Acute Coronary Acute Coronary

Syndrome Syndrome
Rich Derby, Lt Col, USAl Rich Derby, Lt Col, USAl
MGMC lamily Practice Program MGMC lamily Practice Program
-ectives -ectives
Deine & delineate acute coronary syndrome Deine & delineate acute coronary syndrome
Reiew Management Guidelines Reiew Management Guidelines
Unstable Angina , NS1LMI Unstable Angina , NS1LMI
S1LMI S1LMI
Reiew secondary preention initiaties Reiew secondary preention initiaties
Scope of Pro-em Scope of Pro-em
(2004 stats) (2004 stats)
ClD single leading cause o ClD single leading cause o
death in United States death in United States
452,32 deaths in the U.S. in 2004 452,32 deaths in the U.S. in 2004
1,200,000 new & recurrent 1,200,000 new & recurrent
coronary attacks per year coronary attacks per year
38 o those who with 38 o those who with
coronary attack die within a year coronary attack die within a year
o haing it o haing it
Annual cost >300 billion Annual cost >300 billion
panding Risk Iactors panding Risk Iactors
Smoking Smoking
lypertension lypertension
Diabetes Mellitus Diabetes Mellitus
Dyslipidemia Dyslipidemia
Low lDL 40 Low lDL 40
Lleated LDL , 1G Lleated LDL , 1G
lamily listory lamily listory- -eent in eent in
irst degree relatie irst degree relatie 55 55
male,65 emale male,65 emale
Age Age-- -- 45 or male,55 45 or male,55
or emale or emale
Chronic Kidney Disease Chronic Kidney Disease
Lack o regular physical Lack o regular physical
actiity actiity
Obesity Obesity
Lack o Ltoh intake Lack o Ltoh intake
Lack o diet rich in ruit, Lack o diet rich in ruit,
eggies, iber eggies, iber
Acute Coronary Syndromes Acute Coronary Syndromes
Similar pathophysiology Similar pathophysiology
Similar presentation and Similar presentation and
early management rules early management rules
S1LMI requires ealuation S1LMI requires ealuation
or acute reperusion or acute reperusion
interention interention
Unstable Angina Unstable Angina
Non Non--S1 S1--Segment Segment
Lleation MI Lleation MI
,NS1LMI, ,NS1LMI,
S1 S1--Segment Segment
Lleation MI Lleation MI
,S1LMI, ,S1LMI,
iagnosis of Acute MI iagnosis of Acute MI
S1MI / NS1MI S1MI / NS1MI
At least 2 o the ollowing At least 2 o the ollowing
Ischemic symptoms Ischemic symptoms
Diagnostic LCG Diagnostic LCG
changes changes
Serum cardiac marker Serum cardiac marker
eleations eleations
iagnosis of Angina iagnosis of Angina
1ypical angina 1ypical angina--All three o the ollowing All three o the ollowing
Substernal chest discomort Substernal chest discomort
Onset with exertion or emotional stress Onset with exertion or emotional stress
Relie with rest or nitroglycerin Relie with rest or nitroglycerin
Atypical angina Atypical angina
2 o the aboe criteria 2 o the aboe criteria
Noncardiac chest pain Noncardiac chest pain
1 o the aboe 1 o the aboe
iagnosis of Unsta-e Angina iagnosis of Unsta-e Angina
Patients with typical angina Patients with typical angina -- An episode o angina An episode o angina
Increased in seerity or duration Increased in seerity or duration
las onset at rest or at a low leel o exertion las onset at rest or at a low leel o exertion
Unrelieed by the amount o nitroglycerin or rest that had Unrelieed by the amount o nitroglycerin or rest that had
preiously relieed the pain preiously relieed the pain
Patients not known to hae typical angina Patients not known to hae typical angina
lirst episode with usual actiity or at rest within the lirst episode with usual actiity or at rest within the
preious two weeks preious two weeks
Prolonged pain at rest Prolonged pain at rest
Unstable Unstable
Angina Angina
S1LMI S1LMI
NS1LMI NS1LMI
Non occusive
throm-us
Non specific
CG
Norma cardiac
enzymes
ccuding throm-us
sufficient to cause
tissue damage & mid
myocardia necrosis
S1 depression +/-
1 wave inversion on
CG
evated cardiac
enzymes
Compete throm-us
occusion
S1 eevations on
CG or new LBBB
evated cardiac
enzymes
More severe
symptoms
Acute Management Acute Management
Initial ealuation & Initial ealuation &
stabilization stabilization
Licient risk Licient risk
stratiication stratiication
locused cardiac care locused cardiac care
vauation vauation
Licient & direct history Licient & direct history
Initiate stabilization interentions Initiate stabilization interentions
Plan or moing rapidly to Plan or moing rapidly to
indicated cardiac care indicated cardiac care
irected 1herapies
are
1ime Sensitive!
