ACUTE CORONARY SYNDROME :

PATHOPHYSIOLOGY AND MANAGEMENT

Surya Dharma, MD, FIHA
Department ! Car"#$%y an" &a'(u$ar Me"#(#ne
Fa(u$ty ! Me"#(#ne Un#)er'#ty ! In"ne'#a
Nat#na$ Car"#)a'(u$ar Center Harapan *#ta

Death rates for major CV diseases Death rates for major CV diseases
have decreased in USA have decreased in USA

Sex-adjusted mortality from CHD Sex-adjusted mortality from CHD

Risk Factors
Risk Factors

Atheroenesis
Atheroenesis
Fi!rous "la#ue Formation
Fi!rous "la#ue Formation

Atheroenesis
Atheroenesis
Unsta!le "la#ue
Unsta!le "la#ue

Plaque Evolution
$ntramural %hrom!us
$ntramural %hrom!us
"arietal %hrom!us
"arietal %hrom!us
$ntraluminal %hrom!us
$ntraluminal %hrom!us
&ro'in "la#ue
&ro'in "la#ue
Ru(tured "la#ue
Ru(tured "la#ue

Angina Pectoris
)
*
Su((ly
)
*
Demand
Heart Rate
S+"
,all Stress
Coronary flo'
H!
)
*

Anina "ectoris
Anina "ectoris

Clinical Presentation
Clinical Presentation

Acute Coronary Syndromes
Acute Coronary Syndromes
Unstable angina and evolving
myocardial infarction are
different clinical presentations
resulting from a common
underlying pathophysiological
mechanism

Ru(tured Ru(tured
Fi!rous Ca( Fi!rous Ca(
Su(erficial Su(erficial
-rosion -rosion
.odified from /i!!y " .odified from /i!!y "
Circ 01234567*110 Circ 01234567*110
Acute Coronary
Acute Coronary
Syndrome
Syndrome

8o S% -levation
8o S% -levation
S% -levation
S% -levation
Acute Coronary Syndrome
Acute Coronary Syndrome
Unsta!le Anina Unsta!le Anina 89.$ 89.$
9' .$ 9' .$
8S%-.$
8S%-.$
Myocardial Infarction Myocardial Infarction
Da)#e' M+ Da)#e' M+
Heart ,-:-./, 0111 Heart ,-:-./, 0111
$schemic Discomfort
$schemic Discomfort
Presentation Presentation
Working Dx Working Dx
ECG ECG
Biochem. Biochem.
Marker Marker
Final Dx Final Dx
Hamm /ancet 46:306447*110 Hamm /ancet 46:306447*110

CAUS-S )F UA;8S%-.$
%hrom!osis
%hrom!osis
.echanical
)!struction
.echanical
)!struction
Dynamic
)!struction
Dynamic
)!struction
$nflammation;
$nfection
$nflammation;
$nfection
.V)
*
.V)
*
+raun'ald7 Circulation
<:3**0<7 0<<:
=
=

UA;8S%-.$
%HR-- "R$8C$"A/ "R-S-8%A%$)8S
Rest Anina> Anina occurrin at rest and
(roloned7 usually ? *1 minutes
8e'-onset Anina 8e'-onset anina of at least CCS
Class $$$ severity
$ncreasin Anina "reviously dianosed anina that
has !ecome distinctly more fre#uent7
loner in duration7 or lo'er in
threshold @i=e=7 increased !y ? 0 CCSA
class to at least CCS Class $$$ severity=
+raun'ald
Circulation :13201B 0<:<
2 Pt' 3#th NSTEMI u'ua$$y pre'ent 3#th an%#na at re't4

Chan%e' #n F(u' n Heart
Fa#$ure
TROPONIN I LE&ELS PREDICT THE RIS*
OF MORTALITY IN UA5NSTEMI
0=1
0=C
4=2
4=C
5=1
C=6
1
0
2
5
:
1 to D1=2 1=2 to D0=1 0=1 to D*=1 *=1 to D6=1 6=1 to D<=1 ?<=1
:40 0C2 02: 042 5C 61
Cardiac %ro(onin $ @n;mlA
Risk Ratio 0=1 0=: 4=6 4=< 5=* C=:
Antman
8 -nl E .ed= 4463042*7 0<<5
.
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RECOMMENDATION
Class $
0= "atients 'ith sus(ected ACS 'ith chest
discomfort at rest for ?*1 min7 hemodynamic
insta!ility7 or recent synco(e or (resynco(e
should !e referred immediately to an -D or a
s(ecialiGed chest (ain unit=
)ther (atients 'ith a sus(ected ACS may !e
seen initially in an -D7 a chest (ain unit7 or
an out(atient facility=
UA;8S%-.$ <;11

