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MOCHAMMAD FATHONIDEPART. OF CARDIOLOGY,

MEDICAL FACULTY,SEBELAS MARET

UNIVERSITY,Dr. MOEWARDI HOSPITAL,

SOLO

 

 Acute Coronr! Acute Coronr!

S!n"ro#eS!n"ro#e

FAST RESPONSE OF

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!!

cu e oronr!cu e oronr!S!n"ro#eS!n"ro#e

Clinical syndromes caused by acute myocardialClinical syndromes caused by acute myocardial

ischemiaischemia Unstable anginaUnstable angina

 Angina at rest or new onset angina, accelerating Angina at rest or new onset angina, accelerating

symptomssymptoms

No detectable increase of biomarkersNo detectable increase of biomarkers Non-ST-elevation !Non-ST-elevation !

 Angina at rest or new onset angina, accelerating Angina at rest or new onset angina, accelerating

symptomssymptoms

"etectable release of biomarkers"etectable release of biomarkers ST-elevation !ST-elevation !

Clinical presentation of acute myocardial infarctionClinical presentation of acute myocardial infarction

with #$% evidence of ST-segment elevationwith #$% evidence of ST-segment elevation

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 Acute Coronr! Acute Coronr!

S!n"ro#e)S!n"ro#e)

 SimilarSimilar

pathophysiologypathophysiology

  Similar presentationSimilar presentationand early managementand early managementrulesrules

 ST#! re&uiresST#! re&uiresevaluation for acuteevaluation for acute

reperfusion andreperfusion andinterventionintervention

Unstable AnginaUnstable Angina

Non-ST-SegmentNon-ST-Segment#levation !#levation !'NST#!('NST#!(

ST-SegmentST-Segment#levation !#levation !'ST#!('ST#!(

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D*+no)*) o Acute MID*+no)*) o Acute MI

 STEMI - NSTEMISTEMI - NSTEMI

 At least ) of the At least ) of the

followingfollowing

!schemic!schemicsymptomssymptoms

"iagnostic #C%"iagnostic #C%

changeschangesSerum cardiacSerum cardiac

markermarker

elevationselevations

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D*+no)*) o An+*nD*+no)*) o An+*n

Typical angina * three of the followingTypical angina * three of the following Substernal chest discomfortSubsternal chest discomfort +nset with eertion or emotional stress+nset with eertion or emotional stress

elief with rest or nitroglycerinelief with rest or nitroglycerin

 Atypical angina Atypical angina ) of the above) of the above criteriacriteria

NoncardiacNoncardiac chest painchest pain . of the above. of the aboveTypical anginaTypical angina/All/All

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D*+no)*) o Un)t/eD*+no)*) o Un)t/e

 An+*n An+*n

0atients with typical angina - An episode of0atients with typical angina - An episode ofanginaangina

!ncreased!ncreased in severity or durationin severity or duration

1as onset1as onset at restat rest or at a low level ofor at a low level of

eertioneertionUnrelievedUnrelieved by the amount ofby the amount of nitroglycerinnitroglycerin or rest that had previously relieved the painor rest that had previously relieved the pain

0atients not known to have typical angina0atients not known to have typical angina2irst episode2irst episode with usual activity or at restwith usual activity or at rest

within the previous two weekswithin the previous two weeks

0rolonged pain at rest0rolonged pain at rest

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U NSTABLEU NSTABLE

ANGINAANGINASTEMISTEMI  NSTEMINSTEMI

Nonocc/u)*0e

t1ro#u)

Non)&ec*2c

ECG

Nor#/cr"*c

en3!#e)

Occ/u"*n+t1ro#u))u4*c*ent to

cu)et*))ue "#+e 5#*/"#!ocr"*/necro)*)

ST "e&re))*on6-7T 80e *n0er)*on

onECG

E/e0te" cr"*cen3!#e)

Co#&/ete t1ro#occ/u)*on

ST e/e0t*on) on

ECG or ne8 LBB

E/e0te" cr"*cen3!#e)

More )e0ere)!#&to#)

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TttTro&on*n

I r*)e

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E9&n"*n+ R*): Fctor)E9&n"*n+ R*): Fctor) SmokingSmoking

