1.
Acute Coronary Syndrome
(ACS)
3 Aug 2011
Khanittha L,M.D
Naresuan University Hospital

2.
Coronary Artery

3.
Hospital
Hx
PE
EKG
Ventricular systolic dysfunction (LV/RV)
Recurrent ischemia/infarct
• Inhospital admission
• After discharged
ACS
Mechanical complication
•Myocardial rupture
•MR
•VSD
Electrical instability
•VT/VF
•Heart Block
•Atrial arrhythmia

4.
หัวใจล้มเหลว
ล้ามเนื้อหัวใจขาดเลือดซ๊ำ๊า
n-hospital admission
fter discharged
ACS
หัวใจเต้นผิด
จังหวะ
•VT/VF
•Heart Block
•Atrial arrhythmia
ภาวะแทรกซ๊้อนทาง
mechanical
•Myocardial rupture
•MR
•VSD

5.
Coronary Artery Disease (CAD)
*Acute coronary syndrome
*Unstable angina
*Acute non ST-elevation myocardial infarction
*Acute ST-elevation myocardial infarction
*Chronic coronary artery disease : chronic stable
angina

6.
Spectrum of CAD/ACS
No ST elevation
Stable
angina
Unstable
angina
ST elevation
NSTEMI
ACUTE CORONARY SYNDROMES
CAD = coronary artery disease; NSTEMI = non-ST-segment elevation myocardial infarction;
STEMI = ST-segment elevation myocardial infarction.
Source (Photos): Davies MJ. Heart. 2000;83:361-366.
STEMI

7.
Pathophysiology of ACS
Subtotal artery occlusion
Non ST elevation ACS
(UA/NSTEMI)
Complete total occlusion
ST elevation ACS
(STEMI)

8.
Structure of thrombus
following plaque disruption
UA/NSTEMI
Non-occlusive thrombus
(platelets, some fibrins)
STEMI
Occlusive thrombus
(platelets, fibrins, red cell)
Plaque core
Intra-plaque thrombus
(platelet dominated)

9.
Understanding Myocardial Ischemia
Imbalance

10.
Understanding Myocardial Ischemia
Decrease O2 Supply
Increase Demand
Mechanical
Obstruction
Dec. Oxygenated
Blood Flow
Increase cardiac output………..
(Thyrotoxicosis)
Atheroma
Anemia
Myocardial Hypertrophy
Thrombosis
Carboxyhemoglobinemia
Spasm
Hypotension CAUSING DEC
CORONARY PERFUSION PRESSURE
Embolus
Coronary arteritis
Coronary trauma
(AS,HTN)

11.
Plaque
Fissure or
Rupture
Platelet
Adhesion
Platelet
Activation
Platelet
Aggregation
Thrombotic
Occlusion

12.
Consequence of
Acute Coronary Occlusion

13.
TYPICAL HISTORY
ECG CHANGES
INC CARDIAC
ENZYMES

14.
Clinical
Presentation
Of ACS

15.
Focused History
• Aid in diagnosis and rule
out other causes
– Palliative/Provocative
factors
– Quality of discomfort
– Radiation
– Symptoms associated
with discomfort
– Cardiac risk factors
– Past medical history
-especially cardiac
• Reperfusion questions
– Timing of presentation
– ECG c/w STEMI
– Contraindication to
fibrinolysis
– Degree of STEMI risk

16.
Symptom
* Acute chest pain
* Nausea/ vomiting
* Sweating
* Dyspnea
* Palpitation
* Syncope
* Pulmonary edema
* Epigastric pain
* Post-op hypotension
* Oliguria
* Acute confusional state
* Stroke
* Diabetic hyperglycemia state

17.
ACS Clinical Presentation
* Substernal chest pain or pressure (>20-30 min)
* Localization or radiation to arms, back, throat, jaw
* Accompanying features
* Dyspnea
* Nausea/vomiting
* Diaphoresis
* Weakness
* Atypical: syncope

