ACUTE CORONARY ACUTE CORONARY SYNDROMESYNDROME

(ACS)(ACS)

ACSACS

Pathophysiology is that of a ruptured Pathophysiology is that of a ruptured or eroded atheromatous plaque.or eroded atheromatous plaque.

Acute Myocardial Infarction (AMI)Acute Myocardial Infarction (AMI)– ST-segment elevation MI (STEMI)ST-segment elevation MI (STEMI)– Non-ST-segment elevation MI (NSTEMI)Non-ST-segment elevation MI (NSTEMI)

Unstable Angina (UA)Unstable Angina (UA)

Goals of Therapy in ACSGoals of Therapy in ACS Reduce the amount of myocardial necrosis Reduce the amount of myocardial necrosis

that occurs in patients with MI, preserving that occurs in patients with MI, preserving left ventricular function and preventing left ventricular function and preventing heart failureheart failure

Prevent major adverse cardiac events: Prevent major adverse cardiac events: death, nonfatal MI, and need for urgent death, nonfatal MI, and need for urgent revascularizationrevascularization

Treat acute, life threatening complications Treat acute, life threatening complications of ACS, such as ventricular of ACS, such as ventricular fibrillation/pulseless ventricular tachycardia, fibrillation/pulseless ventricular tachycardia, symptomatic bradycardias, and unstable symptomatic bradycardias, and unstable tachycardiastachycardias

Copyright ©2005 American Heart Association

Circulation 2005;112:IV-89-IV-110

Acute Coronary Syndromes Algorithm

Targeted HistoryTargeted History

Chest discomfortChest discomfort– what, where, when & how much?what, where, when & how much?

Associated Signs & symptomsAssociated Signs & symptoms– dyspnea, diaphoresis, nausea dyspnea, diaphoresis, nausea

Prior cardiac historyPrior cardiac history– similar pain?similar pain?

Risk FactorsRisk Factors Pertinent PmHxPertinent PmHx

EKGEKG

ST-segment elevation or presumed new ST-segment elevation or presumed new LBBB is characterized by ST-segement LBBB is characterized by ST-segement elevation >1mm in 2 or more contiguous elevation >1mm in 2 or more contiguous precordial leads or 2 or more adjacent limb precordial leads or 2 or more adjacent limb leads and is classsified as ST-elevation MIleads and is classsified as ST-elevation MI

Ischemic ST-segment depression> or = Ischemic ST-segment depression> or = 0.5mm or dynamic T-wave inversion with 0.5mm or dynamic T-wave inversion with pain or discomfort is classified as high-risk pain or discomfort is classified as high-risk UA or NSTEMI. Transient ST elevation of < 20 UA or NSTEMI. Transient ST elevation of < 20 minutes is also included within this catagoryminutes is also included within this catagory

Normal or nondiagnostic changes in Normal or nondiagnostic changes in ST segment or T-waves are ST segment or T-waves are inconclusive and require further risk inconclusive and require further risk stratification. This includes patients stratification. This includes patients with normal EKGs and those with ST-with normal EKGs and those with ST-segment deviation of <0.5segment deviation of <0.5

Cardiac BiomarkersCardiac Biomarkers

CK & CK-MBCK & CK-MB– Rise 4-6 hours after injuryRise 4-6 hours after injury– Peak 12-24 hours after injuryPeak 12-24 hours after injury– Return to baseline in 24-48 hoursReturn to baseline in 24-48 hours

Troponin – Most sensitive and specificTroponin – Most sensitive and specific– Rises 4-6 hours after injuryRises 4-6 hours after injury– Peaks 18-24 hours after injuryPeaks 18-24 hours after injury– May take a week to return to baselineMay take a week to return to baseline

Longer if poor renal functionLonger if poor renal function

ReperfusionReperfusion

Ultimate goal in ACS and immediate Ultimate goal in ACS and immediate goal in STEMI goal in STEMI

Shown to reduce mortality by 47%Shown to reduce mortality by 47% Major determinants of myocardial Major determinants of myocardial

salvage and long term prognosis aresalvage and long term prognosis are– Short time to perfusionShort time to perfusion– Complete and sustained patency of the Complete and sustained patency of the

infarcted artery with normal flowinfarcted artery with normal flow– Normal microvascular perfusionNormal microvascular perfusion

Percutaneous Coronary Percutaneous Coronary Intervention (PCI)Intervention (PCI)

Treatment of choice if can be Treatment of choice if can be performed in <90 minutes from performed in <90 minutes from patient presentationpatient presentation

Goal should be <30 minutes from Goal should be <30 minutes from patient presentation to either PCI, or patient presentation to either PCI, or transfer to facility that performs PCItransfer to facility that performs PCI

Also preferred in patients with Also preferred in patients with contraindications to fibrinolysis and is contraindications to fibrinolysis and is reasonable in patients with reasonable in patients with cardiogenic shock or heart failure. cardiogenic shock or heart failure.

FibrinolysisFibrinolysis

Indicated for STEMI if <12 hours of symptoms Indicated for STEMI if <12 hours of symptoms and PCI unable to be performed in <90 and PCI unable to be performed in <90 minutesminutes

Goal is “door to needle” time of <30 minutesGoal is “door to needle” time of <30 minutes Absolute contraindications include: prior Absolute contraindications include: prior

intercranial hemorrhage, AVM or malignant intercranial hemorrhage, AVM or malignant neoplasm, ischemic stroke>3 hour neoplasm, ischemic stroke>3 hour and<3months, suspected aortic dissection, and<3months, suspected aortic dissection, active bleeding or bleeding diathesis, active bleeding or bleeding diathesis, significant closed head or facial trauma < significant closed head or facial trauma < 3months 3months

Copyright ©2005 American Heart Association

Circulation 2005;112:IV-89-IV-110

Acute Coronary Syndromes Algorithm