ACS UPDATE.ppt

8/9/2019 ACS UPDATE.ppt

http://slidepdf.com/reader/full/acs-updateppt 1/64

ACUTE CORONARY

SYNDROMESR MAHARAJ

EMERGENCY MEDICINE



LECTURE OUTLINE

• INTRODUCTION –EPIDEMIOLOGY/PREVALENCE/DEFINITION

• PATHOPHYSIOLOGY OF ACUTE CORONARYSYNDROMES

• APPROACH TO SUSPECTED ACUTE

CORONARY SYNDROME – GUIDELINEUPDATE

• TREATMENT/MANAGEMENT UPDATE



INTRODUCTION

• Coronary Artery Dieae – !ea"in# $a%e o& 'or(i"ity ) 'orta!ity in

in"%tria!ie" nation*

• A!t+o%#+ "e$reae in $ar"io,a$%!ar 'orta!ity ti!! 'a-or $a%e

o& 'or(i"ity ) (%r"en o& "ieae*

• So%t+ A&ri$an .er.e$ti,e o& $ar"io,a$%!ar "ieae

• “A World in One Country” 0 Y%%& et a!

• E.i"e'io!o#i$a! tranition o& $ar"io,a$%!ar "ieae*



• HIGH RIS1 POPULATION FOR CAD/ACS

INDIAN/2HITE/COLOURED

• INCREASING rate in 3!a$4 .o.%!ation – !i&ety!e/o$ioe$ono'i$

$+an#e5 %r(aniation

• GF 6oote tat 78*9: o& a"'iion to re%* %nit &or $+et

.ain/a$ re!ate" ;tat <6an 7==> – 79 Fe( 7==>? <@=/79 entrie*

• In US – 7==B – <*@ 'i!!ion a"'iion &or ACS – > === &or

%nta(!e an#ina5 9> === &or MI

• Hi#+er .re,e!an$e &or NSTEMI*



DEFINITIONS

• CAD i a $ontin%%' o& "ieae*

• An#ina 0 %nta(!e an#ina 0 AMI 0 %""en $ar"ia$ "eat+

• A$%te $oronary yn"ro'e en$o'.ae %nta(!e an#ina5 NSTEMI5STEMI

• Sta(!e an#ina – tranient e.io"i$ $+et .ain "/t 'yo$ar"ia!

i$+ae'ia5 re.ro"%$i(!e5 &re%en$y $ontant o,er ti'e*%%a!!y

re!ie,e" it+ ret/NTG*

• C!ai&i$ation o& an#ina – Canadian Cardiovascular Society

classification.



Cana"ian Car"io,a$%!ar Ao$iation C!ai&i$ation o&

An#ina

CLASS < NO PAIN 2ITH ORDINARY PHYSICAL ACTIVITY

CLASS 7 SLIGHT LIMITATION OF PHYSICAL ACTIVITY –

PAIN OCCURS 2ITH 2AL1ING5 CLIM3INGSTAIRS5STRESS

CLASS 8 SEVERE LIMITATION OF DAILY ACTIVITY – PAINOCCURS ON MINIMAL EERTION

CLASS B UNA3LE TO CONDUCT ANY ACTIVITY 2ITHOUTPAIN5 PAIN AT REST



• UNSTA3LE ANGINA –

• Pain o$$%rrin# at ret – "%ration 7='in5 it+in one ee4 o& &irt

,iit

• Ne onet an#ina – C!a 7 e,erity5 onet it+ !at 7 'ont+

• 2orenin# o& $+et .ain – in$reae (y at !eat < $!a5 in$reae in&re%en$y5 "%ration

• An#ina (e$o'in# reitan$e to "r%# t+at .re,io%!y #a,e #oo"

$ontro!*

• N3 ECG – nor'a!5 ST "e.reion;=*@''?5 T a,e $+an#e



• ACUTE MYOCARDIAL INFARCTION –

• ECC/ACC DEFN –rie an" &a!! in $ar"ia$ enJy'e it+ one or 'ore

o& t+e &o!!oin#

• I$+ae'i$ ty.e $+et .ain/y'.to'