18.
Risk Factor for Acute Coronary Syndrome
*Non-modifiable
*Modifiable

19.
Risk Factor
*Age
Incidence increase with age.
*Male gender
* Men > premenupausal women
* After menupause , incidence is
almost same
*Family History of IHD

20.
Modifiable
Risk Factors
•Smoking
•Hyperlipidemia
•Hypertension
•Diabetes mellitus
•Lack of exercise
•Blood coagulation factors
•Personality
•Obesity

21.
Targeted Physical Examination
*Vital signs
*Cardiovascular
system
*Respiratory system
*Abdomen
*Neurological status
*Recognize factors that
increase risk
*Hypotension
*Tachycardia
*Pulmonary rales, JVP,
pulmonary edema,
*New murmurs/heart sounds
*Diminished peripheral pulses
*Signs of stroke

22.
Acute coronary syndromes
Aortic dissection
Esophageal reflux
Pneumothorax
Chest pain
Myocarditis
Costochronditis
Acute pulmonary embolism
Acute pericarditis
Psychosomatic

23.
Acute Coronary Syndromes
ST-elevation MI
Cardiac marker +ve
Non-ST elevation ACS
Cardiac marker +ve
Unstable angina
Cardiac marker - ve

24.
*Normal
*ST-depression
*T-wave inversion
*ST-elevation or
*LBBB
*Repeat EKG when patient
is in pain
*Continuous ST – segment
monitoring

25.
Cardiac Markers

26.
Timing of Release of Various Biomarkers After Acute
Myocardial Infarction
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

27.
Cardiac Markers
Troponin ( T, I)
CK-MB isoenzyme
*Very specific and more sensitive
*Rises 4-6 hours after injury and
than CK
*Rises 4-8 hours after injury
*May remain elevated for up to
two weeks
*Can provide prognostic
information
*Troponin T may be elevated
with renal dz,
poly/dermatomyositis
peaks at 24 hours
*Remains elevated 36-48 hours
*Positive if CK/MB > 5% of total
CK and 2 times normal
*Elevation can be predictive of
mortality
*False positives with exercise,
trauma, muscle dz,

28.
Chest pain
Non
Cardiac
Diagnosis
–
–
–
–
Assess 12 lead ECG
Initial assesment
Hx
PE
EKG and EKG monitoring
CXR
Possible
Chronic
ACS
Stable
Angina
Goal = 10 min
Definite
ACS

29.
Chest Pain Suggestive of Ischemia
Immediate assessment within 10 Minutes
Initial labs
and tests
*12 lead ECG
*Obtain initial cardiac
enzymes
*Electrolytes, CBC,
lipids, BUN/Cr,
glucose, Coags
*CXR
Emergent
care
 IV access
 Cardiac
monitoring
 Oxygen
 Aspirin
 Nitrates
History &
Physical




Establish
diagnosis
Read ECG
Identify
complications
Assess for
reperfusion

30.
แนวทางการรักษาคนไข้
ACS
*Prevent plaque rupture : Statins
*Decrease O2 need
*Decrease platelet activation and aggregation
*Open blocked vessel

31.
Acute ST Elevation Myocardial Infarction

32.
Assessments and treatments to consider for
patients who present with ACS
Initial general treatment (“M O N A C”)
*Morphine 2-4 mg q 5-10 min
*Oxygen 4 L/min
*NTG sublingual or spray, followed by infusion for persistent chest
pain
*Aspirin 160 -325 mg chew and swallow or/and
*Clopidogrel 300mg oral

33.
Specific Treatment : Reperfusion Therapy
Fibrinolysis vs primary PCI
“Time is muscle”

34.
Treatment of ASTEMI
 Open
coronary artery within 12 hr
 Reperfusion
 Fibrinolytic
 Primary
Therapy
agents : Streptokinase, tPA
PTCA

