Dr, A. Banerjee. D.M(Cardiology)

1. Acute Coronary Syndrome
Dr. A. Bandyopadhyay
D.M.(Cardiology)

2. ACUTE CORONARY SYNDROME
What is ACS?
-Refers to a spectrum of clinical presentations ranging from those for
ST-segment elevation myocardial infarction (STEMI) to presentations
found in non–ST- segment elevation myocardial infarction (NSTEMI) or in
unstable angina.
-In general reserved for ischemia precipitated by acute coronary
athero-thrombosis

3. Endstage Heart
Arrhythmia & Loss of Muscle
Remodeling Ventricular Dilation
Congestive Heart Failure .
Myocardial Infarction
Myocardial Ischemia
Risk Factors + Hypertension
Endothelial Dysfunction
Atherosclerosis IHD/Angina Pectoris
Coronary Thrombosis
Chronic
Coronary
Syndromes
Acute
Coronary
Syndromes

4. Ischemic Heart
Disease

5. ACUTEACUTE CORONARYCORONARY SYNDROMESYNDROME
Ischemic Heart
Disease
Chronic coronary artery
disease (CAD) with
STABLE ANGINA
Acute Coronary
Syndrome
• STEMI
• NSTE-ACS
• Unstable Angina

6. ACUTE CORONARY SYNDROME
Classic manifestation of ischemia is angina pectoris:
Pressure,
Tightness,
Squeezing,
Heaviness,
Burning
ACS most commonly occurs without obvious precipitating factors

8. Coronary Circulation

9. Coronary Circulation

10. Coronary Circulation

11. LOCALIZATION OF CORONARY CIRCULATION IN M.I.
ANATOMIC ECG LEADS CORONARY
ARTERY
Septal V1-v2 Proximal LAD
Anterior V3-V4 LAD
Apical V5-V6 Distal LAD, LCx, or RCA
Lateral I, aVL LCx
Inferior II, III, aVF RCA(85%), LCx (15%)
RV V1-V2 & V4R (most Se) Proximal RCA
Posterior ST depression V1-V3 RCA or LCx

13. ACUTE CORONARY SYNDROME

14. ACUTE CORONARY SYNDROME

15. ACUTE CORONARY SYNDROME
The American College of Cardiology (ACC) guidelines list the following
as pain descriptions uncharacteristic of myocardial ischemia:
•Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory movements
or coughing)
•Primary or sole location of the discomfort in the middle or lower abdominal
region
•Pain that may be localized by the tip of one finger, particularly over the left
ventricular apex
•Pain reproduced with movement or palpation of the chest wall or arms
•Constant pain that persists for many hours
•Very brief episodes of pain that last a few seconds or less
•Pain that radiates into the lower extremities

16. ISCHEMIC HEART DISEASE

17. Ischemic Heart Disease
The major determinants of myocardial oxygen demand
(MVO2) are:
•heart rate,
•myocardial contractility, and
•myocardial wall tension (stress)
About 75% of the total coronary resistance to flow occurs
across three sets of arteries:
•large epicardial arteries (Resistance 1 = R1),
•Pre-arteriolar vessels (R2), and
•arteriolar and intramyocardial capillary vessels (R3)

18. Coronary Blood Flow Limitation:
•spasm,
•arterial thrombi, and,
•rarely, coronary emboli
•ostial narrowing due to aortitis
•Congenital Anomalies
50% Stenosis:
there is a limitation of the ability to increase flow to
meet increased myocardial demand.
80% Stenosis:
myocardial ischemia at rest or with minimal stress
Ischemic Heart Disease

19. ACUTE CORONARY SYNDROME

20. The severity and duration of the imbalance between myocardial
oxygen supply and demand determine whether the damage is :
•reversible ;≤20 min for total occlusion in the absence
of collaterals) or
•permanent, with subsequent myocardial necrosis (>20 min).
Ischemic Heart Disease

