1. Acute Coronary Syndrome
Garland Anderson MD
September 29th 2014

2. Goals and Objectives
Review the etiologies of Acute Coronary Syndrome (ACS)
Gain understanding of how to diagnose ACS
Understand the different types of ACS
Review the treatment of ACS
Understand risk stratification in patients with unstable angina and non-ST segment elevation myocardial infarction
Brief review of optimizing risk in secondary prevention after myocardial infarction

3. Etiologies Atherosclerosis is a diffuse arterial disease
Endothelial dysFx
Formation of plaques
Treatment of most risk factors reduces the dysfunction
Progression of plaques
Foam cells →fibrous cap
Prone to Rupture
Result ACS

6. Etiologies Rupture of Plaque Total Occlusion
ST-segment elevation myocardial infarction (STEMI)
Partial Occlusion-Spectrum of Disease
Unstable Angina→
non- ST-segment elevation myocardial infarction (NSTEMI)
Acute Coronary Syndrome
Imbalance between coronary blood flow and myocardial oxygen demand

7. DDX Acute Chest Pain Anxiety/panic disorder Aortic dissection
Costochondritis
Esophageal Conditions (spasm)
Gall bladder disease
Myocarditis/pericarditis
Peptic Ulcer Disease
Pneumonia
Pulmonary Embolus

8. Acute Coronary Syndrome
Diagnosis
History and Physical Exam
EKG
Cardiac Biomarkers

9. History Chest pain Dyspnea Weakness Fatigue Nausea/Vomiting
Present in less than half of patients over 85 years of age
Typically poorly localized to anterior chest
+/- Radiation ( Arms, neck, epigastrium, or back)
Dyspnea
Most common “atypical” symptom
Weakness
Fatigue
Nausea/Vomiting
Diaphoresis

10. History Further define likelihood of ACS with chest pain
Atherosclerotic risk factors
Associated medical conditions (HTN/HLD)
Age
Smoking
Similar pain with prior MI
Chest pain characteristics not likely to represent ACS
Worsens with
Localized palpitation
Deep breathing
Movement of the affected area

11. Electrocardiogram
Should be obtained within 10 minutes of presentation to the emergency department
ST-segment elevation of 0.1 mV or more in at least 2 contiguous ECG leads
Diagnostic of STEMI
Degree of ST-segment elevation correlates with the amount of myocardium experiencing injury
ST-segment depression and/or T-wave inversion can indicate ischemia
Suggestive of, but not specific for, the diagnosis of unstable angina or NSTEMI

12. Electrocardiogram
ECG results can be initially normal in up to 20% of patients experiencing ACS.
Might not be helpful If patient’s baseline ECG is abnormal
Preexisting ST-segment or T-wave changes
Left bundle-branch block
Left ventricular hypertrophy
Left ventricular aneurysm
Myocarditis
Electrolyte abnormality
Preexcitation syndrome
Ventricular pacemaker rhythm

13. Electrocardiogram

14. Electrocardiogram

15. Electrocardiogram

16. Electrocardiogram

17. Electrocardiogram

18. Electrocardiogram

19. Cardiac Biomarkers Troponins
Highly sensitive and specific markers of myocardial damage
Elevated in patients with NSTEMI and STEMI but are normal in patients with unstable angina
Typically do not increase until approximately 6 hours after onset of chest pain.
ECG results consistent with ischemia, normal cardiac troponin levels should not be used in the decision to discharge a patient
Serial levels should be measured at 8-hour intervals on the first day
When levels are elevated, they can remain elevated for up to 10 days

20. Cardiac Biomarkers
In ACS, the amount of troponin elevation is directly related to infarct size
Normal serial troponin levels rule out an acute MI with a high negative predictive value
Multiple nonischemic etiologies of elevated troponin

22. Acute Coronary Syndrome

23. Treatment
Critical to initiate therapy promptly to limit ongoing myocardial damage
Must be tailored to the type of ACS and specific patient characteristics

24. Treatment
Oxygen
Supplemental oxygen is usually administered to all patients
Recommended in patients with:
Arterial oxygen saturation level less than 90%
Respiratory distress
Incipient heart failure

