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    Acute Coronary Syndrome - YM

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    Nirwana
    This document discusses the diagnosis and management of acute coronary syndrome (ACS). It begins by defining ACS as acute thrombosis or erosion of an atherosclerotic coronary plaque causing reduced blood flow. It then covers the following key points in 3 sentences or less: 1) Clinical presentation of ACS can include chest pain (angina) or equivalent symptoms like shortness of breath. ECG often shows ST elevation in STEMI or non-specific changes in NSTEMI. Cardiac biomarkers like troponins rise later and indicate heart muscle damage. 2) Management of STEMI involves immediate reperfusion therapy like primary PCI if available within 120 minutes or fibrinolytic drugs. Management of NSTEMI relies on risk strat

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    Acute Coronary Syndrome - YM

    Uploaded by

    Nirwana
    38 views64 pages
    This document discusses the diagnosis and management of acute coronary syndrome (ACS). It begins by defining ACS as acute thrombosis or erosion of an atherosclerotic coronary plaque causing reduced blood flow. It then covers the following key points in 3 sentences or less: 1) Clinical presentation of ACS can include chest pain (angina) or equivalent symptoms like shortness of breath. ECG often shows ST elevation in STEMI or non-specific changes in NSTEMI. Cardiac biomarkers like troponins rise later and indicate heart muscle damage. 2) Management of STEMI involves immediate reperfusion therapy like primary PCI if available within 120 minutes or fibrinolytic drugs. Management of NSTEMI relies on risk strat

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    Acute Coronary Syndrome_YM

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    This document discusses the diagnosis and management of acute coronary syndrome (ACS). It begins by defining ACS as acute thrombosis or erosion of an atherosclerotic coronary plaque causing reduced blood flow. It then covers the following key points in 3 sentences or less: 1) Clinical presentation of ACS can include chest pain (angina) or equivalent symptoms like shortness of breath. ECG often shows ST elevation in STEMI or non-specific changes in NSTEMI. Cardiac biomarkers like troponins rise later and indicate heart muscle damage. 2) Management of STEMI involves immediate reperfusion therapy like primary PCI if available within 120 minutes or fibrinolytic drugs. Management of NSTEMI relies on risk strat

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    38 views64 pages

    Acute Coronary Syndrome - YM

    Uploaded by

    Nirwana
    This document discusses the diagnosis and management of acute coronary syndrome (ACS). It begins by defining ACS as acute thrombosis or erosion of an atherosclerotic coronary plaque causing reduced blood flow. It then covers the following key points in 3 sentences or less: 1) Clinical presentation of ACS can include chest pain (angina) or equivalent symptoms like shortness of breath. ECG often shows ST elevation in STEMI or non-specific changes in NSTEMI. Cardiac biomarkers like troponins rise later and indicate heart muscle damage. 2) Management of STEMI involves immediate reperfusion therapy like primary PCI if available within 120 minutes or fibrinolytic drugs. Management of NSTEMI relies on risk strat

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    of 64

    DIAGNOSIS AND MANAGEMENT

    OF ACUTE CORONARY
    SYNDROME

    MUHAIMIN MUNIZU
    ACUTE CORONARY SYNDROME
    Acute thrombosis induced by a ruptured or eroded
    atherosclerotic coronary plaque, with or without
    concomitant vasoconstriction, causing a sudden and
    critical reduction in blood flow

    2 Hamm CW et al. EurHeart J 2011;32:2999 –3054


    SPECTRUM ACS
    1. CLINICAL PRESENTATION
    1. CLINICAL PRESENTATION

    • ANGINA
    • ANGINA EQUIVALENT
    ANGINA

    Chest pain caused by reduced blood flow to the heart muscle


    (imbalanced between O2 supply and demand)

    Substernal Substernal, Substernal, Epigastric


    radiated to jaw radiated to left arm

    Epigastric, radiated to Neck and Jaw Left shoulder and Intrascapular


    neck, jaw and arm both arm
    ANGINAL EQUIVALENT
    • Symptom such as :
    – Shortness of breath
    – Diaphoresis
    – Extreme fatigue
    – Pain at site other than chest
    Occuring in a patient at high cardiac risk

    • Mostly :
    – Elderly (>75 years old)
    – Woman
    – Diabetic
    – Chronic Kidney Disease (CKD)
    ANGINA PRESENTATION IN ACS
    1. Prolonged (>20 min) anginal pain at rest;
    2. New onset (de novo) angina (class II or III of
    the Canadian Cardiovascular Society
    classification);
    3. Recent destabilization of previously stable
    angina with at least Canadian
    Cardiovascular Society Class III angina
    characteristics (crescendo angina); or
    4. Post-MI angina.
    2. ECG PRESENTATION
    2. ECG PRESENTATION
    Based on the ECG, two groups of patients
    should be differentiated:
    (1) Patients with acute chest pain and persistent

    (>20 min) ST-segment elevation


    (ST-elevation ACS )

    (2) Patients with acute chest pain but no


    persistent ST-segment elevation
    (Non-ST-elevation ACS)
    ECG

    • Resting 12-lead ECG is the first-line diagnostic


    tool
    • Performed 10 min after first medical contact
    • Repeated in the case of recurrence of
    symptoms, and after 6–9 and 24 h, and before
    hospital discharge.
    ECG PRESENTATION IN STEMI

    Typical ECG Presentation


    ST elevation measured at the J point in at least 2
    contiguous leads with elevation :
    1. ≥0.25 mV in men <40 years old in leads V2-V3,
    2. ≥0.2 mV in men >40 years old in leads V2-V3,
    3. ≥ 0.15 mV in women in leads V2-V3, and/or
    4. ≥0.1 mV in other leads.