1ypertension1ypertension

"iabetes ellitus"iabetes ellitus

"yslipidemia"yslipidemia

3ow 1"3 4 563ow 1"3 4 56

#levated 3"3 7#levated 3"3 7

T%T%

2amily 1istory/2amily 1istory/

event in 8rstevent in 8rst

degree relativedegree relative 99::::

male7;: femalemale7;: female

 Age-- Age-- 99 5: for5: for

male7:: formale7:: for

femalefemale

ChronicChronic$idney$idney"isease"isease

3ack of3ack ofregularregularphysicalphysicalactivityactivity

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e no e o e)e co##on ) +n) o ncute coronr! )!n"ro#e;

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$$=

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 Acute Acute

Mn+e#entMn+e#ent

!nitial!nitial

evaluation =evaluation =

stabili>ationstabili>ation

#?icient risk#?icient risk

strati8cationstrati8cation2ocused2ocused

cardiac carecardiac care

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E0/ut*onE0/ut*on

#?icient = direct history#?icient = direct history !nitiate stabili>ation!nitiate stabili>ation

interventionsinterventions

0lan for moving rapidly to0lan for moving rapidly to

indicatedindicatedcardiac carecardiac care

D*recte" T1er&*e) re T*#e Sen)*t*0e>

Occur)Occur))*#u/tneo)*#u/tneo

u)/! u)/! 

t t

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e)t & n )u++e)t 0e oe) & n )u++e) 0e o*)c1e#**)c1e#*

.) lead #C%.) lead #C% +btain initial+btain initial

cardiac en>ymescardiac en>ymes

electrolytes, cbcelectrolytes, cbc

lipids, bun7cr,lipids, bun7cr,glucose, coagsglucose, coags

C@ C@ 

!mmediate assessment within .6inutes

#stablish#stablishdiagnosisdiagnosis

ead #C%ead #C%

!dentify!dentify

complicaticomplicati

onsons

 Assess for Assess for

reperfusioreperfusio

!nitial!nitial

labslabs

and testsand tests

#mergent#mergent

carecare

1istory1istory

==

0hysical0hysical

! access! access CardiacCardiac

monitorinmonitorin

gg

+ygen+ygen

 Aspirin Aspirin

NitratesNitrates

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Focu)e" H*)tor! Focu)e" H*)tor!   Aid in diagnosis and rule Aid in diagnosis and rule

out other causesout other causes 0alliative70rovocative0alliative70rovocative

factorsfactors

Buality of discomfortBuality of discomfort

adiationadiation

Symptoms associatedSymptoms associated

with discomfortwith discomfort

Cardiac risk factorsCardiac risk factors 0ast medical history0ast medical history

-especially cardiac-especially cardiac

eperfusioneperfusion&uestions&uestions

Timing ofTiming of

presentationpresentation

#C% c7w ST#!#C% c7w ST#!

Contraindication toContraindication to

8brinolysis8brinolysis"egree of ST#!"egree of ST#!

risk risk 

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Tr+ete" P1!)*c/Tr+ete" P1!)*c/

ecogni>e factors thecogni>e factors th  increase risk increase risk 

1ypotension1ypotension

TachycardiaTachycardia 0ulmonary rales,0ulmonary rales,

0ulmonary edema,0ulmonary edema,

New murmurs7heartNew murmurs7heart

"iminished peripher"iminished peripher

Signs ofSigns of strokestroke

#amination#amination itals italsCardiovasculCardiovascul

ar systemar systemespiratoryespiratory

systemsystem

 Abdomen AbdomenNeurologicalNeurological

statusstatus  

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ECG ))e))#entECG ))e))#ent

T #levation or new 3T #levation or new 3

ST#!ST#!

Non-speci8c #C%Non-speci8c #C%

Unstable AnginaUnstable Angina

ST "epression or dynamicST "epression or dynamic

T wave inversionsT wave inversions

NST#!NST#!

