Management of

Acute Coronary Syndrome

Erwinanto Department of Cardiology and Vascular Medicine Division of Cardiovascular, Department of Internal Medicine Padjadjaran University School of Medicine/Hasan Sadikin Hospital Bandung

The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance
Myocardial Ischemia

CAD

plaque
Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

STENOSIS SEVERITY AND RISK OF MI

80
60

68

% MI

40

18

14

20
0

50%

50%-70%

70%

% Stenosis
Falk E et al. Circulation 1995;92:657-671

The cardiovascular continuum of events

Coronary Thrombosis Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

ACS
Coronary Thrombosis Myocardial Ischemia

CAD

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

The cardiovascular continuum of events

ACS
Coronary Thrombosis Arrhythmia and Loss of Muscle

Myocardial Ischemia

Remodeling

CAD

Ventricular Dilatation Congestive Heart Failure End-stage Heart Disease

Adapted from Dzau et al. Am Heart J. 1991;121:1244-1263

Atherosclerosis

Risk Factors ( DYSLIPIDEMIA , BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

Coronary Plaque Stable UA/NSTEMI STEMI thrombosis rupture angina

Chronic plaque change: Stable angina Acute plaque change : Unstable angina Acute MI

Unstable angina
Acute MI = Acute coronary syndrome

DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of ischemia

ISCHEMIC CHEST PAIN

TYPICAL ANGINA

EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT 1. CHEST DISCOMFORT 2. LOCATION

2. LOCATION
3. INDIGESTION 4. UNEXPLAINED WEAKNESS 5. DIAPORESIS 6. SHORTNESS OF BREATH

3. RADIATION
4. UNLIKELINESS

Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min)

Vital sign Oxygen saturation Obtain IV access Obtain ECG 12 lead Brief history and physical exam Check contraindication for fibrinolytic Initial serum cardiac markers Initial electrolyte and coagulation

Immediate ED general treatment

O2 at 4 L/min (maintain O2 sat 90%) Aspirin 160-325 mg Nitroglycerin SL, spray, or IV Morphine IV 2-4 mg repeated every 5-10 minutes (if pain not relieved with nitroglycerine)

Memory: MONA greets all patients

study
Portable chest x-ray ( 30 minutes)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

ST-segment elevation is characterized by:

ST-segment elevation 1 mm in 2 or more contiguous precordial leads or in 2 or more adjacent limb leads

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-91

ST-segment elevation

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

ST-depression or dynamic T-wave inversion strongly suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Ischemic ST-segment depression 0.5 mm or

dynamic T-wave inversion with pain or discomfort is classified as high risk. Nonpersistent or transient

ST-segment elevation 0.5 mm for 20 minutes is

also included in this category.

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

ST-segment depression

T-wave inversion

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI) ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI) Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Nondiagnostic changes in ST-segment ot T waves is characterized by: ST-segment deviation of 0.5 mm or T-wave inversion of 0.2 mv.

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI)
Start adjunctive treatment

ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI)

Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

ADJUNCTIVE TREATMENT (Do not delay reperfusion)

1. Beta-adrenergic receptor blocker 2. Clopidogrel 3. Heparin (UFH or LMWH)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 hours of onset - Statin 2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors Nitroglycerin IV -Adrenoreceptor blockers IV Clopidogrel

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hrs Admit to monitored bed Assess risk status

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves Develops high or intermediate risk criteria or troponin-positive Monitored bed in ED Develops high or intermediate risk criteria or troponin-positive

Start adjunctive treatment 12 hrs Admit to monitored bed Assess risk status

No evidence of ischemia and MI: discharge with follow-up

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90

HIGH-RISK PATIENT

1. Refractory chest pain 2. Recurrent/persistent ST deviation 3. Ventricular tachycardia 4. Hemodynamic instability 5. Sign of pump failure 6. Shock within 48 hours

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90