• ECG $+an#e – ST $+an#e5 .at+o!o#i$a! K a,e• Coronary artery inter,ention "ata

• Pat+o!o#i$a! &in"in# o& an a$%te MI

• NSTEMI UNSTA3LE ANGINA SYMPTOMS/FINDINGS POSITIVE CARDIAC ENYMES

• STEMI ST ELEVATION ON ECG SYMPTOMS



• 2HY IS IT IMPORTANT TO RECOGNISE PATIENTS 2ITH

UNSTA3LE ANGINA

• @ 0<: %&&er an MI it+in a ee4 a&ter a"'iion*

• 8 0<@: "ie it+in a year*



ACS PATHOPHYSIOLOGY

• Ditr%.tion o& $oronary artery

.!a%e 0 .!ate!et

a$ti,ation/a##re#ation

/a$ti,ation o& $oa#%!ation

$a$a"e 0 en"ot+e!ia!

,ao$ontri$tion 0intra!%'ina!

t+ro'(%/e'(o!iation 0

o(tr%$tion 0 ACS

• Se,erity o& $oronary ,ee!

o(tr%$tion ) eQtent o&

'yo$ar"i%' in,o!,e"

"eter'ine $+ara$teriti$ o&

$!ini$a! .reentation



APPROACH

• I"enti&yin# t+oe it+ $+et .ain %##eti,e o& IHD/ACS*

• T+oro%#+ +itory re%ire"

• C+ara$ter o& .ain

• Onet an" "%ration

• Lo$ation an" ra"iation

• A##ra,atin# an" re!ie,in# &a$tor

• A%tono'i$ y'.to'

• TYPICAL VS ATYPICAL HISTORY• Fai!%re to re$o#nie y'.to' ot+er t+an $+et .ain 0 a..roQ 7 +r

"e!ay in ee4in# 'e"i$a! attention



CHARACTERISTICS OF TYPICAL ANGINAL CHEST PAIN ;ADAPTED

FROM ROSENS5 EMERGENCY MEDICINE?

CHARACTERISTIC SUGGESTIVE OF ANGINA LESS SUGGESTIVE OFANGINA

TYPE OF PAIN DULLPRESSURE/CRUSHINGPAIN

SHARP/STA33ING

DURATION 70@ MIN5 7= MIN SECONDSTOHOURS/CONTINUOUS

ONSET GRADUAL RAPID

LOCATION/CHEST WALL

TENDERNESS

SU3STERNAL5 NOT

TENDER TO PALP*

LATERAL CHEST

2ALL/TENDER TO PALP*REPRODUCIBALITY 2ITH

EERTION/ACTIVITY2ITH3REATHING/MOVING

AUTONOMIC SYMPTOMS PRESENT USUALLY A3SENT



ATYPICAL PAIN

• RIS1 FACTORS FOR DEVELOPING ATYPICAL PAIN

• Dia(ete5 &e'a!e5 non +ite .atient5 e!"er!y5 "e'entia5 no .rior +itory o&MI

• ATYPICAL SYMPTOMS

• GIT y'.to'

• Syn$o.e• SO3

• P!e%riti$/.oitiona! .ain

• C+et a!! ten"erne

• No $+et .ain/y'.to'

• NRMI 2 STUDY – MI it+o%t $+et .ain 0 in$reae" ri4 o& "eat+ ;78: ,>:?

• More $o'.!i$ation – +y.otenion5+eart &ai!%re5 tro4e

• De!aye" ED .reentation5 "e!aye" inter,ention



RIS1 STRATIFICATION IN ACS

• Reaon

• Pro,i"e .ro#noti$ in&or'ation

• Deter'ine treat'ent an" !e,e! o& inter,ention 0 !o ri4 .atient –

ear!y "i$+ar#e5 +i#+ ri4 0 a"'iion to +i#+ $are

• He!. "e$on#et t+e ED an" 'a4e a,ai!a(!e 'e"i$a! reo%r$e to'ore nee"y .atient

• Ri4 trati&i$ation +o%!" (e on#oin# – at a"'iion5 09 +r5 7B+r5"i$+ar#e



TOOLS USED IN RIS1 STRATIFICATION

• HISTORY

• ECG

• 3IOCHEMICAL MAR1ERS





ECG

• Firt .oint o& entry into ACS a!#orit+'

• A(nor'a! or nor'a!