ccurs ccurs
simutaneousy simutaneousy
Chest pain suggestive of ischemia Chest pain suggestive of ischemia
12 lead LCG 12 lead LCG
Obtain initial Obtain initial
cardiac enzymes cardiac enzymes
electrolytes, cbc electrolytes, cbc
lipids, bun,cr, lipids, bun,cr,
glucose, coags glucose, coags
CXR CXR
Immediate assessment within 10 Minutes
Lstablish Lstablish
diagnosis diagnosis
Read LCG Read LCG
Identiy Identiy
complications complications
Assess or Assess or
reperusion reperusion
Initial labs Initial labs
and tests and tests
Lmergent Lmergent
care care
listory & listory &
Physical Physical
IV access IV access
Cardiac Cardiac
monitoring monitoring
Oxygen Oxygen
Aspirin Aspirin
Nitrates Nitrates
Iocused History Iocused History
Aid in diagnosis and rule Aid in diagnosis and rule
out other causes out other causes
Palliatie,Proocatie Palliatie,Proocatie
actors actors
Quality o discomort Quality o discomort
Radiation Radiation
Symptoms associated Symptoms associated
with discomort with discomort
Cardiac risk actors Cardiac risk actors
Past medical history Past medical history --
especially cardiac especially cardiac
Reperusion questions Reperusion questions
1iming o presentation 1iming o presentation
LCG c,w S1LMI LCG c,w S1LMI
Contraindication to Contraindication to
ibrinolysis ibrinolysis
Degree o S1LMI risk Degree o S1LMI risk
1argeted Physica 1argeted Physica
Recognize actors that Recognize actors that
increase risk increase risk
lypotension lypotension
1achycardia 1achycardia
Pulmonary rales, JVD, Pulmonary rales, JVD,
pulmonary edema, pulmonary edema,
New murmurs,heart sounds New murmurs,heart sounds
Diminished peripheral Diminished peripheral
pulses pulses
Signs o stroke Signs o stroke
Lxamination Lxamination
Vitals Vitals
Cardioascular Cardioascular
system system
Respiratory system Respiratory system
Abdomen Abdomen
Neurological status Neurological status
CG assessment CG assessment
S1 Lleation or new LBBB S1 Lleation or new LBBB
S1LMI S1LMI
Non Non--speciic LCG speciic LCG
Unstable Angina Unstable Angina
S1 Depression or dynamic S1 Depression or dynamic
1 wae inersions 1 wae inersions
NS1LMI NS1LMI
Norma or non Norma or non- -diagnostic G diagnostic G
S1 epression or ynamic 1 wave S1 epression or ynamic 1 wave
Inversions Inversions
S1 S1- -Segment evation MI Segment evation MI
New LBBB New LBBB
QRS > 0.12 sec
L Axis deviation
Prominent R wave V1-V3
Prominent S wave 1, aVL, V5-V6
with t-wave inversion
Cardiac markers Cardiac markers
1roponin , 1, I, 1roponin , 1, I,
Very speciic and more Very speciic and more
sensitie than CK sensitie than CK
Rises 4 Rises 4--8 hours ater 8 hours ater
injury injury
May remain eleated or May remain eleated or
up to two weeks up to two weeks
Can proide prognostic Can proide prognostic
inormation inormation
1roponin 1 may be 1roponin 1 may be
eleated with renal dz, eleated with renal dz,
poly,dermatomyositis poly,dermatomyositis
CK CK--MB isoenzyme MB isoenzyme
Rises 4 Rises 4--6 hours ater injury 6 hours ater injury
and peaks at 24 hours and peaks at 24 hours
Remains eleated 36 Remains eleated 36--48 48
hours hours
Positie i CK,MB 5 Positie i CK,MB 5
o total CK and 2 times o total CK and 2 times
normal normal
Lleation can be predictie Lleation can be predictie
o mortality o mortality
lalse posities with lalse posities with
exercise, trauma, muscle dz, exercise, trauma, muscle dz,
DM, PL DM, PL
Prognosis with 1roponin Prognosis with 1roponin
1.0
1.7
3.4
3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/mI)
M
o
r
t
a
I
i
t
y

a
t

4
2

D
a
y
s
831 174 148 134 50 67
K

Risk Stratification Risk Stratification

UA or NS1LMI UA or NS1LMI
-- Laluate or Inasie s. Laluate or Inasie s.
conseratie treatment conseratie treatment
-- Directed medical therapy Directed medical therapy
Based on initia Based on initia
vauation, CG, and vauation, CG, and
Cardiac markers Cardiac markers
-- Assess or reperusion Assess or reperusion
-- Select & implement Select & implement
reperusion therapy reperusion therapy
-- Directed medical therapy Directed medical therapy
S1MI
Patient?
