- The document provides guidelines for the management of acute coronary syndrome (ACS), including definitions, risk stratification, diagnostic criteria, treatment protocols for STEMI, NSTEMI/UA, and secondary prevention strategies. - It outlines the pathophysiology of ACS as resulting from atherosclerotic plaque rupture and thrombus formation, and differentiates between STEMI, NSTEMI, and UA based on ECG changes and cardiac biomarker levels. - Initial management involves optimal medical therapy, while risk stratification determines whether conservative treatment or an invasive strategy including angiography and revascularization is most appropriate for intermediate-to-high risk NSTEMI/

1. Overview In Managements Of Acute Coronary
Syndrome
(American Heart Association Guidelines)
Dr. Ayman Selim Ibrahim Abougalambou
MB,CHB(UOG),M.MED(USM) ,Malaysian Board Of Medicine, Clinical and
Interventional Cardiology Fellowship(IJN)
Associate Consultant Interventional Cardiologist,, Senior
Physician
King Abdullah Cardiac Center
King Abdullah Medical City- Mecca
(18th
sep 2013)

2. Objectives

3. Cases

4. Pathology, Pathophysiology, and
Epidemiology

5. ACUTE CORONARY SYNDROMES
ETIOLOGY

6. The Vulnerable Plaque
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
Large Lipid Core
Thin, Vulnerable,
Fibrous Cap

7. Ruptured Plaque with Occlusive
Thrombus Formation
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
Thrombus
Formation

8. Atherothrombosis: Thrombus Superimposed
on Atherosclerotic Plaque
Adapted with permission from Falk E, et al. Circulation. 1998;92:657-671. Slide reproduced with permission
from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

9. ACUTE CORONARY SYNDROMES
DEFINITION

10. Diagnosis of Acute MI (STEMI /
NSTE-ACS)
At least 2 of the above

11. Diagnosis of ACS

12. Diagnosis of Angina Pectoris

13. Management

14. Chest pain suggestive of ischemia

15. ECG assessment

16. ECG assessment
INFARCT LOCATION

17. INTERPRETATION OF TROPONINS

18. Risk Stratification
UA or NSTE-ACS
- Evaluate for Invasive vs.
conservative treatment
- Directed medical therapy
Based on initialBased on initial
Evaluation, ECG, andEvaluation, ECG, and
Cardiac markersCardiac markers
-- Assess for reperfusion
- Select & implement
reperfusion therapy
- Directed medical therapy
STEMI
Patient?
YESYES NONO

19. STEMI Cardiac Care
STEP 1: Assessment

20. STEMI Cardiac Care
STEP 2: Determine preferred reperfusion strategy

21. Primary PCI

22. Absolute contraindications for
fibrinolysis

23. Relative contraindications for fibrinolysis therapy in
patients with acute STEMI
• History of chronic, severe, poorly controlled hypertension.
• Severe 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 contraindications
• Traumatic or prolonged (greater than 10 minutes) CPR or major surgery
(less than 3 weeks).
• Recent (within 2-4 weeks) internal bleeding.
• Noncompressible vascular punctures.
• For streptokinase/anistreplase: prior exposure (more than 5 days ago) or
prior allergic reaction to these agents.
• Pregnancy.
• Active peptic ulcer.
• Current use of anticoagulants: the higher the INR, the higher the risk of
bleeding.

24. Relative contraindications for
fibrinolysis

25. Unstable Angina /NSTE-ACS Cardiac care
• Evaluate for conservative vs. invasive therapy based upon:
• Risk of actual ACS
• TIMI risk score
• ACS risk categories per AHA guidelines
LowLow
IntermediateIntermediate
HighHigh

26. TIMI RISK SCORE FOR
UA/NSTEMI
• HISTORICAL POINTS
• age >/= 65 y 1
• >/= 3 CAD risk factors 1
• known CAD (stenosis >/= 50%) 1
• ASA use in past 7 days 1
• PRESENTATION
• severe angina </= 24 hours 1
• elevated cardiac markers 1
• ST deviation >/= 0.5 mm 1
RISK SCORE: /7

27. TIMI RISK SCORE FOR
UA/NSTEMI
RISK OF CARDIAC EVENT IN 14 DAYS

28. Low
risk
High
risk
ConservativeConservative
therapytherapy
InvasiveInvasive
therapytherapy
Chest PainChest Pain
centercenter
Intermediate
risk

29. Medical Therapy
• Morphine (class I, level C)
• Analgesia
• Reduce pain/anxiety—decrease sympathetic tone, systemic
vascular resistance and oxygen demand.
• Careful with hypotension, hypovolemia, respiratory
depression.
• Oxygen (2-4 liters/minute) (class I, level C)
• Up to 70% of ACS patient demonstrate hypoxemia
• May limit ischemic myocardial damage by increasing
oxygen delivery/reduce ST elevation.