35.
Reperfusion Therapy
จุดมุ่งหมาย : ให้การวินิจฉัยและรักษาผู้ปวย STEMI
่
อย่างรวดเร็ว
* Door to needle time
( หรือ First medical contact-to-needle time)
ระยะเวลาที่เริ่มให้ fibrinolytic therapy ควรอยู่ภายใน
30 นาที
* Door to balloon time
( หรือ First medical contact-to-balloon time )

36.
Contraindications and Cautions for Fibrinolysis in STEMI
• Any prior intracranial hemorrhage
• Known structural cerebral vascular lesion
Absolute
(e.g., arteriovenous malformation)
Contraindications
• Known malignant intracranial neoplasm
(primary or metastatic)
• Ischemic stroke within 3 months EXCEPT
acute ischemic stroke within 3 hours
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
(excluding menses)
• Significant closed-head or facial trauma
within 3 months
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction 2004

37.
Contraindications and Cautions
for Fibrinolysis in STEMI
• History of chronic, severe, poorly controlled
Relative
hypertension
Contraindications
• 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)
ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction 2004

38.
การรัก ษาผู้ป ่ว ย ST-Elevation MI
หรืelevation หรือ new LBBB
อ New LBBB
ST
> 12 hour
< 12 hour
Eligible for
reperfusion Rx
Thrombolytic is
contra-indicated
1° PCI
Thrombolytic Rx
: Streptokinase
: rt-PA
Not candidate for
reperfusion Rx
Other medical treatment
B-blocker
ACEI / ARB
Nitrate
Statin
Persistent symptom
No
Yes
Consider
reperfusion Rx

39.
Door to
needle
<30 MIN
Door to
balloon
<90 MIN
Reperfusion
Goals
REPERFUSION
<120 MIN
SYMPTOM ONSET –
TO-REPERFUSION
ONSET OF
SYMPYOMS
EMS
ARRIVAL
HOSP
ARRIVAL
ECG
INCREASING LOSS OF MYOCYTES

40.
Door to Needle Time and Mortality
In hospital
mortality (%)
20
18
16
14
12
10
8
6
4
2
0
18.1
14.14
10.3
6.3
4.3
0-30
16
31-60
Door to Balloon Time and Mortality
61-90
>90
no
thrombolysis
14.1
14
12
10
10
8
6
9.1
7
5.6
4
2
0
<60
61-90
91-120
120-180
>180
Thai ACS registry

41.
Comparison of Approved Fibrinolytic Drugs
Feature
SK
t-PA
Fibrin-specific
-
++
Half-life (minutes)
20
5
Antigencity
Y
N
90 minutes patency
60
84
Rate of ICH
0.34
0.69
Requires concomitant heparin +/-
Y
Weight adjusted dosing
N
Y
Dose
1.5 mL units IV over 60
minutes
15 mg IV /1-2min
0.75 mg/kg IV/30 min
(max 50 mg)
0.5 mg/kg IV/60 min
(max 35 mg)
SK
Bolus administration
N
N
Cost per dose (Baht)
9,606
49,857
50

42.
ACS : Unstable angina or NSTEMI

43.
การแบ่งผู้ป่วยทีมาด้วย chest pain ตามปัจจัยเสี่ยงถึงความน่าจะ
่
เป็นโรคหัวใจโคโรนารี
(CAD)ตามลักษณะทางคลินิก และ EKG แรกรับ

44.
ปัจจัยเสี่ยงต่อการตาย และ nonfatal MI ในผู้ป่วยทีมี chest pain
่
สงสัย ischemia

45.
ACS : NSTEMI or UA

46.
ACS : NSTEM or UA
Fibrinolytic
Antithrombin
UFH, LMWH
Stabilized
Severe
stenosis
Antiplatelets
Subtotal
occlusion
ASA, clopidogrel,
G2b3a inhibitors