DEATH OR MI AT -1 DAYS
"
e
r
c
e
n
t

o
f

"
a
t
i
e
n
t
s
01=<
0=:
<
2=:
01=0
4=5
02=0
4=<
01=*
6=<
05=C
00=5
1
*
5
01
02
0:
-"$C CA"%UR- -"$/)& -"$S%-8% "R$S.-"/US "URSU$%
"lace!o &" $$!-$$$a $nhi!itor

DEATH, MI OR URGENT
RE&ASC4 6 -1 DAYS
"
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r
c
e
n
t

o
f

"
a
t
i
e
n
t
s
0*=:
2=:
06=<
00=4
0*=*
2=<
02=:
2=6
00=6
01=4
01=6
:
1
2
:
0*
05
-"$C CA"%UR- -"$/)& -"$S%-8% $."AC% $$ R-S%)R-
"lace!o &" $$!-$$$a $nhi!itor

ED MANAGEMENT OF
UA5NSTEMI
8o recurrent (ainB
8e follo'-u( studies
8ondianostic -C&
8ormal serum cardiac markers
)!serve
Follo'-u( at 2-: hours3 -C&7 cardiac markers
8e3 nonischemic
discomfortBlo'-risk U!"#$EMI
H-S
8)
S% and;or % 'ave chanes
)noin (ain
I cardiac markers
Hemodynamic a!normalities
Recurrent ischemic (ain or
I UA;8S%-.$ follo'-u( studies
Diagnosis of U!"#$EMI
confirmed
AD.$% % U!"#$EMI confirmed
)ut(atient follo'-u(
-valuate
for
Re(erfusion
S% J

Stress study to (rovoke

ischemia (rior to dischare
or as out(atient

UA5NSTEMI
HOSPITAL MANAGEMENT
.onitorin @rhythm and ischemiaA
!locker
8itrate
He(arin
&" $$!;$$$a inhi!itor @JA
0*-2: hour
aniora(hy
"atient sta!iliGes
$mmediate
aniora(hy
-valuate /V function
-F?=21
Stress %est
8ot lo' risk /o' risk
.edical Rx
Recurrent
sym(toms;ischemia
Heart failure
Serious arrhythmia
-FD=21
-arly invasive stratey
-arly conservative stratey

TIMI R#'7 S(re Fr UA5NSTEMI
TIMI R#'7 S(re Fr UA5NSTEMI
D
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.
$
;
U
r

R
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a
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c

@
F
A
D
;
.
$
;
U
r

R
e
v
a
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c

@
F
A
8um!er of Risk Factors 8um!er of Risk Factors
UFH UFH
-8)K -8)K
Antman et al Antman et al &M '() &M '() 3 :467 *111 3 :467 *111
8
Ae Ae ? ? 56 y 56 y
8
? ? 4 CAD Risk Factors 4 CAD Risk Factors
8
"rior Stenosis ? 61 F "rior Stenosis ? 61 F
8
S% deviation S% deviation
8
? ? * Aninal events * Aninal events D D *2 h *2 h
8
ASA in last C days ASA in last C days
8
-lev Cardiac .arkers -lev Cardiac .arkers

EARLY IN&ASI&E STRATEGY
Class $
0= Any of the follo'in hih-risk indicators3
a= Recurrent anina;ischemia at rest or 'ith lo'-
level activities des(ite intensive anti-ischemic
thera(y
!= Recurrent anina;ischemia 'ith CHF sym(toms7
S
4
7 (ulmonary edema7 increasin rales7 or ne' or
'orsenin .R
c= Hih-risk findins on noninvasive stress testin
d= De(ressed /V systolic function @e==7 -FD1=21 on
noninvasive studyA
e= Hemodynamic insta!ility