• Neit+er <==: eniti,e or <==: .e$i&i$ &or AMI

• Sin#!e ECG &or AMI – eniti,ity o& =:5 .e$i&i$ity >=:

• Re.reent in#!e .oint in ti'e –nee" to (e rea" in $onteQt

• Nor'a! ECG "oe not eQ$!%"e ACS – <0: .ro,en to +a,e AMI5 B:%nta(!e an#ina



• GUIDELINES

• Initia! <7 !ea" ECG – #oa! "oor to ECG ti'e <='in5 rea" (y

eQ.erien$e" "o$tor ;C!a < 3?

• I& ECG not "ia#noti$/+i#+ %.i$ion o& ACS – eria! ECG initia!!y

<@ 08= 'in inter,a! ;C!a < 3?

• ECG a"-%n$t – !ea" V –V>5 RV B ;C!a 7a 3?

• Contin%o% <7 !ea" ECG 'onitorin# reaona(!e a!ternati,e to eria!

ECG ;C!a 7a 3?



3IOCHEMICAL MAR1ERS

• IDEAL MAR1ER

• Hi#+ $on$entration in 'yo$ar"i%'

• Myo$ar"i%' .e$i&i$

• Re!eae" ear!y in in-%ry

• Pro.ortionate to in-%ry

• Non eQ.eni,e tetin#

• Tro.onin

• C1M3• Myo#!o(in

• Ot+er 'ar4er





TROPONINS T/I

• Tro.onin T , I –

• (ot+ e%i,a!ent in "ia#noti$ an" .ro#noti$ a(i!itie ; eQ$e.t in

rena! &ai!%re – Tro. T !e eniti,e?

• E!e,ation 7+r to <7+r

• 8= – B=: o& ACS .atient it+o%t ST e!e,ation – +a" nor'a!

C1M3 (%t e!e,ate" tro.onin on .reentation

• Meta0ana!yi ;Heindereich et al) – o"" o& "eat+ in$reae" 8 to 9

&o!" it+ .oiti,e tro.onin



• Morta!ity at B7 "ay in tro.onin .oiti,e .atient



MYOGLO3IN

• Ra.i" re!eae it+in 7 +o%r

• Not $ar"ia$ .e$i&i$

• R%!e o%t &or NSTEMI rat+er t+an r%!e in*

C1M3

Ue" in $on-%n$tion it+ tro.onin Ue&%! in "ia#noin# re0in&ar$tion



MAR1ER CHANGE SCORES

• 7 +o%r "e!ta C1M3 'a

• Ai' – to eQ$!%"e MI it+in +r o& y'.to' onet

• Deter'ine $+an#e in er%' 'ar4er !e,e! o,er $ertain ti'einter,a! –"e!ta ,a!%e

• In$reain# ,a!%e +i!e ti!! it+in nor'a! ran#e %##eti,e o&

i$+ae'ia – 'ore ra.i" anti0 i$+ae'i$ 'Qn*



OTHER MAR1ERS

• INDICATORS OF INFLAMMATION OR ACTIVATION OF

COAGULATION CASCADE

• Mye!o.eroQi"ae5 o!%(!e CDB= !i#an"5 IL5 +CRP5 " "i'er5

.rot+ro'(in &ra#'ent < ) 7

• E!e,ate" (e&ore onet o& irre,eri(!e in-%ry

• La$4 .e$i&i$ity

• Co'.!eQ !a( aay





ISCHAEMIA MODIFIED AL3UMIN

• Mea%re" it+ a!(%'in $o(a!t (in"in# aay

• In i$+ae'ia 0 "e$reae" (in"in# o& a!(%'in to $o(a!t

• In$reae" it+ 'in%te o& i$+ae'ia – e!e,ate" &or 0<7+r – #one

(y 7B+r

• >=: ne#ati,e .re"i$ti,e ,a!%e• Co'(ine" it+ 'yo#!o(in/C1M3/tro.onin – in$reae "ia#noti$

eniti,ity o& i$+ae'ia (y B=:

