Acute Coronary Acute Coronary SyndromeSyndrome

ObjectivesObjectives

Define & delineate acute coronary Define & delineate acute coronary syndromesyndrome

Review Management GuidelinesReview Management Guidelines Unstable Angina / NSTEMIUnstable Angina / NSTEMI STEMISTEMI

Review secondary prevention Review secondary prevention initiativesinitiatives

Scope of Problem Scope of Problem (2004 stats)(2004 stats)

CHD single leading cause CHD single leading cause of death in United Statesof death in United States 452,327 deaths in the U.S. in 452,327 deaths in the U.S. in

20042004

1,200,000 new & 1,200,000 new & recurrent coronary recurrent coronary attacks per year attacks per year

38% of those who with 38% of those who with coronary attack die within coronary attack die within a year of having ita year of having it

Annual cost > $300 billionAnnual cost > $300 billion

Expanding Risk FactorsExpanding Risk Factors

SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus DyslipidemiaDyslipidemia

Low HDL < 40Low HDL < 40 Elevated LDL / TGElevated LDL / TG

Family History—Family History—event in first degree event in first degree relative relative >>55 male/65 55 male/65 femalefemale

Age-- Age-- >> 45 for 45 for male/55 for femalemale/55 for female

Chronic Kidney Chronic Kidney DiseaseDisease

Lack of regular Lack of regular physical activityphysical activity

ObesityObesity Lack of Etoh intakeLack of Etoh intake Lack of diet rich in Lack of diet rich in

fruit, veggies, fiberfruit, veggies, fiber

Acute Coronary Acute Coronary SyndromesSyndromes

Similar pathophysiologySimilar pathophysiology

Similar presentation and Similar presentation and early management rulesearly management rules

STEMI requires STEMI requires evaluation for acute evaluation for acute reperfusion interventionreperfusion intervention

Unstable AnginaUnstable Angina

Non-ST-Non-ST-Segment Segment Elevation MI Elevation MI (NSTEMI)(NSTEMI)

ST-Segment ST-Segment Elevation MI Elevation MI (STEMI)(STEMI)

Diagnosis of Acute MIDiagnosis of Acute MI STEMI / NSTEMI STEMI / NSTEMI

At least 2 of the At least 2 of the followingfollowing

Ischemic Ischemic symptomssymptoms

Diagnostic ECG Diagnostic ECG changeschanges

Serum cardiac Serum cardiac marker marker elevationselevations

Diagnosis of AnginaDiagnosis of Angina

Typical angina—All three of the Typical angina—All three of the followingfollowing

Substernal chest discomfortSubsternal chest discomfort Onset with exertion or emotional stressOnset with exertion or emotional stress Relief with rest or nitroglycerinRelief with rest or nitroglycerin

Atypical anginaAtypical angina 2 of the above criteria2 of the above criteria

Noncardiac chest painNoncardiac chest pain 1 of the above1 of the above

Diagnosis of Unstable Diagnosis of Unstable AnginaAngina

Patients with typical angina - An episode of Patients with typical angina - An episode of angina angina

Increased in severity or durationIncreased in severity or duration Has onset at rest or at a low level of exertionHas onset at rest or at a low level of exertion Unrelieved by the amount of nitroglycerin or Unrelieved by the amount of nitroglycerin or

rest that had previously relieved the painrest that had previously relieved the pain

Patients not known to have typical anginaPatients not known to have typical angina First episode with usual activity or at rest First episode with usual activity or at rest

within the previous two weekswithin the previous two weeks Prolonged pain at restProlonged pain at rest

Unstable Unstable AnginaAngina STEMISTEMI NSTEMINSTEMI

Non occlusive thrombus

Non specific ECG

Normal cardiac enzymes

Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis

ST depression +/- T wave inversion on ECG

Elevated cardiac enzymes

Complete thrombus occlusion

ST elevations on ECG or new LBBB

Elevated cardiac enzymes

More severe symptoms

Acute ManagementAcute Management

Initial evaluation Initial evaluation & stabilization& stabilization

Efficient risk Efficient risk stratificationstratification

Focused cardiac Focused cardiac carecare

EvaluationEvaluation Efficient & direct history Efficient & direct history Initiate stabilization Initiate stabilization

interventionsinterventions

Plan for moving rapidly to Plan for moving rapidly to indicated cardiac care indicated cardiac care

Directed Therapies are

Time Sensitive!