EARLY IN&ASI&E STRATEGY 9(nt:";
Class $
f= Sustained ventricular tachycardia
= "C$ 'ithin 5 months
h= "rior CA+&
*= $n the a*sence of these findins7 either an
early conservative or an early invasive
stratey in hos(italiGed (atients 'ithout
contraindication for revasculariGation=
Class $$a
0= An early invasive stratey in (ts 'ith re(eated
(resentation for ACS des(ite thera(y and
'ithout evidence for onoin ischemia or
hih risk=

LM<H IN UNSTA=LE ANGINA
EFFECT ON TRIPLE ENDPOINT2


Day
FR$SC 5
@dalte(arinB n L 072:*
FRAK$S 02
@nadro(arinB n L *746C
-SS-8C- 02
@enoxa(arinB n L 470C0A
%$.$ 00+ 02
@enoxa(arinB n L 47<01A
1=C6 0 0=6
/.,H !etter UFH !etter
> %ri(le end(oint3 death7 .$7 recurrent ischemia I urent revasculariGation
@" L 1=1*<A
@" L 1=14*A

ANTI > ISCHEMIC R?
Class $
0= +ed rest 'ith continuous -C& monitorin in (ts
'ith onoin rest (ain=
*= 8%&7 su!linual ta!let or s(ray7 follo'ed !y $V
administration for onoin chest (ain=
4= Su((lemental )
*
for (ts 'ith hy(oxemia7 cyanosis
or res(iratory distressB finer (ulse oximetry or
arterial !lood as determination to confirm
Sa)
*
?<1F=
2= .or(hine sulfate $V 'hen sym(toms are not
immediately relieved 'ith 8%& or 'hen acute
(ulmonary conestion and;or severe aitation is
(resent=

ANTI > ISCHEMIC R? 9(nt:";
Class $
6= A -!locker 'ith the first dose administered $V if
there
is onoin chest (ain7 follo'ed !y oral
administration=
5= A nondihydro(yridine Ca
*I
!locker @e== vera(amil
or diltiaGemA as initial thera(y in (ts 'ith
continuin or fre#uently recurrin ischemia 'hen
-!locker is contraindicated=
C= An AC-$ 'hen hy(ertension (ersists des(ite
treatment 'ith 8%& and a -!locker in (ts 'ith /V
systolic dysfunction or conestive heart failure
and in ACS (atients 'ith dia!etes=

ANTI > ISCHEMIC R?
Class $$a
0= )ral lon-actin Ca
*I
!locker for recurrent ischemia
'hen
-!locker and nitrate fully used=
*= AC-$ for all (ost-ACS (atients=
4= $ntra-aortic !alloon (um( counter(ulsation for severe
ischemia that is continuin or recurs fre#uently
des(ite intensive medical thera(y or for
hemodynamic insta!ility
in (ts !efore or after coronary aniora(hy=
Class $$!
0= -xtended-release form of nondihydro(yridine Ca
*I

!locker instead of a -!locker=
*= $mmediate-release dihydro(yridine Ca
*I
!locker in the
(resence of a -!locker=

ANTIPLATELET AND
ANTICOAGULATION R?
P-value
"atients 'ith
event @FA
8 F Death or .$
Risk ratio @<6F C$A
%rials
Active "lace!o
ASA vs (lace!o *22: 5=2 0*=6 1=1116
UFH I ASA vs ASA <<< *=5 6=6 1=10:

/.,H I ASA
vs ASA *5*< *=1 6=4 1=1116
All &" $$!;$$$a I UFH I ASA
vs UFH I ASA 0C122 6=0 5=* 1=11**
Active Treatment Inferior Active Treatment Superior

ANTIPLATELET R?
Class $
0= Administer ASA as soon as (ossi!le after
(resentation and continue indefinitely=
*= A thieno(yridine @clo(idorel or ticlo(idineA in
(ts una!le to take ASA=
4= Add $V UFH or su!cutaneous /.,H to
anti(latelet thera(y 'ith ASA7 clo(idorel7 or
ticlo(idine=
2= Add (latelet &" $$!;$$$a rece(tor antaonist in
(ts 'ith continuin ischemia or 'ith other
hih-risk features and in (ts in 'hom early
"C$ is (lanned=