YS YS N N
Cardiac Care Goas Cardiac Care Goas
Decrease amount o myocardial necrosis Decrease amount o myocardial necrosis
Presere LV unction Presere LV unction
Preent major aderse cardiac eents Preent major aderse cardiac eents
1reat lie threatening complications 1reat lie threatening complications
S1MI cardiac care S1MI cardiac care
S1P J S1P J Assessment Assessment
1ime since onset o symptoms 1ime since onset o symptoms
90 min or PCI , 12 hours or ibrinolysis 90 min or PCI , 12 hours or ibrinolysis
Is this high risk S1LMI Is this high risk S1LMI
KILLIP classiication KILLIP classiication
I higher risk may manage with more inasie rx I higher risk may manage with more inasie rx
Determine i ibrinolysis candidate Determine i ibrinolysis candidate
Meets criteria with no contraindications Meets criteria with no contraindications
Determine i PCI candidate Determine i PCI candidate
Based on aailability and time to balloon rx Based on aailability and time to balloon rx
Ii-rinoysis indications Ii-rinoysis indications
S1 segment eleation 1mm in two S1 segment eleation 1mm in two
contiguous leads contiguous leads
New LBBB New LBBB
Symptoms consistent with ischemia Symptoms consistent with ischemia
Symptom onset less than 12 hrs prior to Symptom onset less than 12 hrs prior to
presentation presentation
A-soute contraindications for fi-rinoysis A-soute contraindications for fi-rinoysis
therapy in patients with acute S1MI therapy in patients with acute S1MI
Any prior ICl
Known structural cerebral ascular lesion ,e.g., AVM,
Known malignant intracranial neoplasm
,primary or metastatic,
Ischemic stroke within 3 months LXCLP1 acute
ischemic stroke within 3 hours
Suspected aortic dissection
Actie bleeding or bleeding diathesis ,excluding menses,
Signiicant closed-head or acial trauma within 3 months
Reative contraindications for fi-rinoysis Reative contraindications for fi-rinoysis
therapy in patients with acute S1MI therapy in patients with acute S1MI
listory o chronic, seere, poorly controlled hypertension
Seere uncontrolled hypertension on presentation ,SBP greater
than 180 mm lg or DBP greater than 110 mmlg,
listory o prior ischemic stroke greater than 3 months, dementia,
or known intracranial pathology not coered in contraindications
1raumatic or prolonged ,greater than 10 minutes, CPR or major
surgery ,less than 3 weeks,
Recent ,within 2-4 weeks, internal bleeding
Noncompressible ascular punctures
lor streptokinase,anistreplase prior exposure ,more than 5 days
ago, or prior allergic reaction to these agents
Pregnancy
Actie peptic ulcer
Current use o anticoagulants the higher the INR, the higher the
risk o bleeding
S1MI cardiac care S1MI cardiac care
S1P 2 S1P 2 Determine preerred reperusion strategy Determine preerred reperusion strategy
librinolysis librinolysis preerred i preerred i
3 hours rom onset 3 hours rom onset
PCI not aailable,delayed PCI not aailable,delayed
door to balloon 90min door to balloon 90min
door to balloon minus door to balloon minus
door to needle 1hr door to needle 1hr
Door to needle goal 30min Door to needle goal 30min
No contraindications No contraindications
PCI PCI preerred i preerred i
PCI aailable PCI aailable
Door to balloon 90min Door to balloon 90min
Door to balloon minus Door to balloon minus
door to needle 1hr door to needle 1hr
librinolysis librinolysis
contraindications contraindications
Late Presentation 3 hr Late Presentation 3 hr
ligh risk S1LMI ligh risk S1LMI
Killup 3 or higher Killup 3 or higher
S1LMI dx in doubt S1LMI dx in doubt
Comparing outcomes Comparing outcomes
Comparing outcomes Comparing outcomes
Medica 1herapy Medica 1herapy
MNA + BAH MNA + BAH
Morphine Morphine ,class I, leel C, ,class I, leel C,
Analgesia Analgesia
Reduce pain,anxiety Reduce pain,anxiety- -decrease sympathetic tone, systemic decrease sympathetic tone, systemic
ascular resistance and oxygen demand ascular resistance and oxygen demand
Careul with hypotension, hypoolemia, respiratory Careul with hypotension, hypoolemia, respiratory
depression depression
ygen ygen ,2 ,2--4 liters,minute, ,class I, leel C, 4 liters,minute, ,class I, leel C,
Up to 0 o ACS patient demonstrate hypoxemia Up to 0 o ACS patient demonstrate hypoxemia
May limit ischemic myocardial damage by increasing May limit ischemic myocardial damage by increasing
oxygen deliery,reduce S1 eleation oxygen deliery,reduce S1 eleation
Nitrogycerin Nitrogycerin ,class I, leel B, ,class I, leel B,