• Poi(!e ro!e &or r%!e $riteria in !o ri4 .atient

• Poiti,e IMA – +i#+ ri4 .atient – 'ore a##rei,e 'Qn

• Poiti,e in +y.oQi$ "ior"er – .oor .e$i&i$ity in t+i ettin#



• 3 –ty.e Natri%reti$ Pe.ti"e

• re!eae" &ro' +eart '%$!e in re.one to in$reae" ,entri$%!ar a!!

tre*

• St%"ie – 3NP not a .e$i&i$ 'ar4er (%t a tron# .re"i$tor o& ACS

e.e$ia!!y in .atient it+ $+et .ain5 no ECG $+an#e5 non"ia#noti$ tro.onin*

• A!o .oiti,e in +eart &ai!%re5 PE5 atria! arryt+'ia5 rena! &ai!%re

• Pre#nan$y Ao$iate" P!a'a Protein A ;PAPP0A?

• Re!eae" +en .!a%e r%.t%re

• Pre"i$tor o& i$+ae'ia



• HEART FATTY ACID 3INDING PROTEIN ;HF A3P?

• I"enti&ie AMI B+r a&ter onet

• Protein in,o!,e" in 'yo$ar"ia! !i.i" ynt+ei5 (%t a!o eQ.ree"

o%ti"e +eart

• T+ere&ore 'ay (e eniti,e (%t not .e$i&i$ &or in-%ry• Poi(!e ro!e in '%!ti0'ar4er trate#y

• IMAGING MODALITIES

• Car"ia$ MRI

• M%!ti"ete$tor CT &or $oronary $a!$i&i$ation

• Coronary CT an#io#ra.+y

• Un"er#oin# $!ini$a! e,a!%ation



• 7== ACC/AHA #%i"e!ine• Car"ia$ (io'ar4er 'ea%re" in a!! .atient it+ %.i$ion o& ACS

;C!a < 3?• Tro.onin .re&erre" 'ar4er; C!a < 3?• I& tro.onin ne#ati,e it+in +o%r o& onet5 re.eat 90<7+o%r

!ater;C!a < 3?• Re'ea%rin# o& .oiti,e (io'ar4er to "eter'ine in&ar$t

iJe/ne$roi ;C!a 7a 3?• Patient .reentin# it+in +o%r o& y'.to' onet – 'yo#!o(in in

$on-%n$tion it+ tro.onin 'ea%re" ;C!a 7( 3?• 7+r "e!ta C1M3/De!ta tro.onin $oni"ere" in +r .reentation

;C!a 7( 3?• 3NP !e,e! – &or #!o(a! ri4 ae'ent;C!a 7( 3?• C!a 8 – AST/LDH/C1 it+o%t C1M3



RIS1 STRATIFICATION MODELS



TIMI RIS1 SCORE –in$reae in 'orta!ity it+ in$reain# $ore B=:

a!! $a%e 'orta!ity at <B "ay &or .atient re%irin# %r#ent

re,a$%!ariation



2HICH MODEL IS MOST APPROPRIATE

• 7== ACS/AHA GUIDELINES

• Ri4 trati&i$ation 'o"e! %e&%! in "e$iion 'a4in# it+ re#ar" to

treat'ent o.tion ; C!a 7a 3?

• TIMI , GRACE , PURSUIT

• PURSUIT ) GRACE ri4 $ore a!!o (etter "i$ri'ination o& in

+o.ita! an" < year 'orta!ity in .atient $o'.are" to TIMI* ; Andrew

et al, Ris sc!res "!r ris strati"icati!n in ACS #)

• 2+at a$$r!$riate in !%r settin&'''



MANAGEMENT ALGORITHM



MANAGEMENT UPDATE

7==ACS/AHA GUIDELINES

Ra.i" $ater#oriation o& .atient ;C!a < C?