25. Treatment Relief of Anginal Pain Nitroglycerin (NTG)
0.4 mg should be administered sublingually every 5 minutes for up to 3 doses or until the pain resolves
Patient should be in the seated or recumbent position when administered to optimize benefit and prevent systemic hypotension
Ischemic chest pain continues or recurs, intravenous NTG is indicated
Contraindicated in patients who have taken phosphodiesterase inhibitors (eg, sildenafil, tadalafil) within the previous 24 hours
Use with caution in patients with right ventricular infarction or diastolic dysfunction to prevent systemic hypotension

26. Treatment Relief of Anginal Pain Morphine sulfate (2 to 5 mg)
Major role in analgesia.
Safety concerns have been raised about the use of morphine
Some studies have found a higher likelihood of mortality in patients receiving morphine

27. Treatment Initial Antiplatelet Therapy Aspirin
162 to 325 mg should be started over the telephone or at the initial medical encounter, even if a dose was taken earlier that day.
Administered to patients with STEMI whether or not they will receive fibrinolytic therapy.
Chewed, rather than swallowed whole.
75 to 162 mg should then be continued indefinitely because it results in a significant reduction in mortality and MI.

28. Treatment Initial Antiplatelet Therapy Clopidogrel (Plavix)
Patients who are intolerant of ASA because of allergy or major gastrointestinal disease.
Loading dose of 300 mg
75 mg/day maintenance dosage

29. Treatment

30. Treatment Cardioprotective Drugs Beta blockers
Should be administered within the first 24 hours unless contraindicated.
Marked first-degree atrioventricular (AV) block
PR interval more than 240 ms
Second- or third-degree AV block
Acute heart failure
Low cardiac-output states
Active bronchospasm.

31. Treatment Cardioprotective Drugs Beta blockers
Initial dose should be based on the heart rate and blood pressure.
Reduce oxygen demand, ventricular fibrillation risk, cardiac remodeling, and progression of coronary disease.
Help control heart rate and hypertension

32. Treatment Cardioprotective Drugs
Angiotensin-converting enzyme (ACE) inhibitors
Should be administered at a low dose within the first 24 hours of hospitalization.
Reduce mortality and morbidity rates, prevent cardiac remodeling, and are of extra benefit in the presence of anterior wall infarctions, hypertension, and systolic dysfunction.
Prevents approximately 1 mortality per 200 treated patients.
Angiotensin receptor blockers can be substituted if the patient is intolerant of ACE inhibitors

33. Treatment Cardioprotective Drugs Statins
Shown to be of long-term benefit in patients with ACS.
Patients already taking a statin when presenting with ACS are less likely to have STEMI or acute in-hospital arrhythmias.
Should be started in all patients with ACS during hospital admission, regardless of the LDL level.
Plaque stabilization, reversal of endothelial dysfunction, decreased thrombogenicity, reduced inflammation independent of the long-term cholesterol level-lowering benefit.
Early regression of coronary atherosclerosis, decrease in mortality rates, and significant reduction in the rate of major cardiovascular end points

34. Treatment Management of STEMI Percutaneous Coronary Intervention (PCI)
Coronary angiography and angioplasty with stent placement are the reperfusion therapies of choice in patients presenting with
Acute STEMI
ACS with a new (or presumed new) left bundle-branch block
Posterior wall myocardial infarction (MI)
Therapies of choice if they present
Within 12 hours of symptom onset
Hospital with PCI capability
PCI can be performed within 90 minutes of first medical contact
door-to-balloon time

35. Treatment Management of STEMI Special situations
Hospitals Without PCI Capability. These patients with STEMI should be transferred to a PCI center if the PCI can be performed within 90 minutes of first medical contact.
Lack of Onsite Surgical Backup. Clinical studies indicate that patients at hospitals with PCI and stent capabilities but without onsite surgical backup can experience outcomes that are better than those associated with coronary fibrinolysis, if PCI is performed in a high-volume center by expert operators.
Cocaine Users.
Beta blocker use should always be avoided in cocaine users to prevent the vasoconstriction that can occur when beta blockers leave alpha stimulation unopposed
Bare-metal stent should be considered because of the possibility of poor long-term adherence to antiplatelet drug

36. Treatment Management of STEMI Fibrinolysis
Patients who cannot be transferred to a PCI center within 90 minutes should undergo urgent intravenous fibrinolysis.
Most effective when administered within the first 4 hours, and especially within the first 30 to 60 minutes.
Still beneficial up to 12 hours after symptom onset.
Results in normal coronary perfusion in 55% of patients

37. Treatment Management of STEMI Coronary Artery Bypass Graft Surgery
Associated with low rates of recurrent ischemia, complete revascularization, and few revascularization
Preferred therapy for
Left main coronary disease,
Left main equivalent disease (ie, high-grade proximal stenosis of the left anterior descending and circumflex arteries)
Diffuse 3-vessel disease
Surgical mortality rates after CABG for patients with STEMI are higher in the first week after MI.
when possible, surgery should be postponed for at least 1 week in patients in stable condition.