RE&ASCULARI@ATION
STRATEGY IN UA5NSTEMI
Cardiac Cardiac
CatheteriGation CatheteriGation
.edical %hera(y .edical %hera(y
"C$ or CA+& "C$ or CA+&
0 or * VD 0 or * VD
"C$ or CA+& "C$ or CA+&
8o 8o
CA+& CA+&
/V Dysfunction /V Dysfunction
or Dia!etes or Dia!etes
CA+& CA+&
Hes Hes
Dischare from Dischare from
"rotocol "rotocol
8o 8o
4 VD or * VD 'ith 4 VD or * VD 'ith
(roximal /AD (roximal /AD
Coronary Artery Coronary Artery
Disease Disease
Hes Hes
/eft .ain Disease /eft .ain Disease
8o 8o
8o 8o

MEDICATIONS AT HOSPITAL
DISCHARGE
0= As(irin C6 to 4*6 m;d
*= Clo(idorel C6 m;#d for (atients 'ith
contraindication to ASA
4= -+locker
2= /i(id-lo'erin aent and diet in (atients 'ith /D/
cholesterol ?041 m;d/
6= /i(id-lo'erin aent if /D/ cholesterol level after
diet is ? 011 m;d/
5= AC-$ for (atients 'ith CHF7 /V dysfunction
@-FD1=21A hy(ertension7 or dia!etes
Class $

0= Smokin cessation and achievement or maintenance of
o(timal 'eiht7 daily exercise7 and diet=
*= H.&-CoA reductase inhi!itor for /D/ cholesterol ?041
m;d/=
4= /i(id-lo'erin aent if /D/ cholesterol after diet is ? 011
m;d/=
2= Hy(ertension control to a +" D 041;:6 mm H=
6= %iht control of hy(erlycemia in dia!etics=
5= Consider referral of smokers to a smokin cessation
(roram=
INSTRUCTIONS AT HOSPITAL
DISCHARGE RIS* FACTOR
MODIFICATION
Class $
UA;8S%-.$ <;11

POST>HOSPITAL DISCHARGE CARE
A A'p#r#n an" Ant#(a%u$ant'
+ +eta A$(7er' an" +$" Pre''ure
C Ch$e'ter$ an" C#%arette'
D D#et an" D#aAete'
- -"u(at#n an" -?er(#'e
UA;8S%-.$ <;11

Ebers Papyrus

B><a)e 9ST>'e%ment e$e)at#n;
My(ar"#a$ In!ar(t#n
8
O(($u'#n ! (rnary artery Ay thrmAu'
8
Pr%re''#n ! ne(r'#' 3#th t#me
8
D#a%n'#'
C
C$#n#(a$ 'ymptm'
C
E$e(tr(ar"#%ram
C
Car"#a( enDyme'

Extension / Ischemia Extension / Ischemia
Cmp$#(at#n' ! A(ute MI
Acute MI Acute MI
Arrhythmia Arrhythmia
Heart Failure Heart Failure
Expansion / Aneurysm Expansion / Aneurysm
RV Infarct RV Infarct
Pericarditis Pericarditis
Mechanical Mechanical Mural Thrombus Mural Thrombus

S%--levation
ASA +eta
+locker
?0*h
"ersistent
Sym(toms
%hrom!olytic
thera(y
contraindicated
-lii!le for
throm!olytic
thera(y
8o Hes
)ther medical
thera(y3 AC-
inhi!itor J 8itrates
Consider
Re(erfusion
%hera(y
D0*h
%hrom!olytic
thera(y From
loaded t-"A or SM
"rimary "%CA
or CA+&
8ot a
Candidate for
re(erfusion
thera(i
/EEE Up"ate" ACC5AHA AMI Gu#"e$#ne'
9<eA &er'#n:Mar(h 00, 0110;

+dds ratio , Cls
-C& Fi!rinolytic !etter Control !etter
+++
S% elev7 anterior
S% elev7 interior
S% elev7 other
S% de(ression
)ther a!normality
8ormal
Hours from onset
1 - 0
* - 4
2 - 5
C - 0*
04 - *2
Ae @ yearsA
D 66
66 - 52
56 - C2
C6
0,5 1,0 1,5
"ro(ortional effects of fi!rinolityc thera(y on mortality in the Fi!rinolityc %hera(y
%rialistsN Colla!orative &rou( meta-analysis

+dds ratio , Cls
Gender Fibrinolytic better Control
better
Male
Female
Systolic BP (mm Hg)
< 100
100 1!0
150 1"!
# 1"5
Heart rate
< $0
$0 %%
# 100
Prior M&
'es
(o
)iabetes
'es
(o
*ll +atients
176 071 076
D?
0:F SD * odds reduction
*" D 1=11110
"ro(ortional effects of fi!rinolityc thera(y on mortality in the Fi!rinolityc
%hera(y%rialists Colla!orative &rou( meta-analysis