Poi(!e ACS5 non "ia#noti$ ECG/(io'ar4er – o(er,e" in &a$i!ity

it+ $ar"ia$ 'onitorin# ;C!a < C?

A!ternati,e to in .atient treat'ent &or t+oe it+ <7+r ECG/'ar4er

ne#ati,e – tre ECG in 7+r ;C!a < C?

Gi,in# .re$a%tionary treat'ent &or t+oe &or OPD tre ;C!a < 3?



INITIAL INVASIVE

VS

INITIAL CONSERVATIVE STRATEGY

• CLASS < RECOMMENDATIONS

• Ear!y in,ai,e trate#y &or re&ra$tory an#ina5 +e'o"yna'i$inta(i!ity ;LOE 3?

• Ear!y in,ai,e trate#y &or ta(i!ie" .atient it+ e!e,ate" ri4 &or$!ini$a! e,ent*

• Hi#+ ri4 &a$tor in$!%"e• Re$%rrent an#ina5 i$+ae'ia at ret or 'ini'a! a$ti,ity

• E!e,ate" tro.onin

• Ne ST "e.reion

• Si#n o& +eart &ai!%re/orenin# 'itra! re#%r#*

• Ventri$%!ar ta$+y$ar"ia

• Prior CA3G

• PCI in !at 'ont+

• Hi#+ TIMI/GRACE $ore

• LVEF B=:



• CLASS 7(

• May o.t &or initia! $oner,ati,e trate#y in ta(i!ie" +i#+ ri4

.atient – "e.en"ent on .atient/.+yi$ian .re&eren$e ;LOE 3?

• CLASS 8• In,ai,e trate#y 0not re$o''en"e" in .atient it+ '%!ti.!e $o

'or(i"itie5 !o ri4 .atient5 .atient not $onentin#*;LOE C?



UA/NSTEMI –PHARMACOTHERAPY UPDATE

• GENERAL

• IV 3 3!o$4er "on#ra"e" &ro' C!a < to 7a re$o''en"ation*

;COMMIT Tria!?

• Ora! 3 3!o$4er in &irt 7B+r ti!! C!a < – (%t not %e" in i#n o&

+eart &ai!%re5 $ar"io#eni$ +o$4 an" rea$ti,e airay "ieae*;LOE

3?

• MORPHINE "on#ra"e" &ro' C!a < to 7a – &in"in# &ro'CRUSADE Re#itry



NSTEMI0 PHARMACOTHERAPY UPDATE

• ANTIPLATELET THERAPY

CLASS < RECOMMENDATION

• A.irin to a!! .atient a oon a .oi(!e an" $ontin%e" ;i& no C/I? ;LOE A?

• Initia! "oe <7 087@'#

• Maintenan$e @ 0<7'#

• No a""e" (ene&it &ro' +i#+er "oe eQ$e.t .ot tentin#

• C!o.i"o#re! &or t+oe a!!er#i$ to a.irin or 'a-or GI (!ee"in# ;LOE A?

• For initia! in,ai,e trate#y – a.irin $!o.i"o#re! or IV #!y$o.rotein 7(/8a

t+era.y ;LOE A?• A($iQi'a( i& no "e!ay in an#io#ra.+y/PCI5 e.ti&i(ati"e/tiro&i(an i& "e!aye"

an#io#ra.+y;LOE 3?



• CLASS 7a

• In .atient 'ana#e" $oner,ati,e!y +o "e,e!o. re$%rrent

i$+ae'ia – on $!o.i"o#re!/ASA/Anti$oa#%!ant – $an a""

#!y$o.rotein in+i(itor* ;LOE C?

• In,ai,e trate#y – $an %e $!o.i"o#re! #!y$o.rotein

in+i(itor;LOE C?

• CLASS 7(

• In .atient 'ana#e" $oner,ati,e!y – $an a"" #!y$o.rotein in+i(itort+era.y5 in a""ition to a.irin ) anti$oa#%!ant ;LOE 3?



CLASS 8

• A3CIIMA3 +o%!" not (e #i,en i& PCI not .!anne" ;LOE A?