30. • Nitroglycerin (class I, level B)
• Analgesia—titrate infusion to keep patient pain free.
• Dilates coronary vessels—increase blood flow.
• Reduces systemic vascular resistance and preload.
• Careful with recent ED meds, hypotension, bradycardia,
tachycardia, RV infarction.
• Aspirin (160-325mg chewed & swallowed) (class I, level A)
• Irreversible inhibition of platelet aggregation.
• Stabilize plaque and arrest thrombus.
• Reduce mortality in patients with STEMI.
• Careful with active PUD, hypersensitivity, bleeding
disorders.

31. • Beta-Blockers (class I, level A)
• 14% reduction in mortality risk at 7 days at 23% long term
mortality reduction in STEMI
• Approximate 13% reduction in risk of progression to MI in
patients with threatening or evolving MI symptoms
• Be 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/hypotension
• Start in first 24 hours
• ARB as substitute for patients unable to use ACE-I.

32. • 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 reperfusion
• Adjunct to surgical revascularization and thrombolytic /
PCI reperfusion.
• 24-48 hours of treatment
• Coordinate with PCI team (UFH preferred).
• Used in combo with aspirin and/or other platelet inhibitors
• Changing from one to the other not recommended.

33. Additional medication therapy
• Clopidodrel (class I, level B)
• Irreversible inhibition of platelet aggregation
• Used in support of cath / PCI intervention or if unable to
take aspirin
• 3 to 12 month duration depending on scenario
• Glycoprotein IIb/IIIa inhibitors (class IIa, level B)
• Inhibition of platelet aggregation at final common pathway
• In support of PCI intervention as early as possible prior to
PCI.

34. Additional medication therapy
• Aldosterone blockers (class I, level A)
– Post-STEMI patients
• No significant renal failure (Cr < 2.5 men or 2.0 for
women)
• No hyperkalemis > 5.0
• LVEF < 40%
• Symptomatic CHF or DM

35. Secondary Prevention
• Disease
– HTN, DM, HLP.
• Behavioral
– smoking, diet, physical activity, weight.
• Cognitive
– Education, cardiac rehab program.

36. Secondary Prevention disease management
• Blood Pressure
– Goals < 140/90 or <130/80 in DM /CKD
– Maximize use of cardio-selective beta-blockers & ACE-I
• Lipids
– LDL < 100 (70) ; TG < 200
– Maximize use of statins; consider fibrates/niacin first line
for TG>500; consider omega-3 fatty acids.
• Diabetes
– HBA1c < 7%

37. Secondary prevention behavioral intervention
• Smoking cessation
– Cessation-class, meds, counseling.
• Physical Activity
– Goal 30 - 60 minutes daily
– Risk assessment prior to initiation.
• Diet
– DASH diet, fiber, omega-3 fatty acids.
– <7% total calories from saturated fats.

38. Medication Checklist after ACS
• Antiplatelet agent
– Aspirin* and/or Clopidorgrel
• Lipid lowering agent
– Statin*
– Fibrate / Niacin / Omega-3
• Antihypertensive agent
– Beta blocker*
– ACE-I*/ARB
– Aldactone (as appropriate)

39. CASE ONE
• Frail 67 year old hypertensive male
• 8/10 substernal chest pain
• Radiation down left arm, into jaw
• Diaphoresis, tachypnea, nausea
• Onset within past four hours
• No relief with nitro
• T 37.1 C HR 112/min BP 150/100 RR 22/min

40. CASE ONE
Immediate Assessment:
• IV access – Oxygen – Monitors
• EKG
• Targeted history and exam
• CXR
• Eligibility for thrombolysis/PCI
• Labs

41. CASE ONE
ELECTROCARDIOGRAM

42. CASE ONE
• Risk stratify:
– STEMI, TIMI score >8 (VERY HIGH RISK)
• Immediate Treatment:
– ASA 160 mg po
– Oxygen
– +/- nitro sl
– Metoprolol
– Heparin
– Emergent revascularization strategy

43. CASE ONE
• Adjunctive Treatment:
– Clopidogrel po
– Nitroglycerine iv
– Morphine iv
– Consider IIb/IIIa agents if primary PCI

44. CASE TWO
• 65 year old diabetic female
• Retrosternal/epigastric pressure with no radiation
• Occurs at rest, duration </= 15minutes
• Associated with nausea and diaphoresis
• Pain free currently
• Onset 1/12 ago but increasing 4/7

45. CASE TWO
Immediate Assessment:
• IV access – Oxygen – Monitors
• EKG
• Targeted history and exam
– smoker, dyslipidemic, hypertension, proteinuria
– on ASA, HCTZ, metformin, glyburide, celexa
– normal cardiac exam
• CXR
• Labs

46. CASE TWO
ELECTROCARDIOGRAM

47. CASE TWO
• Risk stratify:
– UA/NSTEMI, TIMI score >4 (INTERMEDIATE RISK)
• Immediate Treatment:
– ASA 160 mg po
– Heparin (LMWH > UFH)
– +/- Clopidogrel
– Coronary angiogram