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Nor#/ or non7Nor#/ or non7

"*+no)t*c E?G"*+no)t*c E?G

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ST De&re))*on or D!n#*cST De&re))*on or D!n#*c

T 80e In0er)*on)T 80e In0er)*on)

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ST7Se+#ent E/e0t*on MIST7Se+#ent E/e0t*on MI

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Cr"*c #r:er)Cr"*c #r:er) Troponin ' T, !(Troponin ' T, !(

 ery speci8c and ery speci8c andmore sensitive thanmore sensitive thanC$ C$ 

isesises 5-D hours5-D hours afterafterinEuryinEury

ay remain elevateday remain elevatedfor up tofor up to two weekstwo weeks

Can provideCan provide

prognosticprognosticinformationinformation

Troponin T may beTroponin T may beelevated with renalelevated with renal

d>,d>,poly7dermatomyositispoly7dermatomyositis

C$- isoen>ymeC$- isoen>yme

isesises 5-; hours5-; hoursafter inEury andafter inEury andpeaks at )5 hourspeaks at )5 hours

emains elevatedemains elevatedF;-5D hoursF;-5D hours 0ositive if C$7 90ositive if C$7 9

:G of total C$ and:G of total C$ and

) times normal) times normal#levation can be#levation can bepredictive ofpredictive ofmortalitymortality

2alse positives with2alse positives with

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T*#*n+ o Re/e)e o Vr*ou)T*#*n+ o Re/e)e o Vr*ou)

B*o#r:er) Ater Acute M!ocr"*/B*o#r:er) Ater Acute M!ocr"*/

Inrct*onInrct*on

S1&*ro BP, @4e AS. Cr"*c *o#r:er). In; Mur&1! @G, L/o!" MA, e"*tor). M!o C/*n*c Cr"*o/o+!; Conc*)eTe9too:. r" e". Roc1e)ter, MN; M!o C/*n*c Sc*ent*2c Pre)) n" Ne8 Yor:; Inor# He/t1cre USA, '((;=(.

 An"er)on @L, et /. J Am Coll Cardiol '(((;e$e$, F*+ure .

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R*): Strt*2ct*onR*): Strt*2ct*on

  UA or NST#!UA or NST#!

-- #valuate for#valuate for

!nvasive vsH!nvasive vsHconservativeconservativetreatmenttreatment

- "irected medical- "irected medicaltherapytherapy

B)e" on *n*t*/B)e" on *n*t*/

E0/ut*on, ECG, E0/ut*on, ECG, Cr"*c #r:er Cr"*c #r:er)

-- Assess for Assess forreperfusionreperfusion

- Select =- Select =implementimplementreperfusionreperfusion

therapytherapy

STEMIPt*ent

 YES YES NONO

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 Assessment Findingsindicating HIGH

likelihood of ACS 

Findingsindicating

INTERMEDIATElikelihood of ACSin absence ofhigh-likelihoodfindings

Findingsindicating !"

likelihood of ACSin absence ofhigh- o#inte#mediate- likelihood findings

History Chest or left armpain ordiscomfort aschief symptomReproduction ofprevious

documentedanginaKnown history ofcoronary arterydisease,includingmyocardialinfarction

Chest or left armpain ordiscomfort aschief symptomAge > 50 years

Proale ischemicsymptomsRecent cocaineuse

R*): Strt*2ct*on to Deter#*ne t1eL*:e/*1oo" o Acute Coronr! S!n"ro#e

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Physicale!amination "ew transientmitralregurgitation,hypotension,diaphoresis,pulmonary

edema or rales

#!tracardiacvasculardisease

Chestdiscomfortreproduced ypalpation

#C$ "ew orpresumalynew transient%&'segment

deviation (>0)05 m*+ or &'wave inversion(> 0) m*+ withsymptoms

-i!ed . wavesAnormal %&segments or &waves not

documented toe new

&'waveflattening orinversion of &waves in leads

with dominant Rwaves"ormal #C$

%erum cardiac #levated "ormal "ormal

R*): Strt*2ct*on to Deter#*ne t1e L*:e/*1oo"o Acute Coronr!S!n"ro#e

T/e $ S1ort Ter# R*): o Det1 or Nont/ MI *n

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2eature

1igh isk'At least . of

the following

features

must bepresent(

!ntermediate

isk 'No

high-riskfeature but

must have .