• For initia! $oner,ati,e trate#y

• A.irin Clopidogrel anti$oa#%!ant – a"'initere" &or <

'ont+;LOE A?5 $ontin%e" i"ea!!y %. to < year;LOE 3?

• I& initia! $oner,ati,e trate#y e!e$te" (%t .atient +a re$%rrenti$+ae'i$ y'.to'/+eart &ai!%re/arryt+'ia – "ia#noti$

an#io#ra.+y re$o''en"e"* Clopidogrel or Gl!opro"ei# $%/&'

i#(i%i"or) +o%!" (e a""e" (e&ore an#io#ra.+y*



ANTICOAGULANT THERAPY

CLASS <

• Anti$oa#%!ant t+era.y +o%!" (e a""e" a oon a .oi(!e

• For .atient %n"er#oin# an#io#ra.+y/PCI – enoQa.arin/UFH ;LOE

A? o& 3i,a!ir%"in/ &on"a.arin%Q ;LOE 3?

• For $oner,ati,e trate#y enaQa.arin5 UFH ;LOE A?5 &on"a.arin%Q

• For .atient it+ in$reae" ri4 o& (!ee"in# it+ $oner,ati,e

trate#y – &on"a.arin%Q



• CLASS 7a

• EnoQa.arin /&on"a.arin%Q , UFH

• EnoQa.arin/&on"a.arin%Q .re&erre" eQ$e.t in t+oe %n"er#oin#

CA3G it+in 7B+r ;LOE 3?



ADDITIONAL MANAGEMENT

• STRESS TEST +o%!" (e .er&or'e" &or t+oe 'ana#e"

$oner,ati,e!y*

• I& tre tet .oiti,e/ +i#+ ri4 – nee" "ia#noti$

an#io#ra.+y;C!a < LOE A?

• I& $!ae" a !o ri4 –

• nee" to $ontin%e a.irin in"e&inite!y ; LOE A?

• C!o.i"o#re! &or at !eat < 'ont+;LOE A?5 i"ea!!y %. to < year;LOE 3?



UA/NSTEMI ALGORITHM0 INVASIVE STRATEGY



UA/NSTEMI ALGORITHM –CONSERVATIVE STRATEGY



STEMI

• PHARMACOLOGICAL UPDATE

• ANALGESIA – $+an#e &ro' 7==B #%i"e!ine

• MORPHINE ti!! re'ain C!a < C &or STEMI5 titrate" "oe

• NSAIDS/CO 7 INHI3ITORS t+oe on it +o%!" +a,e it

"i$ontin%e" ; in$reae" ri4 o& 'orta!ity5 re in&ar$tion5 +eart &ai!%re5

'yo$ar"ia! r%.t%re? C!a < C

• NSAIDS +o%!" not (e a"'initere" in +o.ita! &or MI ;C!a 8?



• 3ETA 3LOC1ERS

• Mo"i&ie" re$o''en"ation

• Ora! 3eta 3!o$4er +o%!" (e initiate" in &irt7Br5 i& no $ontra0

in"i$ation ;+eart &ai!%re5 ri4 o& $ar"io#eni$ +o$4? C!a < 3

• Patient it+ ear!y $ontrain"i$ation 0 re0 e,a!%ate" !ater &or.oi(!e %e

• Ro!e o& IV 3 (!o$4er – %e" in +y.erteni,e .atient it+ STEMI

C!a 7a 3

• C!a 8 LOE A – IV 3 (!o$4er +o%!" not (e a"'initrate" to

.atient it+ +eart &ai!%re5 ri4 o& $ar"io#eni$ +o$4



• No 'a-or $+an#e to re.er&%ion trate#ie*

• E'.+ai on "e$reain# i$+ae'i$ ti'e*

• In$reae %e o& .re+o.ita! <7 !ea" ECG e'.+aie"*

• In PCI $a.a(!e +o.ita! – "oor to PCI ti'e >= 'in ;C!a < A?

•In non PCI $a.a(!e +o.ita! – "oor to nee"!e ti'e 8= 'in or ti'eo%tran&er to PCI $a.a(!e +o.ita!* ;C!a < 3?