Why are the first - ho.rs
im/ortant 0
8
$hrom*olytic thera/y 1 $IMI grade III flo2

$nfarct siGe

Healin

/V Function

.or!idity

Survival - early @46 dA O late @2 yA

Thrombus Formation

Uncontrolled HTN (BP > 180/110) on

Uncontrolled HTN (BP > 180/110) on
presentation
presentation

History prior CVA beyond 1 yr

History prior CVA beyond 1 yr

Anticoagulant Rx with INR > 2-3; bleeding

Anticoagulant Rx with INR > 2-3; bleeding
diathesis
diathesis

Recent trauma (within 2-4 wks)

Recent trauma (within 2-4 wks)

Noncompressible vascular punctures

Noncompressible vascular punctures

Recent internal bleeding (within 2-4 wks)

Recent internal bleeding (within 2-4 wks)

Pregnancy
Pregnancy

Active peptic ulcer

Active peptic ulcer

Prior exposure (5 day - 2 yr) for SK or APSAC

Prior exposure (5 day - 2 yr) for SK or APSAC
ThrmA$y'#' #n A(ute MI
Relative Contraindications

ThrmA$y'#' #n A(ute MI
Absolute Contraindications

Previous hemorrhagic stroke

Previous hemorrhagic stroke

CVA within previous yr

CVA within previous yr

Intracranial neoplasia or AVM

Intracranial neoplasia or AVM

Active internal bleeding (not

Active internal bleeding (not
menses)
menses)

Suspected aortic dissection

Suspected aortic dissection

My(ar"#a$ Reper!u'#n
The Original Paradigm
Re-establish
Re-establish
Infarct Vessel
Infarct Vessel
Patency
Patency
Limit Infarct
Limit Infarct
Size
Size

Mortality
Mortality

Mortality Trial Angiographic Trial
41,021 Patients 41,021 Patients
30-day Outcome 30-day Outcome
2,431 Patients 2,431 Patients
TIMI 3 fow TIMI 3 fow

SK+SQ
Hep
SK+SQ
Hep
SK+IV
Hep
SK+IV
Hep
Accel.
t-PA
Accel.
t-PA
t-PA+
SK
t-PA+
SK
0 0
10 10
20 20
30 30
40 40
50 50
60 60
29 29
33 33
54 54
38 38
% of Patients % of Patients
SK+SQ
Hep
SK+SQ
Hep
SK+IV
Hep
SK+IV
Hep
Accel.
t-PA
Accel.
t-PA
t-PA+
SK
t-PA+
SK
0 0
10 10
20 20
30 30
40 40
50 50
60 60
29 29
33 33
54 54
38 38
% of Patients % of Patients
SK (IV)
SK (SubQ)
t-PA + SK
Accel. t-PA
8 8
6 6
4 4
2 2
0 0
0 0 2 2 4 4 6 6 8 8 10 10 12 12 14 14 16 16 18 18 20 20 22 22 24 24 26 26 28 28 30 30
F .ortality F .ortality
Days from RandomiGation Days from RandomiGation
GUSTO

Streptokinase Streptokinase GISSI GISSI 495/4865 495/4865 623/4878 623/4878 23% 6
ISAM ISAM 50/842 50/842 61/868 61/868 16% 18
ISIS-2 ISIS-2 471/5350 471/5350 648/5360 648/5360 30% 5
APSAC APSAC AIMS AIMS 32/502 32/502 61/502 61/502 50% 16
t-PA t-PA ASSET ASSET 182/2516 182/2516 245/2495 245/2495 28% 9
Overall: any thrombolytic Overall: any thrombolytic 1230/14075 1230/14075 1623/14103 1623/14103 27% 3
Patients < 6 hours Patients < 6 hours 8.7% 8.7% 11.6% 11.6%
Odds Odds
Agent Agent Trial Name Trial Name Deaths/Patients Deaths/Patients Odds Ratio Odds RatioReduction Reduction
Active Active Control Control (& 95% Cl) (& 95% Cl) ( s.d.) ( s.d.)
Lytic better Lytic better Lytic worse Lytic worse
0.0 0.0 0.5 0.5 1.0 1.0 1.5 1.5
Meta-Analysis
ThrmA$yt#(: P$a(eA>Cntr$