Occurs Occurs simultaneosimultaneo

uslyusly

Chest pain suggestive of Chest pain suggestive of ischemiaischemia

12 lead ECG12 lead ECG Obtain initial Obtain initial

cardiac cardiac enzymesenzymes

electrolytes, cbc electrolytes, cbc lipids, bun/cr, lipids, bun/cr, glucose, coagsglucose, coags

CXRCXR

Immediate assessment within 10 Minutes

Establish Establish diagnosisdiagnosis

Read ECGRead ECG Identify Identify

complicaticomplicationsons

Assess for Assess for reperfusioreperfusionn

Initial Initial labslabs

and testsand tests

Emergent Emergent carecare

History History & &

PhysicalPhysical IV accessIV access Cardiac Cardiac

monitorinmonitoringg

OxygenOxygen AspirinAspirin NitratesNitrates

Focused HistoryFocused History Aid in diagnosis and Aid in diagnosis and

rule out other rule out other causescauses

Palliative/Provocative Palliative/Provocative factorsfactors

Quality of discomfortQuality of discomfort RadiationRadiation Symptoms associated Symptoms associated

with discomfortwith discomfort Cardiac risk factorsCardiac risk factors Past medical history -Past medical history -

especially cardiacespecially cardiac

Reperfusion Reperfusion questionsquestions

Timing of Timing of presentationpresentation

ECG c/w STEMI ECG c/w STEMI Contraindication Contraindication

to fibrinolysisto fibrinolysis Degree of STEMI Degree of STEMI

riskrisk

Targeted PhysicalTargeted Physical Recognize factors Recognize factors

that increase riskthat increase risk HypotensionHypotension TachycardiaTachycardia Pulmonary rales, Pulmonary rales,

JVD, pulmonary JVD, pulmonary edema,edema,

New murmurs/heart New murmurs/heart soundssounds

Diminished Diminished peripheral pulsesperipheral pulses

Signs of strokeSigns of stroke

ExaminationExamination VitalsVitals Cardiovascular Cardiovascular

systemsystem Respiratory Respiratory

systemsystem AbdomenAbdomen Neurological Neurological

statusstatus

ECG assessmentECG assessment

ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI

Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina

ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions

NSTEMINSTEMI

Normal or non-Normal or non-diagnostic EKGdiagnostic EKG

ST Depression or Dynamic T wave ST Depression or Dynamic T wave InversionsInversions

ST-Segment Elevation MIST-Segment Elevation MI

New LBBBNew LBBB

QRS > 0.12 secL Axis deviationProminent R wave V1-V3Prominent S wave 1, aVL, V5-V6 with t-wave inversion

Cardiac markersCardiac markers Troponin ( T, I)Troponin ( T, I)

Very specific and more Very specific and more sensitive than CKsensitive than CK

Rises 4-8 hours after Rises 4-8 hours after injuryinjury

May remain elevated May remain elevated for up to two weeksfor up to two weeks

Can provide Can provide prognostic informationprognostic information

Troponin T may be Troponin T may be elevated with renal dz, elevated with renal dz, poly/dermatomyositispoly/dermatomyositis

CK-MB isoenzymeCK-MB isoenzyme

Rises 4-6 hours after Rises 4-6 hours after injury and peaks at 24 injury and peaks at 24 hourshours

Remains elevated 36-Remains elevated 36-48 hours48 hours

Positive if CK/MB > Positive if CK/MB > 5% of total CK and 2 5% of total CK and 2 times normaltimes normal

Elevation can be Elevation can be predictive of mortalitypredictive of mortality

False positives with False positives with exercise, trauma, exercise, trauma, muscle dz, DM, PEmuscle dz, DM, PE

Prognosis with TroponinPrognosis with Troponin

1.01.7

3.4 3.7

6.0

7.5

0

1

2

3

4

5

6

7

8

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0

Cardiac troponin I (ng/ml)

Mo

rtal

ity

at 4

2 D

ays

831 174 148 134 50 67

%%

%%

%

%

Risk StratificationRisk Stratification

UA or NSTEMIUA or NSTEMI- Evaluate for - Evaluate for

Invasive vs. Invasive vs. conservative conservative treatmenttreatment

- Directed medical - Directed medical therapytherapy

Based on initialBased on initialEvaluation, ECG, andEvaluation, ECG, and

Cardiac markersCardiac markers

- Assess for - Assess for reperfusionreperfusion

- Select & - Select & implement implement reperfusion reperfusion therapytherapy

- Directed medical - Directed medical therapytherapy

STEMI Patient?

YESYES NONO

Cardiac Care Goals Cardiac Care Goals

Decrease amount of myocardial Decrease amount of myocardial necrosisnecrosis

Preserve LV functionPreserve LV functionPrevent major adverse cardiac Prevent major adverse cardiac events events

Treat life threatening Treat life threatening complicationscomplications

STEMI cardiac care STEMI cardiac care STEP 1STEP 1: Assessment: Assessment

Time since onset of symptomsTime since onset of symptoms 90 min for PCI / 12 hours for fibrinolysis90 min for PCI / 12 hours for fibrinolysis

Is this high risk STEMI?Is this high risk STEMI? KILLIP classificationKILLIP classification If higher risk may manage with more If higher risk may manage with more

invasive rxinvasive rx

Determine if fibrinolysis candidateDetermine if fibrinolysis candidate Meets criteria with no contraindicationsMeets criteria with no contraindications

Determine if PCI candidateDetermine if PCI candidate Based on availability and time to balloon Based on availability and time to balloon

rxrx

Fibrinolysis indicationsFibrinolysis indications

ST segment elevation >1mm in two ST segment elevation >1mm in two contiguous leadscontiguous leads