38. Treatment Management of STEMI Anticoagulants
Recommended for all patients with STEMI.
Unfractionated heparin (UFH)
Low-molecular-weight heparin (LMWH)
Synthetic heparin (fondaparinux [Arixtra])
Direct thrombin inhibitors (bivalirudin)
Should be administered before invasive procedures are started.
Choice of anticoagulant be guided by the reperfusion therapy planned and the individual’s risk of bleeding.
PCI = UFH plus a glycoprotein inhibitor IIb/IIIa, or bivalirudin alone
Fibrinolysis = UFH, LMWH, or fondaparinux If bleeding is a concern,
LMWH is associated with a lower rate of reinfarction at 30 days than UFH, but it is also associated with more major bleeding.

39. Treatment Management of STEMI Antiplatelets
ASA is indicated for all patients with STEMI whether they receive reperfusion therapy with PCI, fibrinolysis, or bypass surgery.
Thienopyridines. If PCI is to be performed, clopidogrel should be administered in addition to ASA before the procedure (loading dose of 300 to 600 mg, followed by 75 mg/day). These drugs are indicated even when patients receive anticoagulants.
Glycoprotein IIb/IIIa inhibitors (eg, abciximab [Reopro], eptifibatide [Integrilin], tirofiban [Aggrastat])
Not recommended for STEMI patients already receiving dual antiplatelet therapy plus an anticoagulant.
Might have a role in the catheterization laboratory in select patients with large thrombi or those who have not received adequate pre-procedure thienopyridine therapy.
More potent than clopidogrel, faster in onset, and more consistent in platelet inhibition.

40. Treatment Management of NSTEMI/UA
Anti-Ischemic, Antiplatelet, and Anticoagulant therapy
Identical to management of STEMI
Non-ST-segment elevation MIs occur more frequently than STEMIs, but are associated with similar long-term outcomes.
In contrast to STEMIs, for which urgent revascularization is required because of complete or near-complete vessel occlusion, urgent intervention is less often required for NSTEMIs because the involved vessel is partially patent in 60% to 85% of patients.

41. Treatment Predicting Mortality Risk
The Thrombolysis in Myocardial Infarction (TIMI) risk score helps determine the risk of mortality within the first 30 days of presentation.
High-Risk Clinical Presentations
Cardiogenic Shock
Hemodynamic Instability
Clinical Heart Failure
Severe Systolic Dysfunction (EF < 40%)
Persistent or Recurrent Ischemia
Sustained Ventricular Tachycardia
High-risk Thombolysis in Myocardial Infarction (TIMI) score

42. TIMI Risk Score for UA/NSTEMI
Treatment
TIMI Risk Score for UA/NSTEMI
Calculation of Risk Score
Application of Risk Score
Characteristic
Point
Score
Death/MI/Urgent Revascularization (14 d)
Historical
0-1 5%
Age ≥ 65 y 1 2 8%
≥3 Risk factors for CAD 3
13%
Known CAD (stenosis ≥50%) 4
20%
Aspirin use in past 7 days 5
26%
Presentation
6-7
41%
Severe angina (≥ 2 episodes w/in 24h)
ST deviation > 0.5 mm
+ cardiac markers (Troponin, CK-MB)
RISK SCORE = Total points
(0-7)

43. Treatment

44. Treatment Secondary Risk Factor Prevention Blood Pressure
Lipid Management
Physical Activity
Smoking Cessation
Weight Management
Other Considerations
Diabetes Management
Metabolic Syndrome
Influenza Immunization

45. Summary Acute coronary syndrome requires prompt diagnosis
Early medical management is needed to reduce risk to myocardial tissue
The type of ACS guides the choice of treatment modalities
Risk stratification/TIMI scores show what patients with NSTEMI/UA could benefit from early PCI
Risk factor modification is important in secondary prevention of myocardial infarctions

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