    15
    Atypical ECG presentation
    1. LBBB
    The original three criteria (Sgarbossa
    Criteria) used to diagnose infarction in
    patients with LBBB are:
    • Concordant ST elevation > 1mm in
    leads with a positive QRS complex
    (score 5)
    • Concordant ST depression > 1 mm in
    V1-V3 (score 3)
    • Excessively discordant ST elevation >
    5 mm in leads with a -ve QRS complex
    (score 2).

    These criteria are specific, but not sensitive for myocardial infarction. A
    total score of ≥ 3 is reported to have a specificity of 90% for diagnosing
    myocardial infarction.
    2. RBBB
    • The presence of RBBB may confound the diagnosis of STEMI.
    • Although RBBB usually will not hamper interpretation of ST-
    segment elevation, prompt management should be considered
    when persistent ischaemic symptoms occur in the presence of
    RBBB.
    • Patients with MI and right bundle branch block (RBBB) have a
    poor prognosis.
    3. Isolated Posterior MI

    4. LM Occlusion or MVD

    5. Ventricular Paced Rhytm


    ECG CHANGES IN STEMI

    Lilly. Pathophysiology of Heart Disease, 4th Ed. Lippincott Williams, 2007. Page 182
    ECG PRESENTATION IN
    NSTE-ACS

    1. Transient ST-segment elevation


    2. Persistent or transient ST-segment
    depression
    3. T-wave inversion
    4. Flat T waves
    5. Pseudo-normalization of T waves
    6. ECG may be normal.

    23
    ST Depression ST Depression ST Depression T wave
    Upsloping Downsloping Horizontal inverted
    24
    3. CARDIAC BIOMARKER

    25
    Serum Markers of
    Myocardial Infarction
    • Myocardial necrosis causes sarcolemma
    disruption
    • Intracellular macromolecules are released
    • Can be measured by serial blood testing
    • Pattern and level of rise correlates with
    timing and size of MI
    Cardiac-Specific Troponins
    • Regulatory protein that controls interaction
    between actin & myosin
    • 3 subunits: TnC, I, T Skeletal &
    cardiac muscle
    • Unique cardiac troponins I and T exist - absent in
    serum of healthy people
    • Powerful marker of myocyte damage
    • Rise at 3-4 hours post-MI, peak 18-36 hrs,
    decline slowly 10-14 days
    Creatinine Kinase
    • Enzyme that converts ADP to ATP
    • Found in many tissues: heart, brain, skeletal
    muscle, kidney, etc.
    • Can be elevated after injury to any of these
    tissues
    • 3 isoenzymes: - CK-MM
    - CK-MB
    - CK-BB
    CPK-MB

    • Makes up 1-3% of skeletal CK

    • Makes up much higher % of cardiac CK

    • Rises 4-8 hours after MI, peaks by 24 hours

    • Returns to normal in 48-72 hours


    3. CARDIAC BIOMARKER
    • Troponins are more specific and
    sensitive than the traditional cardiac
    enzymes
    • The test should be repeated 6–9 h after
    initial assessment if the first
    measurement is not conclusive
    • Do not wait biomarker result in STEMI
    patients

    30
    Kumar A; Cannon CP et al. Mayo Clin Proc. 2009;84(10):917-938; Steg G et al. Eur Heart J. 2012;33:2569-619;
    Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
    4. MANAGEMENT
    Management of Acute
    Coronary Syndromes:

    STE vs. Non STE


    Management of ACS
    • Anti-ischemic therapies • Β-blocker
    • Nitrates
    • +/- Calcium channel blocker

    • General measures: • Pain control (morphine)


    • Supplemental O2 if needed

    • Antithrombotic therapies
    Antiplatelet agents: • Aspirin
    • Clopidogrel (or prasugrel), Ticagrelor
    • GP IIb/IIIa inhibitor (for selected high
    risk patients; may be deferred until PCI)
    Anticoagulants (use one): • LMWH (enoxaparin)
    • Unfractionated intravenous heparin
    • Fondaparinux
    • Bivalirudin (should be used in ACS
    patient only if undergoing PCI)

    • Adjunctive therapies: • Statin


    • Angiotensin converting-enzyme
    inhibitor/ARB
    Management of Acute
    Coronary Syndromes
    ST-Elevation Non-ST-Elevation
    (STEMI) (UA and NSTEMI)

    Primary PCI available Risk Assessment


    within 120 min? (e.g., GRACE Score)

    No Yes Low High


    Fibrinolytic Primary PCI Conservative Invasive
    Therapy Strategy Strategy
    (e.g., Streptase, (Proceed to cardiac cath (Cardiac cath
    tPA) only if recurrent angina leading to
    or predischarge PCI or CABG)
    stress test is markedly
    positive)
    MANAGEMENT OF STEMI
    MANAGEMENT OF NSTE-ACS
    Risk Stratification is important in NSTE-ACS Management

    1 CLINICAL CONDITION

    2 3
    TIMI SCORE GRACE SCORE

    Less accurate in predicting recommended as the preferred


    events but its simplicity makes classification to apply on
    it useful and widely accepted admission and at discharge in
    daily clinical routine practice

    Hamm W et al. European Heart Journal 2007; 28:1598–1660; Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
    Clinical Condition
    Clinical Condition
    Thrombolysis In Myocardial Infarction (TIMI) Risk Score
    GRACE RISK SCORE
    Global Registry of Acute Coronary Events
    (GRACE) scores
    THANK YOU

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