PTCA vs Lysis
11 RCTs (2725 patients) 11 RCTs (2725 patients) PCAT Collaborative Group, 2001 PCAT Collaborative Group, 2001
A(ute STEMI
20
20
15
15
10
10
5
5
0
0
0
0
2
2
4
4
6
6
Death + MI (%)
p<0.0001
Months from Randomization
Months from Randomization
Thrombolysis
PTCA
Death + MI (%)
20
20
15
15
10
10
5
5
0
0
0
0
2
2
4
4
6
6
Death + MI (%)
p<0.0001
Months from Randomization
Months from Randomization
Thrombolysis
PTCA
Death + MI (%)

Pr#mary An%#p$a'ty #n A(ute MI
Pooled Analysis of Randomized Trials
%rial %rial
"%CA "%CA
Lysis
Lysis
8 8
*=1F *=1F Pijlstra Pijlstra C=2F C=2F 4:< 4:<









)dds Ratio O <6F C$ )dds Ratio O <6F C$
14/ 14/ / / /1 /1
/ysis +etter /ysis +etter PTCA PTCA+etter +etter
#3 #3
$rials $rials
<=4F <=4F &rinfeld &rinfeld 01=4F 01=4F 00* 00*
5=6F 5=6F De,ood De,ood 2=6F 2=6F <1 <1
*=5F *=5F "A.$ "A.$ 5=6F 5=6F 4<6 4<6
2=4F 2=4F &i!!ons &i!!ons 4=5F 4=5F 014 014
1=1F 1=1F Ri!ichini Ri!ichini *=2F *=2F :4 :4
4=*F 4=*F -liGaa -liGaa 01=5F 01=5F 0:< 0:<
6=CF 6=CF &US%) $$ &US%) $$ C=1F C=1F 004: 004:
2=2F 2=2F "ooled "ooled 5=6F 5=6F *6<< *6<<
5=1F 5=1F Ri!eiro Ri!eiro *=1F *=1F 011 011
t1P t1P
$rials $rials
ccel ccel
t1P t1P
$rials $rials
Topol, Van de Werf. Textbook Cardiovasc Med 1998;p416 Topol, Van de Werf. Textbook Cardiovasc Med 1998;p416
Pooled 32% RR


Treatment arm' 9reper!u'#n 'trate%#e';
Ln% "#'tan(e tran'prt !r pr#mary PCI )er'u' #mme"#ate
!#Ar#n$y'#' #n AMI
Grup !#Ar#n$y'#' Grup PCI
F#Ar#n$y'#' #n the !#r't h'p#ta$ Tran'prtat#n !r pr#mary PCI
Imme"#ate !#Ar#n$y'#' Imme"#ate tran'prt
A'p#r#n F11 m% #) A'p#r#n F11 m% #)
Strept7#na'e /4F m#$ U5 GF m#n Hepar#n 011 U5 7% =<>PCI
C$p#"%re$ HF m% !r / mnth C$p#"%re$ HF m% !r / mnth
Fra?#par#ne 14, m$ '( !r - "ay' Fra?#par#ne 14, m$ '( !r - "ay'
PRAGUE>0 Stu"y %rup #n)e't#%atr'4 Eur Heart J 011-I *2: EG>/1G


TIMI !$3 Ae!re an" a!ter PCI
PRAGUE>0 Stu"y %rup #n)e't#%atr'4 Eur Heart J 011-I *2: EG>/1G

PRAGUE>0 Stu"y %rup #n)e't#%atr'4 Eur Heart J 011-I *2: EG>/1G



Current: =RA&E
On%#n%: FINESSE
Up(m#n%: ASSENTG>PCI
NumAer ! pat#ent'
P
O
<
E
R
Favora!le Unfavora!le
Lar%e RCT' !r pharma(>#n)a'#)e 'trate%y