of the

followingfeatures(

3ow isk

'No high- or

intermediate-risk feature

but may

have any of

the followingfeatures(

1istory  Acceleratingtempo of

ischemicsymptoms in

preceding

5D hrs

0rior !,

peripheral

orcerebrovasc

ular disease,

or CA%I

prior aspirin

T/e $. S1ort7Ter# R*): o Det1 or Nont/ MI *n

T/e $ S1ort Ter# R*): o Det1 or Nont/ MI *n

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2eature

1igh isk

'At least . of

the following

featuresmust be

present(

!ntermediate

isk 'Nohigh-risk

feature but

must have .

of thefollowing

features(

3ow isk

'No high- orintermediate

-risk feature

but may

have any ofthe following

features(Character of

pain

0rolonged

ongoing'9)6 min(

rest pain

 no relieved

with rest or

est angina

'4)6 min orrelieved

with rest or

sublingual

NT%

New-onset

CCS Class!!! or !

angina in

the past )

wk with

T/e $. S1ort7Ter# R*): o Det1 or Nont/ MI *n

!ntermediate

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  2eature

1igh isk 'At

least . of thefollowing

features must

be present(

!ntermediate

isk 'No high-

risk feature

but must have. of the

following

features(

3ow isk 'No

high- or

intermediate-risk

feature but mayhave any of the

following

features(

#C% 8ndings Angina at restwith transient

ST-segment

changes

96H6: m 

T-waveinversions

96H) m 

Normal orunchanged

#C% during

an episode of

chestdiscomfort

undle-

branch block,

new or

0athological B

waves

!ntermediate

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  2eature

1igh isk 'At

least . of thefollowing

features must

be present(

!ntermediate

isk 'No high-

risk feature

but must have. of the

following

features(

3ow isk 'No

high- or

intermediate-risk

feature but mayhave any of the

following

features(

  Cardiacmarkers

arkedlyelevated 'eg,

Tn! 96H.

ng7m3(

Slightlyelevated 'eg,

Tn ! 96H6. but

46H. ng7m3(

Normal

C

C "* CC "* C

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Cr"*c CreCr"*c Cre

Go/)Go/)"ecrease amount of"ecrease amount ofmyocardial necrosismyocardial necrosis

0reserve 3 function0reserve 3 function

0revent maEor adverse0revent maEor adverse

cardiac eventscardiac events

Treat life threateningTreat life threatening

complicationscomplications

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STEMI CARDIAC CARESTEMI CARDIAC CARE

 Assessment Assessment Time since onset of symptomsTime since onset of symptoms

J6 min for 0C! 7 .) hours for 8brinolysisJ6 min for 0C! 7 .) hours for 8brinolysis

!s this high risk ST#!K!s this high risk ST#!K $!33!0 classi8cation$!33!0 classi8cation !f higher risk may manage with more!f higher risk may manage with more

invasive rinvasive r

"etermine if 8brinolysis candidate"etermine if 8brinolysis candidate eets criteria with no contraindicationseets criteria with no contraindications

"etermine if 0C! candidate"etermine if 0C! candidate ased on availability and time to balloon rased on availability and time to balloon r

F* * / *F* * / *

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F*r*no/!)*)F*r*no/!)*)

*n"*ct*on)*n"*ct*on)ST segment elevationST segment elevation 9.mm9.mmin two contiguous leadsin two contiguous leads

New 3New 3Symptoms consistent withSymptoms consistent with

ischemiaischemiaSymptom onsetSymptom onset less than .)less than .)

hrshrs prior to presentationprior to presentation

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 A)o/ute contr*n"*ct*on) or A)o/ute contr*n"*ct*on) or

2r*no/!)*) t1er&! *n &t*ent)2r*no/!)*) t1er&! *n &t*ent)

 8*t1 cute STEMI 8*t1 cute STEMI  Any prior !C1

$nown structural cerebral vascular lesion

$nown malignant intracranial neoplasm'primary or metastatic(

!schemic stroke within F months #@C#0Tacute ischemic stroke within F hours

Suspected aortic dissection

 Active bleeding or bleeding diathesis'ecluding menses(

Signi8cant closed-head or facial trauma

within F montH

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Re/t*0e contr*n"*ct*on) orRe/t*0e contr*n"*ct*on) or