Analgesia Analgesia--titrate inusion to keep patient pain ree titrate inusion to keep patient pain ree
Dilates coronary essels Dilates coronary essels- -increase blood low increase blood low
Reduces systemic ascular resistance and preload Reduces systemic ascular resistance and preload
Careul with recent LD meds, hypotension, bradycardia, Careul with recent LD meds, hypotension, bradycardia,
tachycardia, RV inarction tachycardia, RV inarction
Aspirin Aspirin ,160 ,160--325mg chewed & swallowed, ,class I, leel A, 325mg chewed & swallowed, ,class I, leel A,
Irreersible inhibition o platelet aggregation Irreersible inhibition o platelet aggregation
Stabilize plaque and arrest thrombus Stabilize plaque and arrest thrombus
Reduce mortality in patients with S1LMI Reduce mortality in patients with S1LMI
Careul with actie PUD, hypersensitiity, bleeding Careul with actie PUD, hypersensitiity, bleeding
disorders disorders
Beta Beta- -Bockers Bockers ,class I, leel A, ,class I, leel A,
14 reduction in mortality risk at days at 23 long term 14 reduction in mortality risk at days at 23 long term
mortality reduction in S1LMI mortality reduction in S1LMI
Approximate 13 reduction in risk o progression to MI Approximate 13 reduction in risk o progression to MI
in patients with threatening or eoling MI symptoms in patients with threatening or eoling MI symptoms
Be aware o contraindications ,Cll, leart block, Be aware o contraindications ,Cll, leart block,
lypotension, lypotension,
Reassess or therapy as contraindications resole Reassess or therapy as contraindications resole
AC AC- -Inhi-itors / ARB Inhi-itors / ARB ,class I, leel A, ,class I, leel A,
Start in patients with anterior MI, pulmonary congestion, Start in patients with anterior MI, pulmonary congestion,
LVLl 40 in absence o contraindication,hypotension LVLl 40 in absence o contraindication,hypotension
Start in irst 24 hours Start in irst 24 hours
ARB as substitute or patients unable to use ACL ARB as substitute or patients unable to use ACL--I I
Heparin Heparin ,class I, leel C to class IIa, leel C, ,class I, leel C to class IIa, leel C,
LM\l or Ull LM\l or Ull ,max 4000u bolus, 1000u,hr, ,max 4000u bolus, 1000u,hr,
Indirect inhibitor o thrombin Indirect inhibitor o thrombin
less supporting eidence o beneit in era o reperusion less supporting eidence o beneit in era o reperusion
Adjunct to surgical reascularization and thrombolytic , Adjunct to surgical reascularization and thrombolytic ,
PCI reperusion PCI reperusion
24 24--48 hours o treatment 48 hours o treatment
Coordinate with PCI team ,Ull preerred, Coordinate with PCI team ,Ull preerred,
Used in combo with aspirin and,or other platelet inhibitors Used in combo with aspirin and,or other platelet inhibitors
Changing rom one to the other not recommended Changing rom one to the other not recommended
Additiona medication therapy Additiona medication therapy
Copidodre Copidodre ,class I, leel B, ,class I, leel B,
Irreersible inhibition o platelet aggregation Irreersible inhibition o platelet aggregation
Used in support o cath , PCI interention or i Used in support o cath , PCI interention or i
unable to take aspirin unable to take aspirin
3 to 12 month duration depending on scenario 3 to 12 month duration depending on scenario
Gycoprotein II-/IIIa inhi-itors Gycoprotein II-/IIIa inhi-itors
,class IIa, leel B, ,class IIa, leel B,
Inhibition o platelet aggregation at inal common Inhibition o platelet aggregation at inal common
pathway pathway
In support o PCI interention as early as possible In support o PCI interention as early as possible
prior to PCI prior to PCI
Additiona medication therapy Additiona medication therapy
Adosterone -ockers Adosterone -ockers ,class I, leel A, ,class I, leel A,
Post Post--S1LMI patients S1LMI patients
no signiicant renal ailure ,cr 2.5 men or 2.0 or women, no signiicant renal ailure ,cr 2.5 men or 2.0 or women,
No hyperkalemis 5.0 No hyperkalemis 5.0
LVLl 40 LVLl 40
Symptomatic Cll or DM Symptomatic Cll or DM
S1MI care CCU S1MI care CCU
Monitor or complications Monitor or complications
recurrent ischemia, cardiogenic shock, ICl, arrhythmias recurrent ischemia, cardiogenic shock, ICl, arrhythmias
Reiew guidelines or speciic management o Reiew guidelines or speciic management o
complications & other speciic clinical scenarios complications & other speciic clinical scenarios
PCI ater ibrinolysis, emergent CABG, etc. PCI ater ibrinolysis, emergent CABG, etc.