The Mana%ement ! Pat#ent'
3#th A(ute My(ar"#a$
In!ar(t#n
H'p#ta$ Mana%ement

Samp$e A"m#tt#n% Or"er'
Condition Ser#u'
$V NS r D
F
< t 7eep )e#n pen
Vital sins J /50 hr unt#$ 'taA$e, the J G hr' an" p4r4n4
Nt#!y #! HR K.1 r L//1I =P KE1 r L/F1I
RR K, r L004 Pu$'e ?#metry ? 0G hr'
Activity=e" re't 3#th Ae"'#"e (mm"e an" pr%re'' a'
t$erate" a!ter appr?#mate$y /0 hr'
Diet NPO unt#$ pa#n !ree, then ($ear $#Ju#"'4 Pr%re'' t a heart>
hea$thy "#et
.edications Na'a$ O
0
0L5m#n ? - hr'
Enter#(>(ate" a'p#r#n "a#$y 9/.F m%;
St$ '!tener "a#$y
=eta>a"renre(eptr A$(7er' M
Cn'#"er nee" !r ana$%e'#(', n#tr%$y(er#n, an?#$yt#(

Heart>Hea$thy D#et
8
(mp$e? (arAhy"rate' N F1>FFO ! 7#$(a$r#e'
8
un'aturate" !at' 9 -1O ! 7#$(a$r#e';
8
!"' h#%h #n:
C
pta''#um 9e%4 !ru#t', )e%etaA$e', 3h$e %ra#n', "a#ry
pr"u(t';
C
ma%ne'#um 9 e%4 %reen $ea!y )e%etaA$e', 3h$e
%ra#n', Aean', 'ea!";
C
!#Aer 9e%4 !re'h !ru#t' an" )e%etaA$e', 3h$e>%ra#n
Area"', (erea$';

Chronoloy of
Atherosclerotic Vascular Disease "rocess
Develo(ment of
atherosclerosis and
vulnera!le (la#ue Acute Coronary Syndrome Secondary "revention
$schemic
Heart Disease
Cere!rovascular
Disease
"eri(heral Vascular
Disease
.odified from /i!!y "
Circ 01234567*110
Concl.sion 4

Sym(toms suestive of ACS Sym(toms suestive of ACS
Definite Definite
ACS ACS
"ossi!le "ossi!le
ACS ACS
ACS "rotocol ACS "rotocol
Chronic Chronic
Sta!le Sta!le
Anina Anina
8on 8on
Cardiac Cardiac
Dianosis Dianosis
.edical
Rx
As "er
)ther Dx
Assess 0* lead -C& Assess 0* lead -C&
Goal 5 67 min Goal 5 67 min
8a/id $riage 8a/id $riage
+*tain Biomarkers +*tain Biomarkers
ASA ASA
Ant#thrmA#n Ant#thrmA#n
=eta =$(7er =eta =$(7er

Definite ACS Definite ACS
"ossi!le ACS "ossi!le ACS
8o S% elev= 8o S% elev=
? 0*h ? 0*h
D D 0*h 0*h
/ytic /ytic
elii!le elii!le
/ytic /ytic
inelii!le inelii!le
8ot a re(erfusion 8ot a re(erfusion
candidate candidate
Sym(toms Suestive of ACS Sym(toms Suestive of ACS
9ytic 9ytic
@D-8 D 41 mA @D-8 D 41 mA
PCI: PCI:
@D-+ D <1A @D-+ D <1A
Consider3 Consider3
&" $$!;$$$a I stent &" $$!;$$$a I stent
Medical 8x Medical 8x
@AC-$A @AC-$A
Consider Consider
8e/erf.sion 8e/erf.sion
for for
#ym/toms #ym/toms
S% elev= S% elev=
:#killed +/er.!$eam 8a/idly ;aila*le :#killed +/er.!$eam 8a/idly ;aila*le

Definite ACS Definite ACS "ossi!le ACS "ossi!le ACS
S% elev= S% elev= 8o S% elev= 8o S% elev=
8on dx -C& 8on dx -C&
8e= card= markers 8e= card= markers
S%-%' chanes S%-%' chanes
)noin (ain )noin (ain
"ositive card markers "ositive card markers
Hemodynamic a!nl= Hemodynamic a!nl=
)!serve )!serve
f;u studies f;u studies
-valuate for -valuate for
re(erfusion re(erfusion
8e 8e
Stress Stress
Dx of ACS confirmed Dx of ACS confirmed
Admit to hos(ital Admit to hos(ital
Acute ischemia (ath'ay Acute ischemia (ath'ay
8e 8e "os "os
)ut(t f;u )ut(t f;u
"os "os
Sym(toms Suestive of ACS Sym(toms Suestive of ACS

T H A N K Y O U