21. ACUTE CORONARY SYNDROME
Evaluation
of the
patient with
known or
suspected
ischemic
heart
disease

22. Indications and Contraindications for Exercise
Electrocardiographic Testing in the Emergency Department
Requirements:
• Two sets of cardiac enzymes at 4-hr intervals should be normal
• ECG at the time of arrival and pr-eexercise 12-lead ECG show no significant abnormality
• Absence of rest electrocardiographic abnormalities that would preclude accurate assessment
of the exercise ECG
• From admission to the time that results are available from the second set of cardiac enzymes:
patient asymptomatic, lessening chest pain symptoms, or persistent atypical symptoms
• Absence of ischemic chest pain at the time of exercise testing
Contraindications:
• New or evolving electrocardiographic abnormalities on the rest tracing
• Abnormal cardiac enzyme levels
• Inability to perform exercise
• Worsening or persistent ischemic chest pain symptoms.
• Clinical risk profiling indicating that imminent coronary angiography is likely

23. A
C
U
T
E
C S
O Y
R N
O D
N R
A O
R M
Y E

24. ISCHEMIC HEART DISEASE

25. STABLE ISCHEMIC HEART DISEASE
Laboratory Tests:
1. Fasting lipid profile
2.Fasting glucose and/or glycated hemoglobin (HbA1c) level if
available; additional oral glucose tolerance test (OGTT) if both are
inconclusive;
3. Complete blood count (CBC);
4. Creatinine level with estimation of glomerular filtration rate (GFR);
2.Biochemical markers of myocardial injury (Troponin T or I) if clinical
evaluation suggests an Acute Coronary Syndrome (ACS);
3.Thyroid hormone levels
4.Liver function tests early after beginning statin therapy.

26. ISCHEMIC HEART DISEASE
Pre-Test Probability (PTP) Assessment
Diamond and Forrester pre-test probability of cad by age, sex and
symptoms

27. ISCHEMIC HEART DISEASE

28. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Non-invasive stress testing Stress Imaging

29. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS

30. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Exercise ECG (Treadmill Exercise Test or TET)
its simplicity, lower cost and widespread availability, the TET is
the initial test of choice to identify inducible ischemia in the
majority of patients with intermediate PTP who are able to
exercise
The low sensitivity of the TET (45% to 50%) despite a high
specificity (85% to 90%) is the reason why it is not recommended
in patients with a PTP greater than 65%
In the latter case, a stress imaging study is more appropriate.

31. ISCHEMIC HEART DISEASE
CORONARY ARTERIOGRAPHY:
Coronary arteriography is indicated in:
•patients with chronic stable angina pectoris who are severely symptomatic
despite medical therapy and are being considered for revascularization,
i.e., a percutaneous coronary intervention (PCI) or coronary artery bypass grafting.
•patients with troublesome symptoms that present diagnostic difficulties in
whom there is a need to confirm or rule out the diagnosis of IHD;
•patients with known or possible angina pectoris who have survived cardiac
arrest;
•patients with angina or evidence of ischemia on noninvasive testing
with clinical or laboratory evidence of ventricular dysfunction; and
•patients judged to be at high risk of sustaining coronary events based
on signs of severe ischemia on noninvasive testing, regardless of the
presence or severity of symptoms

32. ISCHEMIC HEART DISEASE
MANAGEMENT
Lifestyle Modification and Treatment of Risk Factors
1)Healthy Diet
2)Physical Activity
3)Hypertension
4)Smoking
5)DM
6)Weight Management
7)Lipid Management

33. ISCHEMIC HEART DISEASE
MANAGEMENT
Pharmacologic Therapy to Improve Prognosis
Whether or not revascularization is being considered, receive
the following medications to improve prognosis, thereby
reducing the risk for MI and death:
•Aspirin low-dose (81 to 160 mg/day)
•Clopidogrel in case of aspirin intolerance (75 mg/day)
•Statins irrespective of LDL-cholesterol levels
•Beta blockers post-MI
•ACEIs or ARBs (especially in patients with concomitant HF,
hypertension or diabetes)

34. Pharmacologic Therapy to Improve Prognosis

35. Pharmacologic Therapy to Improve Prognosis

36. Pharmacologic Therapy to Improve Prognosis

37. R
E
V
A
S
C
U
L
A
R
I
Z

38. Non-ST-Segment Elevation
Acute Coronary Syndrome
(Non-ST-Segment Elevation
Myocardial Infarction and
Unstable Angina)