47.
Assessments and treatments to consider for
patients who present with ACS
Initial general treatment (“ M O N A C ”)
*M orphine 2-4 mg q 5-10 min
*O xygen 4 L/min
*N TG sublingual or spray, followed by infusion for persistent
chest pain
*A spirin 160 -325 mg chew and swallow or/and
*C lopidogrel 300mg oral

48.
ACS : NSTEACS or UA
PCI
ยา

49.
Initial Conservative Strategy : Early Hospital Care
*ASA; clopidogrel if intolerant
(I, A)
*Anticoagulant therapy should be added to antiplatelet
therapy as soon as possible after presentation (I, A)
*Enoxaparin or UFH (I, A)
*Fondaparinux (I, B)
*Enoxaparin or fondaparinux preferable
(IIa, B)
*Initiate clopidogrel, loading dose + maintenance dose (I, A)
ACC/AHA 2007 Guidelines for the Management of
Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

50.
Adjunctive Therapies
* Beta-blocker
*ถ้าไม่มีข้อห้าม
* IV nitroglycerine
*สำาหรับ recurrent ischemia, large anterior MI, heart
failure, antihypertensive effects
* ACE inhibitor
*โดยเฉพาะ large anterior wall MI, heart failure ควรให้
หลัง
24 ชม.

51.
Secondary Prevention and Long Term Management
Goals
Smoking
Goal:
Complete
Cessation
Recommendations
• 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.
61

52.
Secondary Prevention and Long Term Management
Goals
Blood pressure
control:
Goal: < 140/90
mm Hg or
<130/80 mm Hg
if chronic kidney
disease or
diabetes
Recommendations
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-angiotensinaldosterone system.
62

53.
Secondary Prevention and Long Term Management
Goals
Physical activity:
Minimum goal:
30 minutes 3 to 4
days per week;
Optimal daily
Recommendations
• 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.
63

54.
Secondary Prevention and Long Term Management
Goals
Lipid
management:
(TG less than
200 mg/dL)
Primary goal:
LDL-C << than
100 mg/dL
Recommendations
• 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:
LDL-C < 100 mg/dL (baseline or on treatment):
Statins should be used to lower LDL-C.
LDL-C ≥ 100 mg/dL (baseline or on
treatment):
Intensify LDL-C–lowering therapy with drug treatment,
giving preference to statins.
64

55.
Secondary Prevention and Long Term Management
Goals
Lipid
management:
(TG 200 mg/dL
or greater)
Primary goal:
Non–HDL-C <<
130 mg/dL
Recommendations
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.
65

56.
Secondary Prevention and Long Term Management
Goals
Weight
management:
Goal:
BMI 18.5 to 24.9
kg/m2
Waist
circumference:
Women: < 35 in.
Men: < 40 in.
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.
66

57.
Secondary Prevention and Long Term Management
Goals
Diabetes
management:
Goal:
HbA1c < 7%
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).
67

58.
Management Strategies in Acute Coronary syndrome(ACS)
Symptoms of Acute Coronary Syndrome
ST elevation
(STEMI)
EKG
Reperfusion approach
All patients
1. ASA
1. Anti-ischemic medications
2. Heparin(UFH or LMWH) Beta-blocker
3. Clopidogrel
Nitrated
4. Choose reperfusion method+/-Ca++ channel blocker
a. Fibrinolytic drug
2. General measures
b. Primary PCI
Oxygen
Pain control (morphine)
3. Additional therapies
ACE inhibitor
Statin
No ST elevation
(UA/NSTEMI)
Antithrombotic approach
1. ASA
2. Heparin(UFH or LMWH)
3. Clopidogrel
4. For high risk patients
GP IIb/IIIa inhibitor
Proceed to cathlab

59.
“ABCDE”
A- antiplatelets, ACE-I
B- beta-blocker, blood pressure control
C- cholesterol lowering, cigarette smoking
cessation
D- diet, diabetes management
E- exercise