2r*no/!)*) t1er&! *n &t*ent)2r*no/!)*) t1er&! *n &t*ent)

 8*t1 cute STEMI 8*t1 cute STEMI1istory of chronic, severe, poorlycontrolled hypertension

Severe uncontrolled hypertension onpresentation 'S0 greater than .D6 mm1g or "0 greater than ..6 mm1g(

1istory of prior ischemic stroke greaterthan F months, dementia, or knownintracranial pathology not covered incontraindications

Traumatic or prolonged 'greater than.6 minutes( C0 or maEor surgery 'lessthan F weeks(

R / t* t * "* t*

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ecent 'within )-5 weeks( internalbleeding

Noncompressible vascular punctures 2or streptokinase7anistreplase* prior

eposure 'more than : days ago( orprior allergic reaction to these agents

0regnancy Active peptic ulcerCurrent use of anticoagulants* the

higher the !N, the higher the risk ofbleeding

Re/t*0e contr*n"*ct*on)or 2r*no/!)*) t1er&! *n

&t*ent) 8*t1 cute STEMI 

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SUMMARY SUMMARY 

 ACS includes UA, NST#!, and ST#! ACS includes UA, NST#!, and ST#! Assesment the diagnosis of ACS Assesment the diagnosis of ACS

anagement guideline focusanagement guideline focus !mmediate assessment7intervention!mmediate assessment7intervention '+NALA1('+NALA1( isk strati8cationisk strati8cation 'UA7NST#! vsH ST#!('UA7NST#! vsH ST#!( A0!" reperfusion for ST#!A0!" reperfusion for ST#! '0C! vsH'0C! vsH

Thrombolytics(Thrombolytics(

Conservative vs !nvasive therapy forConservative vs !nvasive therapy forUA7NST#!UA7NST#!

 Aggressive attention to secondary Aggressive attention to secondaryprevention initiatives for ACS patientsprevention initiatives for ACS patients

eta blocker, ASA, AC#-!, Statineta blocker, ASA, AC#-!, Statin

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SUMMARY SUMMARY 

ST#! CA# C!CUST#! CA# C!CU onitor for complications*onitor for complications*

recurrent ischemia, cardiogenic shock, !C1,recurrent ischemia, cardiogenic shock, !C1,

arrhythmiasarrhythmias

eview guidelines for speci8c managementeview guidelines for speci8c management

of complications = other speci8c clinicalof complications = other speci8c clinical

scenariosscenarios

0C! after 8brinolysis, emergent CA%, etcM0C! after 8brinolysis, emergent CA%, etcM

"ecision making for risk strati8cation at"ecision making for risk strati8cation at

hospital dischargehospital discharge and7orand7or need for CA%need for CA%

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THANK YOU

FOR YOUR

ATTENTION

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STEMI cr"*c creSTEMI cr"*c cre STEP 'STEP '* "etermine preferred reperfusion strategy* "etermine preferred reperfusion strategy

  2ibrinolysis2ibrinol ysis preferred if*preferred if* 44F hours from onsetF hours from onset 0C! not0C! not

available7delayedavailable7delayed door to balloon 9door to balloon 9

J6minJ6min door to balloondoor to balloon

minus door tominus door toneedle 9 .hrneedle 9 .hr

"oor to needle goal"oor to needle goal4F6min4F6min

  0C!0C! preferred if*preferred if* 0C! available0C! available "oor to balloon 4"oor to balloon 4

J6minJ6min "oor to balloon"oor to balloon

minus door tominus door to

needle 4 .hrneedle 4 .hr 2ibrinolysis2ibrinolysis

contraindicationscontraindications 3ate 0resentation 93ate 0resentation 9

F hrF hr 1i h risk ST#!1i h risk ST#!

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Co#&r*n+ outco#e)Co#&r*n+ outco#e)

Me"*c/ T1er&!Me"*c/ T1er&!

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Me"*c/ T1er&! Me"*c/ T1er&! 

