ACS Management : Clinical

Practice for Primary Care

Physician

1
 Acute Coronary Syndrome

Acute thrombosis induced by a ruptured or eroded

atherosclerotic coronary plaque, with or without
concomitant vasoconstriction, causing a sudden and
critical reduction in blood flow

2 Hamm CW et al. EurHeart J 2011;32:2999 3054

Spectrum ACS
 GRACE REGISTRY

STEMI Higher mortality 6

months after
NSTEMI
discharge in
NSTEMI vs STEMI
UA

NSTEMI

STEMI

UA

Fox KAA et al. BMJ 2006;333:1091-1094

 ACS Management

5
 Chest Pain Likelihood ACS

Clinical Presentation

Past Medical History

Differential Diagnosis
6
 Likelihood That Signs and Symptoms Indicate an
ACS Secondary to CAD
High likelihood Intermediate likelihood Low likelihood
Any of the following: Absence of high-likelihood features Absence of high- or intermediate-
Feature
and presence of any of the following likelihood features but may have

Chest or left arm pain or discomfort Chest or left arm pain or discomfort Probable ischemic symptoms in
as chief symptom reproducing as chief symptom absence of any of the intermediate
previously documented angina likelihood characteristics
History
Known history of CAD, including MIAge 70 y Recent cocaine use
Male sex
Diabetes mellitus
Transient MR murmur, hypotension, Extracardiac vascular disease Chest discomfort reproduced by
palpation
Examination diaphoresis, pulmonary edema, or
rales

New, or presumably new, transient Fixed Q waves T-wave flattening or inversion <1 mm
in leads with dominant R waves
ST-segment deviation (1 mm) or T- ST depression of 0.5-1.0 mm or Normal ECG tracing
ECG
wave
inversion in multiple precordial T-wave inversion >1.0 mm
leads
Elevated cardiac TnI, TnT, or CK-MB Normal Normal
Cardiac markers
levels

7 Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938

 Differential diagnoses of ACS in the setting of
acute chest pain
Cardiac Pulmonary Vascular
Myopericarditis Cardiomyopathiesa Pulmonary embolism Symptomatic Aortic dissection
Tachyarrhythmias (Tension)-Pneumothorax Stroke
Acute heart failure Pleuritis
Hypertensive emergencies Bronchitis, pneumonia
Aortic valve stenosis
Tako-Tsubo cardiomyopathy
Coronary spasm
Cardiac trauma

GI Orthopedic Other
Peptic Ulcer, gastritis Chest trauma Herpes Zoster
Pancreatitis Muscle Injury / inflamation Anaemia
Cholecystitis Cervical spine pathologies
Costochondritis

Smith JN et al. J Am Board Fam Med 2015;28:283293

8
 A 12-lead ECG should be performed immediately

Resting 12-lead ECG is the first-line diagnostic tool

Performed 10 min after first medical contact

Repeated in the case of recurrence of symptoms, and after 69 and

24 h, and before hospital discharge

ST-segment depression or transient elevation and/or T-wave

changes.

If the initial ECG is normal or inconclusive, additional recordings

should be obtained if the patient develops symptoms

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

9
 ECG CHANGES OF INJURY ACUTE MYOCARDIAL INFARCTION

In early stage of AMI , ECG may be

normal or near normal

5- 30 min after onset of

infarction

Changes
< 1 mm - > 10 mm

1-2 hours of onset

symptoms

ST resolves - anterior up to 2 weeks;

posterior > 2 weeks
T wave : many months

Morris F, Brady WJ. BMJ 2012;324;831-834

10
 Cardiac BioMarker

Troponins are more specific and

sensitive than the traditional cardiac
enzymes
The test should be repeated 69 h after
initial assessment if the first
measurement is not conclusive
Do not wait biomarker result in STEMI
patients

Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938; Steg G et al. Eur Heart J. 2012;33:2569-619;
11
Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
 STEMI Management : TIME IS MUSCLE

STEMI Diagnosis

Primary-PCI capable EMS or non primary-

center PCI capable center

Preferably PCI possible < 120 min?

< 60 min
Immediate transfer to
PCI center
Primary-PCI Yes No
Preferably 90 min
( 60 min in early
Preferably
Rescue-PCI presenters)
30 min
Immediately Immediate transfer to
No PCI center
Succesful Immediate
fibrinolysis ? fibrinolysis ?
Yes
Preferably 3-24 h

Coronary angiography Steg G et al. Eur Heart J. 2012;33:2569-619

12
 NSTEACS Case Study

A 75-year-old Asian male

Complaining of sudden onset, sharp, central chest
pain, which began on mild exertion. Pain Score 8/10
Nauseous, vomited once and complained of shortness of breath
The patient had pallor, was clammy and at times was displaying Levines
sign
Chest pain has last for a few days intermittently and had visited his general
practitioner (GP) who advised the patient to take analgesia.
No history of CAD
Not a diabetic or hypertensive patient and did not smoke
Unsure any family history of CAD

Reed A . Journal of Paramedic Practice 2012; 4(8): 448-456

13
 ECG

ECG showed right bundle branch block (RBBB), ST segment depression in II, a
VF, V2, V3, V4, V5 with inverted T-waves also in III and V1

14
Reed A . Journal of Paramedic Practice 2012; 4(8): 448-456
15
 Paramount of NSTEACS Management

It is recommended to base diagnosis

and initial short-term ischaemic and
bleeding risk stratification on a
combination of clinical history,
symptoms, vital signs, other physical
findings, ECG and laboratory results.