Decision making or risk stratiication at hospital Decision making or risk stratiication at hospital
discharge discharge and,or and,or need or CABG need or CABG
Unsta-e angina/NS1MI Unsta-e angina/NS1MI
cardiac care cardiac care
Laluate or conseratie s. inasie therapy Laluate or conseratie s. inasie therapy
based upon based upon
Risk o actual ACS Risk o actual ACS
1IMI risk score 1IMI risk score
ACS risk categories per AlA guidelines ACS risk categories per AlA guidelines
Low Low
Intermediate Intermediate
High High
Assessment
Findings indicating
HIGH likelihood of ACS
Findings indicating
INTERMEDIATE
likelihood of ACS in
absence of high-
likelihood findings
Findings indicating
LOW likelihood of ACS
in absence of high- or
intermediate-likelihood
findings
istory
Chest or Ieft arm pain or
discomfort as chief
symptom
Reproduction of previous
documented angina
Known history of coronary
artery disease, incIuding
myocardiaI infarction
Chest or Ieft arm pain or
discomfort as chief
symptom
Age > 50 years
ProbabIe ischemic
symptoms
Recent cocaine use
PhysicaI
examination
New transient mitraI
regurgitation,
hypotension, diaphoresis,
puImonary edema or raIes
Extracardiac vascuIar
disease
Chest discomfort
reproduced by paIpation
ECG
New or presumabIy new
transient ST-segment
deviation (> 0.05 mV) or T-
wave inversion (> 0.2 mV)
with symptoms
Fixed Q waves
AbnormaI ST segments or
T waves not documented
to be new
T-wave fIattening or
inversion of T waves in
Ieads with dominant R
waves
NormaI ECG
Serum cardiac
markers
EIevated cardiac troponin
T or I, or eIevated CK-MB
NormaI NormaI
Risk Stratification to etermine the Likeihood of
Acute Coronary Syndrome
1IMI Risk Score
Predicts risk of death, new/recurrent MI, need for urgent
revascuarization within J4 days
ACS risk criteria ACS risk criteria
ow Risk ACS
o intermediate or high
risk factors
<10 minutes rest pain
on-diagnositic ECG
on-elevated cardiac
markers
Age < 70 years
Intermediate Risk
ACS
Moderate to high likelihood
of CAD
>10 minutes rest pain,
now resolved
T-wave inversion > 2mm
Slightly elevated cardiac
markers
igh Risk ACS
Elevated cardiac markers
ew or presumed new ST depression
Recurrent ischemia despite therapy
Recurrent ischemia with heart failure
High risk findings on non-invasive stress test
Depressed systolic left ventricular function
Hemodynamic instability
Sustained Ventricular tachycardia
PC with 6 months
Prior Bypass surgery
Low
risk
High
risk
Conservative Conservative
therapy therapy
Invasive Invasive
therapy therapy
Chest Pain Chest Pain
center center
Intermediate
risk
Invasive therapy option Invasive therapy option
UA/NS1MI UA/NS1MI
Coronary angiography and reascularization
within 12 to 48 hours ater presentation to LD
lor high risk ACS ,class I, leel A,
MONA - BAl ;|)
Clopidogrel
20 reduction death,MI,Stroke - CURL trial
1 month minimum duration and possibly up to 9 months 1 month minimum duration and possibly up to 9 months
Glycoprotein IIb,IIIa inhibitors Glycoprotein IIb,IIIa inhibitors
Conservative 1herapy for Conservative 1herapy for
UA/NS1MI UA/NS1MI
Larly reascularization or PCI Larly reascularization or PCI not not planned planned
MONA - BA MONA - BAl l ;M! or |) ;M! or |)
Clopidogrel Clopidogrel
Glycoprotein IIb,IIIa inhibitors Glycoprotein IIb,IIIa inhibitors
