ACS.pptx

Acute Coronary Syndrome
( Decisions making)
Dr/Waseem Omar, MD
Lecturer of Cardiology,
Al-Azhar University

www.escardio.org/guidelines
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
©ESC
2020 ESC Guidelines for the
management of acute coronary
syndromes in patients presenting
without persistent ST-segment
elevation

©ESC
ESC Classes of recommendations
Definition Wording to use
ClassI Evidence and/or generalagreement thatagiven
treatment orprocedure isbeneficial, useful,
effective.
Isrecommended
or isindicated
ClassII Conflicting evidence and/ora divergence of opinionabout the
usefulness/efficacyof the given treatment orprocedure.
ClassIIa Weightof evidence/opinionisinfavour
ofusefulness/efficacy.
Shouldbe considered
ClassIIb Usefulness/efficacyisless well
establishedbyevidence/opinion.
May beconsidered
ClassIII Evidence or generalagreement that the given
treatment or procedureisnot useful/effective,
andinsome casesmay beharmful.
Is not recommended

The World’s Biggest Killer!
6
• Ischemic heart disease is the
leading cause of death
worldwide, responsible for 16%
of the world’s total deaths.
• Since 2000, the largest increase
in deaths has been for this
disease, rising by more than 2
million to 8.9 million deaths in
2019.
https://www.who.int/news-room/fact-sheets/detail/the-top-10-
causes-of-death

Definition of ACS
• Clinical syndrome characterized by persistent
symptoms of typical anginal pain, classified
according to ECG and biochemical markers
into:
Unstable angina.
NSTE-MI.
STE-MI.

Chain of decisions of ACS
CP
analysis
• Typical or not
• Acute or chronic
ECG&m
arkers
• Unstable angina or NSTE-MI
• STE-MI
Risk
stratifications
• low
• High
• Very high.
Strategy
• Admission or not.
• Reperfusion or not: Fibrinolytic or PPCI.
• Invasive or conserve
• Immediate or early invasive.
• Timing

Chest Pain Analysis
• Location.
• Duration.
• Character.
• What increase.
• What decrease.

Unstable angina
• Angina crescendo; increased frequency,
duration, severity or need more SL nitrates.
• Angina at rest.
• Angina De novo.
• Post infarction angina.

• Don’t forget:
ECG may be normal without changes.
Additional ECG leads(V3r, V4r, V7 8 9) if
ongoing ischemia is suspected and standard
leads are inconclusive

©ESC
Figure 3 (1)
0 h/1 h rule-out and
rule-in algorithm using
high-sensitivity cardiac
troponin assays in
haemodynamically stable
patients presenting with
suspected non-ST-
segment elevation acute
coronary syndrome to the
emergency department.
aOnly applicable if CPO >3 h.

©ESC
Figure 1
Diagnostic algorithm
and triage in acute
coronary syndrome.

©ESC
Figure 6
Antithrombotic
treatmentsin non-ST-
segment elevation acute
coronarysyndrome
patients:pharmacological
targets. Drugs with oral
administration are shown
in black letters and drugs
with preferredparenteral
administration in red.
Abciximab(in brackets) is
not suppliedanymore.

©ESC
Figure 5
Determinants of
antithrombotic
treatment in
coronary artery
disease.
Intrinsic (in blue: patient’s
characteristics, clinical presentation
& comorbidities) and extrinsic (in
yellow: co-medication & procedural
aspects) variables influencing the
choice, dosing, and duration of
antithrombotic treatment.

©ESC
Table 6 Dose regimen of antiplatelet and anticoagulant drugs in
non-ST-segment elevation acute coronary syndrome patientsa (1)
I. Antiplateletdrugs
Aspirin LD of 150–300 mg orally or 75–250 mg i.v. if oral ingestion is not possible,
followed by oral MD of 75–100 mg o.d.
P2Y12 receptor inhibitors (oral or i.v.)
Clopidogrel LD of 300–600 mg orally, followed by a MD of 75 mg o.d., no specific
dose adjustment in CKD patients.
Prasugrel LD of 60 mg orally, followed by a MD of 10 mg o.d. In patients with body
weight <60 kg, a MD of 5 mg o.d. is recommended. In patients aged ≥75
years, prasugrel should be used with caution, but a dose of 5 mg o.d.
should be used if treatment is deemed necessary. No specific dose
adjustment in CKD patients. Prior stroke is a contraindication for
prasugrel.
aAll dosing regimens refer to doses given for the respective drugs for protection against thrombosis within the arterial system.

©ESC
P2Y12 receptor inhibitors (oral or i.v.) (continued)
Ticagrelor LD of 180 mg orally, followed by a MD of 90 mg b.i.d., no specific dose
adjustment in CKD patients.
Cangrelor Bolus of 30 µg/kg i.v. followed by 4 µg/kg/min infusion for at least 2 h or
the duration of the procedure (whichever is longer).
GP IIb/IIIa receptor inhibitors (i.v.)
Abciximab Bolus of 0.25 mg/kg i.v. and 0.125 μg/kg/min infusion (maximum
10 μg/min) for 12 h (drug is not supplied anymore).
Eptifibatide Double bolus of 180 μg/kg i.v. (given at a 10-min interval) followed by an
infusion of 2.0 μg/kg/min for up to18 h.

©ESC
GP IIb/IIIa receptor inhibitors (i.v.) (continued)
Tirofiban Bolus of 25 μg/kg i.v. over 3 min, followed by an infusion of
0.15 μg/kg/min for up to 18 h.
II. Anticoagulant drugs (for use before and during PCI)
UFH 70–100 U/kg i.v. bolus when no GP IIb/IIIa inhibitor is planned.
50–70 U/kg i.v. bolus with GP IIb/IIIa inhibitors.
Enoxaparin 0.5 mg/kg i.v. bolus.
Bivalirudin 0.75 mg/kg i.v. bolus followed by i.v. infusion of 1.75 mg/kg/h for up to
4 h after the procedure as clinically warranted.

• Reperfusion is the mainstay therapy
• Time=muscle
STE-MI

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