39. NSTE-ACS
Pathophysiology:
1.imbalance between oxygen supply and oxygen demand resulting from a
partially occluding thrombus or on eroded coronary artery endothelium by
1. Plaque disruption
2. Intravascular thrombosis
3. Impaired myocardial blood supply
2.dynamic obstruction
3.severe mechanical obstruction
4.increased myocardial oxygen demand

40. NSTE-ACS

41. NSTE-ACS

42. NSTE-ACS
DIAGNOSIS:
Clinical :
it occurs at rest (or with minimal exertion), lasting >10 minutes;
it is of relatively recent onset (i.e., within the prior 2 weeks); and/or
it occurs with a crescendo pattern (i.e., distinctly more severe,
prolonged, or frequent than previous episodes)
NSTEMI - elevated levels of biomarkers of cardiac necrosis

43. NSTE-ACS
DIAGNOSIS:
3 major noninvasive tools are used in the evaluation of NSTEMI-ACS:
The electrocardiogram (ECG),
Cardiac biomarkers, and
Stress testing
GOALS :
• To recognize or exclude myocardial infarction (MI) using cardiac biomarkers,
preferably cTn;
• To detect rest ischemia (using serial or continuous ECGs);
and
• To detect significant coronary obstruction at rest with CCTA and myocardial
ischemia using stress testing

45. Diagnosis

46. 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary
syndromes using high-sensitivity cardiac troponin assays

47. New: 0 h/1 h rule-in & rule-out algorithm of non-ST- elevation
acute coronary syndromes using hs cardiac troponin assays

50. C
a
u
s
e
s
o
f
e T
l r
e o
v p
a o
t n
e i
d n

51. C
a
u
s
e
so
f
e T
l r
e o
v p
a o
t n
e i
d n

53. • 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
Variables Used in the TIMI Risk Score

54. 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
2
3
4
5
6-7
4.7
8.3
13.2
19.9
26.2
40.9

56. MEDICAL
TREATMENT
• Bed rest
• Continuous ECG monitoring
• Ambulation only if
No recurrence of ischemia (symptoms or ECG changes)
Does not develop an elevation of a biomarker of necrosis for 12–24 h
ANTI-ISCHEMIC ANTITHROMBOTIC

57. NSTE-ACS
Drugs Commonly Used in Intensive Medical Management of
Patients with UA and NSTEMI

58. NSTE-ACS
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
antiplatelet
drugs
anticoagulants.

61. Recommendations for anti-ischaemic drugs in the acute phase

62. NSTE-ACS
ORAL ANTIPLATELETS
Aspirin Initial dose of 325 mg nonenteric formulation followed by 75–100
mg/d of an enteric or a nonenteric formulation
Clopidogrel Loading dose of 300–600 mg followed by 75 mg/d
Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d
Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily
Intravenous Antiplatelet Therapy
Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 μg/ kg per min
(maximum 10 μg/min) for 12–24 h
Eptifibatide 180 μg/kg bolus followed 10 min later by second bolus of 180 μg
with infusion of 2.0 μg/kg per min for 72–96 h following first bolus
Tirofiban 5 μg/kg per min followed by infusion of 0.15 μg/kg per min for
48– 96 h

63. NSTE-ACS
HEPARINS
Unfractionated
heparin
(UFH)
Bolus 70–100 U/kg (maximum 5000 U) IV
followed by infusion of 12–15 U/kg per h (initial
maximum 1000 U/h) titrated to ACT 250–300 s
Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded
by a 30-mg IV bolus; renal adjustment to
1 mg/kg once daily if creatine clearance <30 cc/min
Fondaparinu
x
2.5 mg SC qd
Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of
1.75 mg/kg per h.

