1. Acute Coronary Syndrome David Aymond, MD

2. ACS Definition: Myocardial ischemia typically due to atherosclerotic plaque rupture  Coronary thrombosis ACS is a spectrum: UA vs NSTEMI vs STEMI -Unstable angina/NSTEMI: angina that is new onset, crescendo, or at rest; typically <30mns + TWI or ST- depression *NSTEMI is term used with this history/EKG with slightly elevated Troponin/CK-MB -STEMI: Angina at rest >30mns with ST elevations and markedly elevated enzymes (2x upper limit of NL)

3. How to Triage (ACC/AHA 2007 Guidelines update for UA/NSTEMI) -This is based solely on Pre-test Probability, these the risk of short term death or non fatal MI FeatureHigh (any)Intermediate (no high features) Low (no high/inter. Features) HistoryChest/arm pain like prior angina; h/o CAD (inc MI); TRS > 3; Age > 75 Chest or L arm pain Age>70 Male, DM Atypical Sx ExamHoTN, diapho, CHF, MRPAD or CVDPain rep. on palpation ECGNew STD (>1mm), TWI in mult. Leads Old Qw, STD (.5-.9mm), TWI TWF/TWI (<1m) in dominant leads Biomarkers+ Tn or CK-MBNormal

4. Triage If hx and initial EKG and biomarkers non-dx, repeat ECG and biomarkers 12 h later If low likelihood, CE remain NL and remain pain free, have r/o MI; but if clinical suspicion high based on Hx still need to evaluate for UA/inducible ischemia: if pt has no historical/exam that’s IM/High, can do ETT as outPt w/in 72 hrs ( 0 % mortality,.5% MI) (Ann Emerg Med 2006; 47-427) If has IM RF’s for ACS based on hx, admit and evaluate If ECG or biomarker abnl or high likelihood ACS, then admit and evaluate

5. Conservative vs Early Invasive Approach Conservative approach taken if low risk (- Tn, no ST dep, TRS 0-2, and NO CHF); conservative approach means medical Rx with Pre-d/c stress test; angio only if strongly + ETT; this is SOC in Unstable Angina Early Invasive approach taken if high risk (+TN, ST dep, TRS> 3, s/s CHF); early invasive approach means Med Rx + angiography w/in 24-48 hrs; this is SOC for NSTEMI Med Rx=EMONACAGB

6. Medical Management Enoxaparin: 1mg/kg BID; 10% dec death/MI (JAMA 2004;292:89); greatest benefit in CONS strategy Morphine: consider if pulmonary edema or persistent Sx Oxygen: keep SaO2 >90% Nitrates: dec anginal sx, no dec in mortality ASA: 162-325mg x 1 crushed/chewed; then 75-325/day; 50-70% dec in D/MI (NEJM 1988;319:1105); if ASA allergy, use Clopidogrel Coronary angiography: only if high risk/NSTEMI within 24-48 hrs Clopidogrel: give w/ ASA 20% dec. CVD/MI/stroke, inc. benefit if given upstream prior to PCI, but need to D/C 5 days prior to CABG (NEJM 2001; 345:494; Lancet 2001; 358:257) ACE-I/ARB: esp if CHF and SBP>100 Glycoprotein IIb-IIIa inhibitors: only if TRS>3 will benefit be increased (JACC 2003; 41:895) Beta-Blockers: PO, titrate to keep HR 50-60; IV if ongoing pain=13% dec in progression to MI (JAMA 1988; 260:2259); contraindicated in hypotension, bradycardia and ADHF

7. TIMI Risk Score RISK FACTORScoreScore TotalD/MI/UR Age > 6510-15% > 3 RF for CAD128% Known CAD1313% ASA use in past 7 d1420% Severe Angina (>2 episodes in 24 hrs) 1526% ST deviation > 0.5 mm 16-741% + Tn/CK-MB1

8. GRACE Risk Score GRACE= Global Registry for Acute Coronary Events Very large, multi-national randomized trial When you compare the TIMI, PURSUIT and GRACE risk score for validation of end points, the GRACE is “more advantageous and easier to use; it can categorize a patients risk of death/MI and can help tailor therapy to match the intensity of the patients ACS”

9. Algorithm for the evaluation and management of patients suspected of having an ACS. Braunwald E et al. Circulation 2000;102:1193-1209 Copyright © American Heart Association