MONA 6 BAHMONA 6 BAH

Mor&1*neMor &1*ne 'class !, level C('class !, level C( Analgesia Analgesia )-: mg , maimum )6 mg 7day)-: mg , maimum )6 mg 7day

educe pain7aniety/decrease sympatheticeduce pain7aniety/decrease sympathetic

tone, systemic vascular resistance and oygentone, systemic vascular resistance and oygendemanddemand

Careful with hypotension, hypovolemia,Careful with hypotension, hypovolemia,

respiratory depressionrespiratory depression

O9!+enO9  !+en ')-5 liters7minute( 'class !, level C(')-5 liters7minute( 'class !, level C( Up to 6G of ACS patient demonstrateUp to 6G of ACS patient demonstrate

hypoemiahypoemia

ay limit ischemic myocardial damage byay limit ischemic myocardial damage by

increasing oygen delivery7reduce ST elevationincreasing oygen delivery7reduce ST elevation

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N*tro+/!cer*nN*tr o+/!cer*n 'class !, level ('class !, level ( Analgesia/titrate infusion to keep patient pain Analgesia/titrate infusion to keep patient pain

freefree "ilates coronary vessels/increase blood Oow"ilates coronary vessels/increase blood Oow educes systemic vascular resistance and preloadeduces systemic vascular resistance and preload Careful with hypotension, bradycardia,Careful with hypotension, bradycardia,

tachycardia, infarctiontachycardia, infarction A)&*r*n A)&*r*n ''.;6-F):mg chewed = swallowed.;6-F):mg chewed = swallowed( 'class !,( 'class !,

level A(level A( !rreversible inhibition of platelet aggregation!rreversible inhibition of platelet aggregation

Stabili>e pla&ue and arrest thrombusStabili>e pla&ue and arrest thrombus educe mortality in patients with ST#!educe mortality in patients with ST#! Careful with active 0U", hypersensitivity, bleedingCareful with active 0U", hypersensitivity, bleeding

disordersdisorders

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Bet7B/oc:er)Bet7B/oc:er) 'class !, level A('class !, level A( .5G reduction in mortality risk at days at )FG.5G reduction in mortality risk at days at )FG

long term mortality reduction in ST#!long term mortality reduction in ST#!

 Approimate .FG reduction in risk of Approimate .FG reduction in risk ofprogression to ! in patients with threatening orprogression to ! in patients with threatening orevolving ! symptomsevolving ! symptoms

e aware of contraindications 'C12, 1eart block,e aware of contraindications 'C12, 1eart block,

1ypotension(1ypotension(

 ACE7In1**tor) - ARB ACE7In1**tor) - ARB 'class !, level A('class !, level A( Start in patients with anterior !, pulmonaryStart in patients with anterior !, pulmonary

congestion, 3#2 4 56G in absence ofcongestion, 3#2 4 56G in absence ofcontraindication7hypotensioncontraindication7hypotension Start in 8rst )5 hoursStart in 8rst )5 hours A as substitute for patients unable to use A as substitute for patients unable to use AC#-! AC#-!

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He&r*nHe&r*n 'class !, level C to class !!a, level C('class !, level C to class !!a, level C(

3P1 or U213P1 or U21 'ma 5666u bolus, .666u7hr'ma 5666u bolus, .666u7hr(( !ndirect inhibitor of thrombin!ndirect inhibitor of thrombin

 less supporting evidence of bene8t in era ofless supporting evidence of bene8t in era of

reperfusionreperfusion

 AdEunct to surgical revasculari>ation and AdEunct to surgical revasculari>ation and

thrombolytic 7 0C! reperfusionthrombolytic 7 0C! reperfusion

Coordinate with 0C! team 'U21 preferred(Coordinate with 0C! team 'U21 preferred(

Used in combo with aspirin and7or other plateletUsed in combo with aspirin and7or other platelet

inhibitorsinhibitors

Changing from one to the other not recommendedChanging from one to the other not recommended

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 A""*t*on/ #e"*ct*on t1er&!  A""*t*on/ #e"*ct*on t1er&! 