48. CASE TWO
• Adjunctive Treatment:
– Beta Blockers
– ACE Inhibitors
– +/- Nitrates

49. CASE THREE
• 37 year old male complains of a retrosternal
dull ache for 3 hours
• No radiation of pain
• No associated symptoms
• Smoker, significant family history

50. CASE THREE
Immediate Assessment:
• IV access – Oxygen – Monitors
• EKG
• Targeted history and exam
• CXR
• Labs

51. CASE THREE
ELECTROCARDIOGRAM

52. CASE THREE
• Risk stratify:
– UA/NSTEMI, TIMI score 1 (LOW RISK)
• Immediate Treatment:
– ASA 160 mg po
– Monitor
– Serial EKG and enzymes (X2)
– Exercise Stress Test

53. SUMMARY
• • Acute coronary syndrome is a spectrum of UA/NSTE-ACS and
STEMI. The clinical presentation will depend on the acuteness
and severity of coronary occlusion.
• • The diagnosis of UA/NSTE-ACS is based on history + dynamic
ECG changes (without persistent ST elevation), + raised cardiac
biomarkers.
• • In UA cardiac biomarkers are normal while in NSTE-ACS it is
elevated.
• • Risk stratification is important for prognosis and to guide
management
• • Initial management of intermediate/high risk patients includes
optimal medical therapy with ASA, clopidogrel (or ticagelor) and
UFH or LMWH or fondaparinux. Prasugrel may be considered as
an alternative to clopidogrel after coronary angiography if PCI is
planned.

54. • • Patients with refractory angina and/or hemodynamically
unstable should be considered for urgent coronary angiography
and revascularization.
• • Intermediate/high risk patients should be considered for early
invasive strategy (<72 hours). If admitted to a non-PCI centre,
they should be considered for transfer to a PCI centre.
• • Low risk patients should be assessed non-invasively for
ischemia.
• • All patients should receive optimal medical therapy at discharge.
This includes ASA, clopidogrel (ticagrelor or prasugrel if given
during PCI), β -blockers +CCBs, ACE-I or ARB and statins.
• • These drugs should be uptitrated as outpatient to the
recommended tolerated doses.
• • Cardiac rehabilitation and secondary prevention programs which
includes lifestyle modification is an integral component of
management.

55. Thank you so much for your Auscultations….

56. Diagnosis of Acute MI (STEMI / NSTE-ACS)
• At least 2 of the following
• Ischemic symptoms.
• Diagnostic ECG changes.
• Serum cardiac marker elevations.

57. Diagnosis of Unstable Angina
• Patients with typical angina - An episode of angina
• Increased in severity or duration
• Has onset at rest or at a low level of exertion
• Unrelieved by the amount of nitroglycerin or rest that had
previously relieved the pain
• Patients not known to have typical angina
• First episode with usual activity or at rest within the
previous two weeks
• Prolonged pain at rest

58. 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

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

60. Cardiac markers
• Troponin ( T, I)
– Very specific and more
sensitive 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.
• CK-MB isoenzyme
– Rises 4-6 hours after injury
and 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,
DM, PE

61. Assessment Findings indicating
HIGH likelihood of ACS
Findings indicating
INTERMEDIATE
likelihood of ACS in
absence of high-
likelihood findings
Findings indicating
LOW likelihood of ACS
in absence of high- or
intermediate-likelihood
findings
History Chest or left arm pain or
discomfort as chief
symptom
Reproduction of previous
documented angina
Known history of coronary
artery disease, including
myocardial infarction
Chest or left arm pain or
discomfort as chief
symptom
Age > 50 years
Probable ischemic
symptoms
Recent cocaine use
Physical
examination
New transient mitral
regurgitation, hypotension,
diaphoresis, pulmonary
edema or rales
Extracardiac vascular
disease
Chest discomfort
reproduced by palpation
ECG New or presumably new
transient ST-segment
deviation (> 0.05 mV) or T-
wave inversion (> 0.2 mV)
with symptoms
Fixed Q waves
Abnormal ST segments or
T waves not documented
to be new
T-wave flattening or
inversion of T waves in
leads with dominant R
waves
Normal ECG
Serum cardiac
markers
Elevated cardiac troponin
T or I, or elevated CK-MB
Normal Normal
Risk Stratification to Determine the Likelihood of
Acute Coronary Syndrome

62. ACS risk criteria
Low Risk ACS
No intermediate or high
risk factors
<10 minutes rest pain
Non-diagnositic ECG
Non-elevated cardiac
markers
Age < 70 years
Intermediate Risk ACS
Moderate to high likelihood
of CAD
>10 minutes rest pain,
now resolved
T-wave inversion > 2mm
Slightly elevated cardiac
markers

63. High Risk ACS
*Elevated cardiac markers.
*New or presumed new ST depression.
*Recurrent ischemia despite therapy.
*Recurrent ischemia with heart failure.
*High risk findings on non-invasive stress test.
*Depressed systolic left ventricular function.
*Hemodynamic instability.
*Sustained Ventricular tachycardia.
*PCI with 6 months.
*Prior Bypass(CABG)surgery.