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8/19/2019 ACS- SEPT.12.ppt
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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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