelet therapy

For USA/NSTEMI patients in whom an
initial conservative strategy is selected
clopidogrel (loading dose followed by
maintenance dose) should be added to
ASA and anticoagulant therapy as soon as
possible after admission and administered
for at least 1 month and ideally up to 1
year
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

33. Conservative Rx
Hospital Care
Initial Conservative Strategy:
Anticoagulant Therapy


Anticoagulant therapy should be added to antiplatelet
therapy in UA/NSTEMI patients as soon as possible after
presentation.
For patients in whom a conservative strategy is selected,
regimens using either enoxaparin* or UFH (LOE A) or
fondaparinux (LOE: B) have established efficacy.

In patients in whom a conservative strategy is selected
and who have an increased risk of bleeding,
fondaparinux is preferable.
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
*Limited data are available for the use of other lowmolecular-weight heparins (LMWHs), e.g., dalteparin.

34. Time to use your grey matter


An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponin is mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are not
contraindicated:
a. Clopidogrel
b. Prasugrel
c. Enoxaparin
d. Eptifibatide
e. An intravenous fibrinolytic drug

36. Time to use your grey matter


An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponin is mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are
most appropriate
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel 75 mg daily
c. Intravenous unfractionated heparin
d. ASA 325 mg daily and Intravenous heparin
e. ASA 325 mg OD & Clopidogrel 75mg OD & IV heparin

37. Time to use your grey matter



An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her ECHO showed EF 30% & small pericardial effusion.
Which of the following drugs should be discontinued?
a. Metoprolol
b. Diltiazem
c. Hydralazine
d. Lisinopril

38. Time to use your grey matter

Oral beta blockers should be initiated within first 24 hrs
for those pts who do not have





1)
2)
3)
4)
Signs of heart failure
Evidence of low output state
Increased risk of cardiogenic shock
other contraindications to beta blockers
Risk Factors for Cardiogenic Shock




Age > 70yrs
BP <120
Heart rate >110 or < 60
Increased time since onset of symptoms

39. Time to use your grey matter

40. Time to use your grey matter



An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her ECHO showed EF 30% & small pericardial effusion.
Which of the following is indicated?
a. Transe-esophageal echo
b. Biventricular pacing
c. Implantable cardioverter defibrillator
d. Cardiac catheterization

41. Initial Conservative strategy
Additional Management considerations

42. Conservative Rx

Hospital Care
2011 Focused update
For USA/NSTEMI patients in whom an
initial conservative strategy is selected if
recurrent symptoms/ischemia, CHF, or
serious arrhythmias subsequently appear,
then diagnostic angiography should be
preformed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

43. Conservative Rx
Hospital Care
2011 Focused update


For patients with USA/NSTEMI treated
conservatively without recurrent symptoms, CHF
or arrhythmia a stress test should be performed
If the pt is not classified as low risk after the
stress test then angiography should be
performed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

44. Conservative Rx
Hospital Care
2011 Focused update

If at low risk Post Stress Test:




Continue ASA
Continue clopidogrel for at least 1 month and
ideally up to 1 year
Discontinue GP IIb/IIIa inhibitor if started
Continue UFH for 48 hours or administer
enoxaparin or fondaparinux for the duration
of hospitalization up to 8 days and then
discontinue
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

45. Pharao gets prescription

46. Time to use your grey matter


An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal , ECG is below
What would you recommend?
a. A resting sistamibi scan
b. A nuclear stress test
c. Intravenous fibrinolytic drug
d. Cardiac Cath

47. Selection of Initial Treatment
Wright RS et al. Circ 2011;123;2022-2060.

48. Time to use your grey matter




An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9
Which of the following therapies are most appropriate?
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel 75 mg daily
c. ASA 325 mg daily and prasugrel 10 mg OD
e. Clopidogrel 75mg OD & IV eptifabatide

49. Medium to High
Risk patients…..
Early Hospital Care
2011 Focused update Antiplatelet therapy

Pt with definite USA/NSTEMI at medium or
high risk and in whom an initial invasive
strategy is selected should receive dualantiplatelet therapy on presentation (LOE A)


ASA on presentation
The second should be given before PCI as
follows…..
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

50. Medium to High
Risk patients…..
Early Hospital Care
2011 Focused update Antiplatelet therapy
Before PCI:
 Clopidogrel (LOE B)
 An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide
or tirofiban are the preferred agents
At the time of PCI:
 Clopidogrel if not started before PCI (LOE A)
 Prasugrel (LOE B)
 An IV GP IIb/IIIa inhibitor (LOE A)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

51. Time to use your grey matter




An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9
Which of the following therapies are not appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

52. Initial Invasive Strategy
Anticoagulation

53. Continue Smiling

54. Time to use your grey matter




An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, Creatinin clearance is <30
ml/min, CTn 2.9
Which of the following therapies are not appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

55. Time to use your grey matter




An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin normal but
there is history of heparin induced thrombocytopenia
Which of the following therapies is appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

58. Hospital Care
2011 Focused update

For patients with USA/NSTEMI in whom CABG is
selected post angiography






Continue ASA
Discontinue IV GP IIb/IIIa inhibitor 4 hours before
CABG
Continue UFH
Discontinue enoxaparin 12-24 hours before CABG and
dose with UFH per institution practice
Discontinue fondaparinux 24 hours before CABG and
dose with UFH per institution practice
Discontinue bivalirudin 3 hours before CABG and dose
with UFH per institution practice
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

59. Hospital Care
2011 Focused update



In patients taking thienopyridine in whom
CABG is planned and can be delayed…
Discontinue clopidogrel for at least 5 days
Discontinue prasugrel for at least 7 days
Unless the need for revascularization and or
the net benefit of the thienopyridine
outweighs the potential risks of excess
bleeding… (LOE C)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

60. ACC/AHA Guidelines update 2011
UA/NSTEMI: Long-Term Medical Management
UA or NSTEMI at hospital discharge
Inhospital management with
medical therapy (without
stenting)
Aspirina
75-162 mg/d
indefinitely plus
clopidogrelb 75 mg/d for at
least 1 mo, ideally up to 1 yr
aIf
patient is allergic
to aspirin, use
clopidogrel alone
(indefinitely) or try aspirin
desensitization.
bIf
patient is allergic to clopidogrel,
use ticlodipine 250 mg PO bid.
Inhospital therapy with
drug-eluting stent
implantation
Inhospital therapy with baremetal stent implantation
Aspirina
162-325 mg/d for at
least 1 mo, then
75-162 mg/d indefinitely plus
clopidogrelb 75 mg/d or
prasugrel 10 mg/d for at
least12 months*
Aspirina 162-325 mg/d for at
least 3 mo with Sirolimus and
6 mo paclitaxel, then
75-162 mg/d indefinitely plus
clopidogrelb 75 mg/d or
prasugrel 10 mg/d for at
least 12 mo
Is an indication for
anticoagulation present?
If yes: add
warfarinc,d
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
If no: continue dual
antiplatelet therapy
cContinue
aspirin indefinitely
and warfarin long term, if
indicated for specific conditions.
dIf
warfarin is added to aspirin
and clopidogrel, the
recommended INR is 2.0-2.5.

62. Dear Doctor!

63. Evaluating Recurrent Risk
Secondary Prevention Strategies
Broad Goals during Hospital discharge phase


Prepare the patient for normal activities
Use the acute event as an opportunity to
reevaluate the plan of care - lifestyle and
risk factor modification
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

64. Can U Revise

65. Evidence based medicine
Take all these pills daily until a new clinical
trial is published

66. Questions?
No questions?
Good!
Then let’s go home
& try some herbal Rx