C/o&*"oC/o&*"o++re/re/ 'class !, level ('class !, level ( !rreversible inhibition of platelet aggregation!rreversible inhibition of platelet aggregation Used in support of cath 7 0C! intervention orUsed in support of cath 7 0C! intervention or

if unable to take aspirinif unable to take aspirin F to .) month duration depending onF to .) month duration depending on

scenarioscenario G/!co&rote*n II-III *n1**tor)G/ !co&rote*n II-III *n1**tor) 

'class !!a, level ('class !!a, level ( !nhibition of platelet aggregation at 8nal!nhibition of platelet aggregation at 8nal

common pathwaycommon pathway !n support of 0C! intervention as early as!n support of 0C! intervention as early as

posspossible prior to 0C!ible prior to 0C!

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 A""*t*on/ #e"*ct*on t1er&!  A""*t*on/ #e"*ct*on t1er&! 

 A/"o)terone /oc:er) A/"o)terone /oc:er) 'class !, level A 'class !, level A (( 0ost-ST#! patients0ost-ST#! patients

No signi8cant renal failure 'crNo signi8cant renal failure 'cr

4 )H: men or )H6 for women(4 )H: men or )H6 for women(

No hyperkalemis 9 :H6No hyperkalemis 9 :H6

3#2 4 56G3#2 4 56GSymptomatic C12 or "Symptomatic C12 or "

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STEMI cre CCUSTEMI cre CCU

onitor for complications*onitor for complications* recurrent ischemia, cardiogenic shock, !C1,recurrent ischemia, cardiogenic shock, !C1,

arrhythmiasarrhythmias

eview guidelines for speci8ceview guidelines for speci8cmanagement of complications = othermanagement of complications = other

speci8c clinical scenariosspeci8c clinical scenarios 0C! after 8brinolysis, emergent CA%, etcM0C! after 8brinolysis, emergent CA%, etcM

"ecision making for risk strati8cation at"ecision making for risk strati8cation at

hospital dischargehospital discharge and7orand7or need for CA%need for CA%

U t / * -NSTEMIU t / * -NSTEMI

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Un)t/e n+*n-NSTEMIUn)t/e n+*n-NSTEMI

cr"*c crecr"*c cre

#valuate for conservative vsH invasive#valuate for conservative vsH invasive

therapy based upon*therapy based upon*isk of actual ACSisk of actual ACS

T!! risk scoreT!! risk score

 ACS risk categories per A1A guidelines ACS risk categories per A1A guidelines

Lo8 Lo8 Inter#e"*teInter#e"*te

H*+1H*+1

TIMI R* : S

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TIMI R*): ScorePre"*ct) r*): o "et1, ne8-recurrent MI, nee" or

ur+ent re0)cu/r*3t*on 8*t1*n $ "!)

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* : * *ACS * : * *

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 ACS r*): cr*ter* ACS r*): cr*ter*

3ow Ris/ AC%No intermediate or high

risk factors

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High Ris/ AC%

Elevated cardiac markersNe$ or presumed ne$ '% depression

(ecurrent ischemia despite therapy

(ecurrent ischemia $ith heart failure

)igh risk findings on non-invasive stress test!epressed systolic left ventricular function

)emodynamic insta*ility

'ustained +entricular tachycardia

,C $ith . months,rior /ypass surgery

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Lo8

r*): 

H*+1

r*): 

Con)er0Con)er0

t*0et*0et1er&! t1er&! 

In0)*0eIn0)*0e

t1er&! t1er&! 

C1e)t P*nC1e)t P*n

center center 

Inter#e"*te 

r*): 

In0)*0e t1er&! o&t*onIn0)*0e t1er&! o&t*on

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In0)*0e t1er&! o&t*onIn0)*0e t1er&! o&t*on

UA-NSTEMIUA-NSTEMI Coronary angiography and

revasculari>ation within .) to 5D hoursafter presentation to #"

2or high risk ACS 'class !, level A ( +NA L A 1 (UFH)

Clopidogrel )6G reduction death7!7Stroke Q CU# trial

. month minimum duration and possibly up to J. month minimum duration and possibly up to J

monthsmonths

%lycoprotein !!b7!!!a inhibitors%lycoprotein !!b7!!!a inhibitors

Con)er0t*0e T1er&! orCon)er0t*0e T1er&! or

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Con)er0t*0e T1er&! orCon)er0t*0e T1er&! or

