ACS & AF GUIDELINE

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 ACUTE CORONARY SYNDROME (ACS)


90 coronary
(atheromatous plaque rupture)

2
ACS 3

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Unstable NSTEMI STEMI
angina (UA)
EKG ST depress, T wave inversion ST elevation

Cardiac marker Negative Positive

CK, CK-MB, TnI or TnT
Prolong chest < 20 minutes > 20 minutes
pain 4
PATHOPHYSIOLOGY

1. coronary
atherosclerotic plaque
2. thrombosis
atherosclerotic plaque
3.
(coagulation cascade)
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PATHOPHYSIOLOGY

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: , , ( 65
)

: , ,
(LDL , HDL ), , ,
,

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ACC/AHA Guidelines
ACS Treatment

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 1, 2
MI
1. TIMI Risk Score
(Thrombolysis in Myocardial Infarction Risk Score)

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http://www.timi.org/index.php?page=calculators
2. GRACE Risk Scores (Global Registry of Acute Coronary Events)

6 , 1 , 3
http://www.gracescore.org/WebSite/default.aspx?ReturnUrl=%2f

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 1, 2

1.

2.

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 :
1. Supplemental oxygen O2 saturation < 90%,
2. SL nitrates / IV nitroglycerin
SL nitrates 0.3 0.4 mg 5 min
3

IV nitroglycerin
nitrate phosphodiesterase inhibitor
sildenafil vardenafil 24
tadalafil 48
3. Analgesic therapy

IV morphine 2-8 mg 5-15 min prn
NSAIDs NSAIDs ( aspirin)
MACE (major adverse cardiac events)
aspirin MI
aspirin EC formula LD 162-325 mg (
aspirin clopidogrel LD 300 600 mg 11
 :
4. Oral beta-blockers
oral -blockers ( ,
cardiogenic shock)
24
IV -blocker shock
NSTE-ACS, stabilized HF, and reduced systolic function
SR metoprolol succinate, carvedilol, bisoprolol
5. CCBs
recurrent ischemia -blocker
nondihydropyridine calcium antagonists verapamil diltiazem
(coronary artery spasm)
long-acting CCBs nitrates
-blocker immediate-release nifedipine
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 :
6. Cholesterol management
fasting lipid 24 h
high-intensity statin
statins
high dose atorvastatin 80 mg/day
7. Anticoagulants
IV unfractionated heparin (UFH)
Enoxaparin
Bivalirudin
Fondaparinux

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 1
NSTE-ACS 1

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 NSTE-ACS: Definite or Likely
Ischemic-guided strategy Early invasive strategy
ischemic-guided strategy
Initiate DAPT and GP IIb/IIIa
anticoagulant eptifibatide, tirofiban
therapy
1. Aspirin PCI with stenting CABG
2. P2Y12 inhibitor Initiate/continue antiplatelet and Initiate/ continue ASA therapy and
- clopidogrel or anticoagulant discontinue P2Y12 and/or GPI therapy
therapy
- ticagrelor 1. ASA 1. aspirin
3. Anticoagulant: 2. P2Y12 receptor antagonists 2. elective CABG
- Enoxaparin or 3. GP IIb/IIIa clopidogrel/ticagrelor 5
- UFH or 4 Anticoagulant: prasugrel 7 CABG
- Fondaparinux - UFH IV or 3. urgent CABG
- Bivalirudin or clopidogrel/ticagrelor 24 h
- Enoxaparin or CABG
- Fondaparinux or 4. eptifibatide/tirofiban
CABG 2-4 h abciximab
12 h
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 1 NSTE-ACS1

Late Hospital/Posthospital Care

1. ASA 81-325 mg/day
(Prefer aspirin 81 mg/day ticagrelor)
2. Continue clopidogrel 75 mg/day ticagrelor 90 mg BID
ASA 12 mo ( ticagrelor clopidogrel)
3. PCI with stent: continue clopidogrel or ticagrelor or
prasugrel 12 mo

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 2
REPERFUSION THERAPY
FOR
PATIENTS WITH STEMI 2

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 STEMI reperfusion
PCI PCI
Door in-Door out (DIDO) 30
FMC device > 120 min
FMC to primary
,
PCI 120 min fibrinolytic agent
PCI
refer for primary PCI 30
(cath lab)

FMC to
fibrinolytic therapy
primary PCI 90 min
Urgent transfer
invasive
Diagnostic angiogram PCI
strategy
failed reperfusion
angiography
re-occlusion & revascularization
PCI CABG
3-24 h

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LATE HOSPITAL/POSTHOSPITAL
CARE STEMI
1. ASA 81-325 mg/day
( ticagrelor aspirin 81 mg/day)
2. BMS DAPT 30 d - 1 y
DES DAPT 1 y
3. fibrinolytic agent DAPT (aspirin + clopidogrel)
14 d 1 y
4. PCI after fibrinolytic agent BMS DES
DAPT (aspirin + clopidogrel or prasugrel) 12 mo

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1. The American College of Cardiology Foundation and the American Heart Association.
2014 AHA/ACC Guideline for the Management of Patients With NonST-Elevation Acute
Coronary Syndromes. JACC. 2014;64(24):139-228.
2. The American College of Cardiology Foundation and the American Heart Association.
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. JACC.
2013;61(4):78-140.
3. .
2557. 2. : ; 2557.

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