Only in certain circumstances ,planning PCI, eleated 1nI,1, Only in certain circumstances ,planning PCI, eleated 1nI,1,
Sureillence in hospital Sureillence in hospital
Serial LCGs Serial LCGs
Serial Markers Serial Markers
Secondary Prevention Secondary Prevention
Disease Disease
l1N, DM, lLP l1N, DM, lLP
Behaioral Behaioral
smoking, diet, physical actiity, weight smoking, diet, physical actiity, weight
Cognitie Cognitie
Lducation, cardiac rehab program Lducation, cardiac rehab program
Secondary Prevention Secondary Prevention
disease management disease management
Blood Pressure Blood Pressure
Goals 140,90 or 130,80 in DM ,CKD Goals 140,90 or 130,80 in DM ,CKD
Maximize use o beta Maximize use o beta--blockers & ACL blockers & ACL--I I
Lipids Lipids
LDL 100 ,0, , 1G 200 LDL 100 ,0, , 1G 200
Maximize use o statins, consider ibrates,niacin irst Maximize use o statins, consider ibrates,niacin irst
line or 1G500, consider omega line or 1G500, consider omega--3 atty acids 3 atty acids
Diabetes Diabetes
A1c A1c
Secondary prevention Secondary prevention
-ehaviora intervention -ehaviora intervention
Smoking cessation Smoking cessation
Cessation Cessation--class, meds, counseling class, meds, counseling
Physical Actiity Physical Actiity
Goal 30 Goal 30 -- 60 minutes daily 60 minutes daily
Risk assessment prior to initiation Risk assessment prior to initiation
Diet Diet
DASl diet, iber, omega DASl diet, iber, omega--3 atty acids 3 atty acids
total calories rom saturated ats total calories rom saturated ats
1hinking outside the -o 1hinking outside the -o
r may-e ust move r may-e ust move
Secondary prevention Secondary prevention
cognitive cognitive
Patient education Patient education
In In--hospital hospital -- discharge discharge --outpatient clinic,rehab outpatient clinic,rehab
Monitor psychosocial impact Monitor psychosocial impact
Depression,anxiety assessment & treatment Depression,anxiety assessment & treatment
Social support system Social support system
Medication Checkist Medication Checkist
after ACS after ACS
Antiplatelet agent Antiplatelet agent
Aspirin Aspirin and,or Clopidorgrel and,or Clopidorgrel
Lipid lowering agent Lipid lowering agent
Statin Statin
librate , Niacin , Omega librate , Niacin , Omega--3 3
Antihypertensie agent Antihypertensie agent
Beta blocker Beta blocker
ACL ACL--I I,ARB ,ARB
Aldactone Aldactone ,as appropriate, ,as appropriate,
Prevention news Prevention news
lrom 1994 to 2004 the death rate rom
coronary heart disease declined
But the actual number o deaths declined
only J8
Getting better with treatment.
But more patients deeloping disease -
need or primary prevention ocus
Summary Summary
ACS includes UA, NS1LMI, and S1LMI ACS includes UA, NS1LMI, and S1LMI
Management guideline ocus Management guideline ocus
Immediate assessment,interention Immediate assessment,interention ,MONA-BAl, ,MONA-BAl,
Risk stratiication Risk stratiication ,UA,NS1LMI s. S1LMI, ,UA,NS1LMI s. S1LMI,
RAPID reperusion or S1LMI RAPID reperusion or S1LMI ,PCI s. 1hrombolytics, ,PCI s. 1hrombolytics,
Conseratie s Inasie therapy or UA,NS1LMI Conseratie s Inasie therapy or UA,NS1LMI
Aggressie attention to secondary preention Aggressie attention to secondary preention
initiaties or ACS patients initiaties or ACS patients
Beta blocker, ASA, ACL Beta blocker, ASA, ACL--I, Statin I, Statin