UA-NSTEMIUA-NSTEMI

#arly revasculari>ation or 0C!#arly revasculari>ation or 0C! notnot plannedplanned

+NA L A +NA L A 11 (LMW or UFH)(LMW or UFH)

ClopidogrelClopidogrel

%lycoprotein !!b7!!!a inhibitors%lycoprotein !!b7!!!a inhibitors +nly in certain circumstances 'planning 0C!,+nly in certain circumstances 'planning 0C!,

elevated Tn!7T(elevated Tn!7T( Surveillence in hospitalSurveillence in hospital

Serial #C%sSerial #C%s

Serial arkersSerial arkers

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Secon"r! Pre0ent*onSecon"r! Pre0ent*on

"isease"isease 1TN, ", 1301TN, ", 130

ehavioralehavioral smoking, diet, physical activity, weightsmoking, diet, physical activity, weight

CognitiveCognitive #ducation, cardiac rehab program#ducation, cardiac rehab program

Secon"r! Pre0ent*onSecon"r! Pre0ent*on

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Secon"r! Pre0ent*onSecon"r! Pre0ent*on

"*)e)e #n+e#ent"*)e)e #n+e#ent

lood 0ressurelood 0ressure %oals 4 .567J6 or 4.F67D6 in " 7C$"%oals 4 .567J6 or 4.F67D6 in " 7C$" aimi>e use of beta-blockers = AC#-!aimi>e use of beta-blockers = AC#-!

3ipids3ipids 3"3 4 .66 '6( I T% 4 )663"3 4 .66 '6( I T% 4 )66 aimi>e use of statinsI consideraimi>e use of statinsI consider

8brates7niacin 8rst line for T%9:66I8brates7niacin 8rst line for T%9:66I

consider omega-F fatty acidsconsider omega-F fatty acids

"iabetes"iabetes A.c 4 G A.c 4 G

Secon"r! &re0ent*onSecon"r! &re0ent*on

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Secon"r! &re0ent*onSecon"r! &re0ent*on

e10*or/ *nter0ent*one10*or/ *nter0ent*on

Smoking cessationSmoking cessation Cessation-class, meds, counselingCessation-class, meds, counseling

0hysical Activity0hysical Activity %oal F6 - ;6 minutes daily%oal F6 - ;6 minutes daily isk assessment prior to initiationisk assessment prior to initiation

"iet"iet "AS1 diet, 8ber, omega-F fatty acids"AS1 diet, 8ber, omega-F fatty acids 4G total calories from saturated4G total calories from saturated

fatsfats

Me"*ct*on C1ec:/*)tMe"*ct*on C1ec:/*)t

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Me"*ct*on C1ec:/*)tMe"*ct*on C1ec:/*)t

ter ACSter ACS

 Antiplatelet agent Antiplatelet agent Aspirin Aspirin and7or Clopidorgreland7or Clopidorgrel

3ipid lowering agent3ipid lowering agent

StatinStatin 2ibrate 7 Niacin 7 +mega-F2ibrate 7 Niacin 7 +mega-F

 Antihypertensive agent Antihypertensive agent

eta blockereta blocker AC#-! AC#-!7A7A Aldactone Aldactone 'as appropriate('as appropriate(

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Su##r! Su##r! 

 ACS includes UA, NST#!, and ST#! ACS includes UA, NST#!, and ST#!

anagement guideline focusanagement guideline focus !mmediate assessment7intervention!mmediate assessment7intervention '+NALA1('+NALA1(

isk strati8cationisk strati8cation 'UA7NST#! vsH ST#!('UA7NST#! vsH ST#!( A0!" reperfusion for ST#!A0!" reperfusion for ST#! '0C! vsH Thrombolytics('0C! vsH Thrombolytics( Conservative vs !nvasive therapy for UA7NST#!Conservative vs !nvasive therapy for UA7NST#!

 Aggressive attention to secondary prevention Aggressive attention to secondary prevention

initiatives for ACS patientsinitiatives for ACS patients eta blocker, ASA, AC#-!, Statineta blocker, ASA, AC#-!, Statin

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THANK YOU

FOR YOUR

ATTENTION

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