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

 Management strategy

Step 1. initial evaluation

Step 2. Diagnosis validation and risk

assessment

Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge

and post-discharge management

Hamm CW et al. Eur Heart J 2011;32:2999 3054

17
 Risk Stratification is important in NSTE-ACS
Management

1 CLINICAL CONDITION

2 3
TIMI SCORE GRACE SCORE

Less accurate in predicting events but recommended as the preferred

its simplicity makes it useful and classification to apply on admission
widely accepted and at discharge in daily clinical
routine practice

Hamm W et al. European Heart Journal 2007; 28:15981660; Hamm CW et al. Eur Heart J 2011;32:2999 3054
 HIGH RISK VERY HIGH RISK

Relevant rise or fall in troponin Haemodynamic instability or

Dynamic ST- or T-wave changes cardiogenic shock
(symptomatic or silent) Recurrent or ongoing chest pain
GRACE Score > 140 refractory to medical treatment
Life-threatening arrhythmias or
Intermediete RISK cardiac arrest
Mechanical complications of MI
Diabetes mellitus Acute heart failure
Renal insufficiency Recurrent dynamic ST-T wave
(eGFR <60 mL/min/1.73 m) changes, particularly with intermittent
LVEF < 40% or congestive HF ST-elevation
Early post infarction angina
Prior PCI
Prior CABG
GRACE risk score 109 - 140

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

Timing of angiography for NSTE-ACS

Immediate invasive
Very High Risk
(< 2hr)

Early invasive
High Risk
(<24hr)

Intermediate Invasive
risk (<72hr)

Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320

 Cath lab or later ?
Benefit of early intervention in high risk patients

Primary endpoint : death, myocardial infarction, or stroke.

21 Mehta, SR et al. N Engl J Med 2009;360:2165-75.

TIMI SCORE

Age 65 years or older? Risk TIMI risk score for developing at

Score least 1 component of the primary
end point through 14 days after
At least 3 risk factors for CAD? randomization.1
0-1 4.7%
Prior coronary stenosis of 50% or more?
2 8.3%

ST-segment deviation on ECG 0.5mm? 3 13.2%

4 19.9%
Use of aspirin in prior 7 days
5 26.2%
At least 2 anginal events in prior 24 hours?
6- 7 40.9%

Elevated serum cardiac markers?

Hamm W et al. European Heart Journal 2007;28:15981660

 GRACE RISK SCORE
Non-ST elevation acute coronary syndrome
Predictor Score Predictor Score Predictor Score
Age, years Systolic Blood Pressure (mmHg) Killip class
< 40 0 < 80 63 I 0
40 - 49 18 80 99 58 II 21
50 - 59 36 100 - 119 47 III 43
60 - 69 55 120 - 139 37 IV 64
70 - 79 73 140 - 159 26 Predictor Score
80 91 160 - 199 11 Cardiac 43
> 200 0 arrest at
admission

Predictor Score Elevated 15

Predictor Score
cardiac Total Score
Heart Rate , beats/min Creatinine (mol/L) / mg/dL markers 152
< 70 0 0 34 / 0 0.38 2 ST Segment 30
70-89 7 deviation
35 70 / 0.39 0.79 5
90-109 13 71 105 / 0.8 1.19 8
110 - 149 23 Risk GRACE In-hospital
106 140 / 1.2 1.58 11
category Risk Score death
150 - 199 36 141 176 / 1.59 1.99 14 (tertile) (%)
> 200 46 177 353 / 2.00 3.99 23 Low 108 <1
354 / 4.00 31
Intermediate 109 - 140 1-3

High > 140 >3

Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 e30
Initial Treatment

Initial Therapeutic Measures Checklist of treatments when an ACS

diagnosis appears likely

Hamm CW et al. Eur Heart J 2011;32:2999 3054

 Oral Antiplatelet Plays Important Role in ACS

1. Bode C and Huber K. European Heart Journal Supplements. 2008: 10 (Supplement A), A13A20
2. Bassand JP et al. European Heart Journal 2007;28:15981660
 ESC/EACTS 2014 Guidelines on myocardial
revascularization1

Recommendation in STEMI Class Level Evidence

A P2Y12 inhibitor is recommended in
addition to ASA and maintained over 12 PLATO
months unless there are I A/B TRITON
contraindications such as excessive CURRENT-OASIS 7
bleeding

It is recommended to give P2Y12 2,3,4,5

inhibitors at the time of first medical I B
contact

1. Kolh P et al. Eur Heart J August 29 2014; DOI:10.1093/eurheart/ehu278 [Epub ahead of print]
2. Bellemain-Appaix A et al. JAMA 2012;308:25072516
3. Zeymer U et al. Clin Res Cardiol 2012;101:305312
4. Koul S et al. Eur Heart J 2011;32:29892997
26 5. Dorler J et al. Eur Heart J 2011;32:29542961
ACS PERKI GUIDELINE - STEMI
ACS PERKI GUIDELINE - NSTEACS
 Summary

Acute coronary syndromes (ACS) are a life-threatening

condition , need aggressive management including
aggressive antiplatelet treatment
Critical Role of Primary Care Physician in ACS : initial
diagnosis, initial treatment , identify which and when
patient to be referred
Risk stratification needed to identify the right timing
NSTEACS patients undergoing invasive strategy
DAPT (aspirin + P2Y12 inhibitors) recommended to be given
at the time of first medical contact

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