64. Suggested strategies to reduce bleeding risk related to PCI
NEW

65. Risk criteria mandating invasive strategy in NSTE-ACS

68. Recommendations for
the management of
patients with heart
failure NSTEMI

69. Recommendations for
long-term management
after non-ST- elevation
acute coronary
syndromes

70. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
-syndrome of severe ischemic pain that usually occurs at
rest and is associated with transient ST segment elevation
-focal spasm of an epicardial coronary artery, leading to
severe transient myocardial ischemia and occasionally infarction
-may be related to hypercontractility of vascular smooth muscle
due to adrenergic vasoconstrictors, leukotrienes, or
serotonin
-has decreased substantially during the past few decades
-PVA are generally younger and have fewer coronary risk factors
-The clinical diagnosis of PVA is made by the detection of
transient ST-segment elevation with rest pain
-Focal spasm is most common in the right coronary artery

71. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
Diagnosis:
Hyperventilation or intracoronary acetylcholine has been used
to provoke focal coronary stenosis on angiography or to
provoke rest angina with ST-segment elevation to establish the
diagnosis
TREATMENT
Nitrates and Calcium Channel Blockers
Aspirin- may actually increase the severity of ischemic episodes
PROGNOSIS
•Survival at 5 years is excellent (∼90–95%)
•Nonfatal MI occurs in up to 20% of patients by 5 years
•There is a tendency for symptoms
•and cardiac events to diminish over time

72. NSTE-ACS
CORONARY ANGIOGRAPHY
IS NOT RECOMMENDED in patients with
•extensive co-morbidities (e.g., liver or pulmonary failure;
cancer); in whom the risks of revascularization are not likely
to outweigh the benefits;
•in patients with acute chest pain and a low likelihood of ACS;
•or in patients who will not consent to revascularization
regardless of the findings.

73. NSTE-ACS
Revascularization by PCI
PCI IS RECOMMENDED for NSTE-ACS patients
with 1- to 2-vessel CAD, with or without significant
proximal left anterior descending CAD, but with a
large area of viable myocardium and high-risk
criteria on noninvasive testing.

74. NSTE-ACS
Revascularization by CABG Surgery
CABG IS RECOMMENDED for patients with
•significant left main disease, and is the preferred
revascularization strategy for patients with
1.multi-vessel coronary disease;
2.vessels with lesions not favorable for PCI;
3.depressed systolic function (LVEF lower than
40%); and diabetes.

75. ST-Segment Elevation
Myocardial Infarction
(STEMI)

76. ACUTE CORONARY SYNDROME

78. ACUTE CORONARY SYNDROME

79. STEMI

80. STEMI
• Type I: Spontaneous Myocardial Infarction
• Type 2: Myocardial Infarction Secondary to an Ischemic Imbalance
• Type 3: Myocardial Infarction Resulting in Death When
Biomarker Values Are Unavailable
• Type 4a: Myocardial Infarction Related to Percutaneous Coronary
Intervention (PCI)
• Type 4b: Myocardial Infarction Related to Stent Thrombosis
• Type 5: Myocardial Infarction Related to Coronary Artery
Bypass Grafting (CABG
Classification of Myocardial Infarction

84. Wellens’ Syndrome
 ECG findings in absence of chest pain, but with recent cardiac chest pain
symptoms
 critical stenosis of the LAD
 Not necessarily STEMI equivalent but will require PCI in the next 24-48h
 Deeply-inverted or biphasic T waves in V2-3
 Isoelectric or minimally-elevated ST segment (<1 mm)
 Absent precordial Q waves with preserved R waves
 Type A: Biphasic pattern - 25% - Biphasic T-waves (initial positive deflection
and terminal negative deflection)
 Type B: Inversion pattern - 75% - Deeply inverted and symmetric T- waves

86. De Winter Pattern
 Suggestive of proximal LAD lesion
 Precordial ST-segment depression at the J-point
 Tall, peaked, symmetric T waves in the precordial leads
 Lead aVR shows slight ST- segment elevation in most

87. STEMI
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
Antiplatelet
drugs
Anticoagulants
FIBRINOLYSI
S

89. STEMI
MANAGEMENT IN THE EMERGENCY DEPARTMENT
The goals for the management of patients with suspected STEMI include:
control of cardiac discomfort,
rapid identification of patients who are candidates for urgent reperfusion
therapy,
triage of lower-risk patients to the appropriate location in the hospital,
and
avoidance of inappropriate discharge of patients with STEMI
Aspirin
is essential in the management of patients with suspected STEMI and is
effective across the entire spectrum of acute coronary syndromes
OXYGEN
O2 should be administered by nasal prongs or face mask (2–4 L/min) for the
first 6–12 h after infarction