REPERFUSION STRATEGY



FI3RINOLYTICS

• AVAILA3LE FI3RINOLYTICS• STREPTO1INASE – <*@'% in&%ion o,er 8='in ;<+o%r –ACLS?• rtPA – a$$e!erate" in&%ion o,er <*@+r• 0 <@'# IV (o!%5 =*@'#/4# o,er 8= 'in5 =*@'#/4# o,er <+r • ANISTREPLASE – 8= U IV o,er @ 'in• TENECTEPLASE – 8= TO @= MG• RETEPLASE – <= U IV (o!%5 &&"* <=U IV a&ter 8= 'in

• 2HICH FI3RINOLYTIC TO USE• GISSI 7 tria! – tPA , Stre.to4inae 5 no "i&&eren$e in 'orta!ity5 'ar#ina!!y

+i#+er tro4e rate it+ tPA ;<*8: , <:?

• GUSTO < tria! – ear!y ,ee! .aten$y .ot in&ra$t ao$* it+ (etter %r,i,a!*• A$$!* tPA/+e.arin $& $o'(* Stre.to4inae/tPA/+e.rain $& tre. it+ IV ,S/C +e.arin

• O%t$o'e – (etter &!o rate it+ a$$!* tPA 0 !oer 'orta!ity rate



• ASSENT 7 TRIAL – tene$te.!ae , aTPA

• 0 tene$te.!ae a e%a!!y or 'ini'a!!y 'ore

e&&e$ti,e5 e.e$ia!!y in t+oe .reentin# B+r a&ter y'.to' onet*

• Fi(rino!yi $o'(ine" it+ #!y$o.rotein 7(/8a in+i(itor – no o,era!!a",anta#e ;ASSENT 85 GUSTO @ tria!?



• RESCUE PCI• CLASS < LOE 3 – an#io#ra.+y it+ /0 PCI in .atient ;@ yr?it+

$ar"io#eni$ +o$45 e,ere +eart &ai!%re5 ,entri$%!ar"yryt+'ia

• C!a 7a – .eritent i$+ae'i$ y'.to' .ot &i(rino!yi5+ae'o"yna'i$ inta(i!ity5 e!e$tri$a! inta(i!ity ;LOE C?

• Ne re$o''en"ation – PCI &or &ai!e" &i(rino!yti$ t+era.y ;!e t+an@=: "e$reae in ST e!e,ation in ort !ea"5 >='in .ot &i(rino!yti$t+era.y5 or !ar#e area o& 'yo$ar"i%' in-%re"? LOE 3

• C!a 8 – an#io#ra.+y .er&or'e" i& in,ai,e trate#y$ontrain"i$ate"5 or .atient re&%a! ;LOE C?



ANTICOAGULANT AD6UNCTS

• NE2 RECOMMENDATIONS

CLASS <

• Patient %n"er#oin# &i(rino!yi +o%!" (e 4e.t on anti$oa#%!ant &or

at!eat B9 +r an" .re&era(!y t+e "%ration o& +o.ita! tay* LOE A

• Anti $oa#%!ant it+ .ro,en e&&i$a$y

• Un&ra$tionate" He.arin 0 4ee.in# aPTT <*@ – 7 e$ a(o,e $ontro!

;LOE C?

• EnoQa.arin ;C!eQane? – initia! "oa#e o& 8='# IV (o!% – &&" (y

<'#/4# <7+r!y5 $a%tion in rena! i'.air'ent ;LOE A?• Fon"a.arin%Q – 7*@'# IV5 &&" (y 7*@'# "!y S/C 'aintenan$e &or

"%ration o& +o.ita!iation ;LOE 3?



ANTICOAGULANTS

• CLASS 7a re$o''en"ation to %e anti$oa#%!ant in STEMI it+o%t

re.er&%ion*

• UFH ;LOE 3?

• LM2H ;LOE C?

• Fon"a.arin%Q ;LOE 3?



