ACS

1. “If physicians would read two
articles per day out of the six
million medical articles
published annually, in one year,
they would fall 82 centuries
behind in their reading.”
Miser WF, Critical Appraisal of the Literature. J Am
Board Fam Pract, 12(4):315-333, 1999.

2. Acute Coronary
Syndromes
Coronary artery disease is the leading cause of death
in the United States.
Acute Coronary Syndrome (ACS) includes any
constellation of symptoms compatible with acute
myocardial ischemia:
 Acute MI (AMI) with ST-segment elevation and depression
 Q-wave and non-Q wave
 Unstable Angina (UA)

4. Acute Coronary
Syndromes
Can also be divided into:
STEMI
UA
NSTEMI

5. The implication of ACS is for early diagnosis for
appropriate clinical management, and
placement in an environment with continuous
EKG and defibrillation capability, where an EKG
can be obtained and immediately interpreted.
Priority is to identify patients with AMI to be
considered for immediate reperfusion Rx, and
recognize other potential catastrophic causes of
sudden decompensation such as aortic
dissection.

6. ST-Elevation Myocardial
Infarction (STEMI)
Pre-hospital Management
Initial Management in the ER
Reperfusion Therapy
Initial Adjunctive Treatments
Risk Stratification after MI

7. Pre-hospital
Management
Time is myocardium, regardless of the
strategy to reperfusion.
Prompt reperfusion:
 limits myocardial necrosis
 Preserves LV function
 Reduces mortality

8. Pre-hospital
Management
Most pts don’t seek care for 2 or more hours
Pts should promptly administer ASA
Dial 911
EMS should take pt to facility that can do PCI
16% reduction in mortality in pts given
thrombolytic Rx before hospitalization
? Safety of Rx before correct dx & selection

9. Initial Management in the
ER

10. Initial Management in
the ER
STEMI Protocols in the ER result in
rapid ID and Rx
Initial diagnostic tests:
 EKG
 continuous monitoring of rhythm, HR & BP
 targeted Hx and PE
 stat blood for cardiac markers, heme, chemistry
clotting and lipids
 chest X-ray

11. Selecting Optimal
Reperfusion Rx for Pts with
STEMI

13. Reperfusion Therapy
Success depends on time to therapy
＜ 30 minutes for thrombolytic rx ＞
＜ 90 minutes for primary PCI
Both are effective for achieving
reperfusion

14. PCI in STEMI
If it can be done rapidly, less risk of
recurrent MI
Stents better than POBA:
 ＜ restenosis, better success rates

15. PCI not Available
Or Long Door to Balloon (DB) Time
Peripheral Hospital
＞ mortality if DB time is ＞ 2 hours
If DB time ＞ 1 hour, PCI is no better
than fibrinolytic Rx

16. Initial Adjunctive
Treatments
Platelet activation and aggregation are
important in STEMI causing persistence
of thrombotic occlusions and resistance
to fibrinolytic Rx and risk of reocclusion.
Pathways leading to platelet activation
and aggregation are thus targets of
therapy.

17. Initial Adjunctive
Treatments
ASA given to all (160 – 325mg)
Plavix in pts allergic to ASA
Glycoprotein IIb/IIIa inhibitors for all
undergoing PCI
Thrombin Inhibitors (UFH or LMWH)
O2
NTG
IV B-blockers
ACE-I
Analgesia

18. Risk Stratification after
MI
Ischemic Risk
LV Function
Arrhythmic Substrate

19. Ischemic Risk
Identifying residual ischemia is to
identify high-risk pts who will benefit
from revascularization.
Post MI stress test – not necessary in
pts who had PCI

20. LV Function
LV function and Valvular disease
usually assessed with
echocardiography
Myocardial stunning may persist for 2
weeks

21. Assessment of Risk for
Arrhythmia
Important to assess risk or early or late
arrhythmic deaths is important after
STEMI
ICD implants in pts with low LVEF after
MI reduces mortality
Accuracy of prediction is not good

23. Unstable Angina and
Non--ST-Segment
Elevation MI
UA and NSTEMI

25. UA and NSTEMI
1.5 million patients annually admitted to
hospitals in US
Many advances in last few years:
 Antiplatelet therapies
 Cholesterol lowering
 B-blockade

26. ACC/AHA

27. Overview of Guidelines

28. Features with Higher
Liklihood of ACS

29. TIMI Risk Score for UA/NSTEMI
Predicts Risk of Death, MI, or
Recurrent Ischemia

30. Effects of Plavix Stratified by
TIMI Risk Score at 12 Months

31. Benefit of IIb/IIIa Inhibitors in
UA/NSTEMI by Troponin

32. Antiplatelet Treatment
Antiplatelet Therapy is the
Cornerstone in the Management
of UA/NSTEMI

33. Antiplatement Therapy
ASA reduces events by 50% to 70%
compared with placebo. (160-325mg in
hospital, 81mg at discharge).
Plavix (Clopidogrel) in patients who
cannot take ASA.

34. Antiplatement Therapy
Clopidogrel is a class I recommendation in
addition to ASA
CURE Trial Clopidogrel + ASA had 20%
reduction of CV death, MI and stroke vs ASA
alone in both high and low risk pts with
UA/NSTEMI.
The benefits were seen at 2 hours and 1
year. 31% reduction in cardiac events at 1
and 12 months

35. Glycoprotein IIb/IIIa
Inhibitors
Upstream Management with Integrilin
(eptifibatide) shows clear benefit,
Reopro (abciximab) none in pts treated
conservatively
Aciximab is strongly beneficial in pts
undergoing PCI
Pts at high risk benefit from GP IIb/IIIa
inhibitors

36. UFH and LMWH
All pts with US/NSTEMI
Incremental benefit over ASA alone
Lovenox (enoxaparin) (LMWH) superior
to UFH in reducing recurrent cardiac
events
Beware of pts with bleeding histories

39. Invasive vs Conservative
Strategy
Especially in high risk pts (ST changes and
Tp positive

40. An early invasive strategy is cost-
effective with a cost of $17,500 per life
saved

42. Summary of Hospital
Strategy

43. Summary of Invasive
Strategy

44. Long Term Therapy