90. STEMI

95. STEMI
Initial ER Management
•Aspirin 160 to 320 mg tablet (non-enteric coated, chewed);
•Clopidogrel 300 to 600 mg whether or not fibrinolysis will be given;
•Clopidogrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when a patient will
undergo PCI;
•Nitrates, either sublingual or intra-venous routes.
Nitrates are contraindicated in patients with hypotension
or those who took a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs
for tadalafil);
•Morphine 2 to 4 mg IV for relief of chest pain, and;
•Supplemental oxygen MAY BE RECOMMENDED durign the first 6 hours to
patients with arterial oxygen saturation of less than 90%.

96. STEMI
In-hospital Treatment
Reperfusion therapy IS RECOMMENDED
to all eligible patients with STEMI with
symptom onset within the prior 12 hours.
Early revascularization, the goal being 12
hours, is a primary treatment goal in
patients with STEMI

97. STEMI

98. STEMI

99. STEMI

104. TIMI FLOW GRADE: — The degree of perfusion in the infarct-
related artery (IRA) is typically described by the TIMI flow grade:
●TIMI 0 refers to the absence of antegrade flow beyond a coronary
occlusion.
●TIMI 1 flow is faint antegrade coronary flow beyond the occlusion,
although filling of the distal coronary bed is incomplete.
●TIMI 2 flow is delayed or sluggish antegrade flow with complete
filling of the distal territory.
●TIMI 3 flow is normal flow which fills the distal coronary bed
completely.
TIMI

105. STEMI
Primary Percutaneous Coronary
Intervention (PCI)
RECOMMENDED in patients with STEMI and ischemic
symptoms of less than hours’ durationϭ contraindications to
fibrinolytic therapy, irrespective of the time delay from first
medical contact.
•RECOMMENDED in patients with STEMI and cardiogenic
shock or acute severe heart failure (HF), irrespective of time
delay from MI onset
•MAY BE RECOMMENDED in patients with STEMI if there is
clinical and/or ECG evidence of ongoing ischemia between 12
and 24 hours after symptom onset

106. STEMI
1. RECOMMENDED in failed PCI with persistent pain or
hemodynamic instability in patients with coronary anatomy
suitable for surgery
2. RECOMMENDED in persistent or recurrent ischemia refractory to
medical therapy in patients who have coronary anatomy suitable
for surgery, and are not candidates for PCI or fibrinolytic therapy
3. RECOMMENDED in patients with STEMI at the time of operative
repair of mechanical defects.
Coronary Artery Bypass Grafting (CABG)

107. STEMI
Duration of Dual Antiplatelet Therapy and Antithrombotic
Combination Therapies after STEMI
Combination Therapies after STEMI, DAPT by combining aspirin
and an ADP-receptor blocker (clopidogrel, prasugrel or
ticagrelor) IS RECOMMENDED in patients with STEMI who are
undergoing primary PCI (for up to 12 months) or (clopidogrel)
fibrinolysis (for up to 12 months, although the data available
pertain only to one month of DAPT), and in those who have not
undergone reperfusion therapy (for at least 1 month and up to 12
months).

108. STEMI
1. High-dose statins are RECOMMENDED in all patients during the first 24
hours of admission for STEMI, irrespective of the patient’s cholesterol
concentration, in the absence of contraindications (allergy, active liver
disease).
2. Atorvastatin or Rosuvastatin are recommended during the early phase of
therapy up to at least four weeks.
3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to 40 mg) or
atorvastatin (40 to 80 mg) therapy before emergency percutaneous
coronary intervention to
1. reduce periprocedural inflammatory response,
2. to reduce myocardial dysfunction, and
3. to prevent contrast-induced nephropathy
Lipid Lowering Agents

112. ACUTE CORONARY
SYNDROME

115. THANK
YOU