THIENOPYRIDINES

CLASS I

• CLOPIDOGREL – no re$o''en"e" in a!! STEMI .atient in

a""ition to a.irin5 +et+er %n"er#oin# re.er&%ion or not* Doa#e

@'# "ai!y;LOE A?

• D%ration 0<B "ay ;LOE 3?

CLASS 7 A

In .atient @yr – C!o.i"o#re! 8=='# !oa"in# "oe

re$o''en"e";LOE C?

Lon# ter' 'aintenan$e t+era.y +o%!" (e $oni"ere"5 @'# "!y &or <year ;LOE C?



SECONDARY PREVENTION

• INCREASED FOCUS ON SECONDARY PREVENTION

• SMO1ING CESSATION

• DIET MODIFICATION/2T CONTROL

• 3P CONTROL

• LIPID MANAGEMENT

• EERCISE

• DIA3ETES MANAGEMENT



• De.ite #oo" re.er&%ion trate#ie a..roQ* </8 o& .atient

or!"i"e 'i o%t*

• Attri(%te" to – "e!aye" .reentation5 aty.i$a! .reentation5

$o'.!i$ate" "ieae .reentation5 o!"er a#e

• SYMPTOMS OF INFARCT 3UT NO ESTA3ILISHED ECG

CHANGES 0 4ee. in 'in" aorti$ "ie$tion5 GIT "ieae5 ot+er

$+et .at+o!o#y







CONCLUSION

• 2it+ in$reae (%r"en o& CVD5 an" !a$4 o& +ea!t+ reo%r$e ri4trati&i$ation (e$o'e i'.ortant*

• E'.+ai +o%!" a!o (e .!a$e" on .ri'ary )e$on"ary .re,ention

o& ACS*

• Ear!y inter,ention +e!. .re,ent $o'.!i$ation5 "e$reae 'or(i"ity

) 'orta!ity

• T+e ay &orar" – &%!!y e%i..e" CHEST PAIN O3SERVATIONUNIT



REFERENCES

• EDITORS MAR ET AL5 ROSENS EMERGENCY MEDICINE CONCEPTS AND CLINICALPRACTICE5 TH EDITION

• PAUL PD ET AL5 1EY ARTICLES IN MANAGEMENT OF ACS ) PCI 07== UPDATE5PHARMACOTHERAPY 7==7;<7?5 <77 0<@=

• 2HITE HD5 DEFINING THE LIMITS OF ACS5 CARDIOLOGY AT THE LIMITS IV5 EDITORS

OPIE LH5 YELLON DM

• YUSUF S5 THE GLO3AL EPIDEMIC OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE5CARDIOLOGY AT THE LIMITS IV5 EDITORS OPIE LH5 YELLON DM

• FO 1A5 MANAGEMENT OF ACS AN UPDATE5 HEART*7==B 6UNE5 >=;?>9 0=

• ANDERSON ET AL5 ACC/AHA 7== GUIDELINES FOR MN OF U/A5NSTEMI – EECUTIVESUMMARY – DO2NLOADED $ontent*on!ine-a$$*or#

• SI A6 ET AL5 CHEST PAIN IN THE ER VALUE OF THE HEART SCORE5 NETH* HEART 6*7==9 6UNE5<;?<>< 0<>



• ANTMAN EM ET AL5 7== FOCUSSED UPDATE OF ACC/AHA 7==B GUIDELINES FOR MANOF PATIENTS 2ITH STEMI5 DO2NLOADED +tt.//$ir$*a+a-o%rna!*or#

• M$CANN C6 ET AL5 NOVEL 3IOMAR1ERS IN EARLY DIAGNOSIS OF AMI COMPARED 2ITH

CARDIAC TROPONIN T5 EUROPEAN HEART 6OURNAL 7==957>;78? 79B8 079@=

•1ING III S3 ET AL5 7== FOCUSSED UPDATE OF ACC**FOR PCI5 6OURNAL OF AMERICAN COLLEGE OF CARDIOLOGY5 VOL @<5 NO 75 7==9

http://circ.ahajournals.org/

http://circ.ahajournals.org/

Documents

ACS UPDATE.ppt