New LBBBNew LBBB Symptoms consistent with ischemiaSymptoms consistent with ischemia Symptom onset less than 12 hrs Symptom onset less than 12 hrs

prior to presentationprior to presentation

Absolute contraindications for fibrinolysis Absolute contraindications for fibrinolysis therapy in patients with acute STEMI therapy in patients with acute STEMI

Any prior ICH Known structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm

(primary or metastatic) Ischemic stroke within 3 months EXCEPT acute

ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding

menses) Significant closed-head or facial trauma within 3

months

Relative contraindications for fibrinolysis Relative contraindications for fibrinolysis therapy in patients with acute STEMI therapy in patients with acute STEMI

History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP

greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months,

dementia, or known intracranial pathology not covered in contraindications

Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)

Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than

5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the

higher the risk of bleeding

STEMI cardiac careSTEMI cardiac care STEP 2STEP 2: Determine preferred reperfusion strategy: Determine preferred reperfusion strategy

FibrinolysisFibrinolysis preferred if:preferred if: <<3 hours from onset3 hours from onset PCI not PCI not

available/delayedavailable/delayed door to balloon > door to balloon >

90min90min door to balloon door to balloon

minus door to minus door to needle > 1hrneedle > 1hr

Door to needle goal Door to needle goal <30min<30min

No contraindicationsNo contraindications

PCIPCI preferred if:preferred if: PCI availablePCI available Door to balloon < Door to balloon <

90min90min Door to balloon Door to balloon

minus door to minus door to needle < 1hrneedle < 1hr

Fibrinolysis Fibrinolysis contraindicationscontraindications

Late Presentation > Late Presentation > 3 hr3 hr

High risk STEMIHigh risk STEMI Killup 3 or higherKillup 3 or higher

STEMI dx in doubtSTEMI dx in doubt

Comparing outcomesComparing outcomes

Comparing outcomesComparing outcomes

Medical TherapyMedical TherapyMONA + BAHMONA + BAH

MorphineMorphine (class I, level C)(class I, level C) AnalgesiaAnalgesia Reduce pain/anxiety—decrease sympathetic Reduce pain/anxiety—decrease sympathetic

tone, systemic vascular resistance and oxygen tone, systemic vascular resistance and oxygen demanddemand

Careful with hypotension, hypovolemia, Careful with hypotension, hypovolemia, respiratory depressionrespiratory depression

OxygenOxygen (2-4 liters/minute) (class I, level C)(2-4 liters/minute) (class I, level C) Up to 70% of ACS patient demonstrate Up to 70% of ACS patient demonstrate

hypoxemiahypoxemia May limit ischemic myocardial damage by May limit ischemic myocardial damage by

increasing oxygen delivery/reduce ST elevationincreasing oxygen delivery/reduce ST elevation

NitroglycerinNitroglycerin (class I, level B)(class I, level B) Analgesia—titrate infusion to keep patient pain Analgesia—titrate infusion to keep patient pain

freefree Dilates coronary vessels—increase blood flowDilates coronary vessels—increase blood flow Reduces systemic vascular resistance and Reduces systemic vascular resistance and

preloadpreload Careful with recent ED meds, hypotension, Careful with recent ED meds, hypotension,

bradycardia, tachycardia, RV infarctionbradycardia, tachycardia, RV infarction

AspirinAspirin (160-325mg chewed & swallowed) (class (160-325mg chewed & swallowed) (class I, level A)I, level A)

Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregation Stabilize plaque and arrest thrombusStabilize plaque and arrest thrombus Reduce mortality in patients with STEMIReduce mortality in patients with STEMI Careful with active PUD, hypersensitivity, Careful with active PUD, hypersensitivity,

bleeding disordersbleeding disorders

Beta-BlockersBeta-Blockers (class I, level A)(class I, level A) 14% reduction in mortality risk at 7 days at 23% 14% reduction in mortality risk at 7 days at 23%

long term mortality reduction in STEMIlong term mortality reduction in STEMI Approximate 13% reduction in risk of Approximate 13% reduction in risk of

progression to MI in patients with threatening or progression to MI in patients with threatening or evolving MI symptomsevolving MI symptoms

Be aware of contraindications (CHF, Heart block, Be aware of contraindications (CHF, Heart block, Hypotension)Hypotension)

Reassess for therapy as contraindications resolveReassess for therapy as contraindications resolve

ACE-Inhibitors / ARBACE-Inhibitors / ARB (class I, level A)(class I, level A) Start in patients with anterior MI, pulmonary Start in patients with anterior MI, pulmonary

congestion, LVEF < 40% in absence of congestion, LVEF < 40% in absence of contraindication/hypotensioncontraindication/hypotension

Start in first 24 hoursStart in first 24 hours ARB as substitute for patients unable to use ACE-ARB as substitute for patients unable to use ACE-

II

HeparinHeparin (class I, level C to class IIa, level C) (class I, level C to class IIa, level C) LMWH or UFHLMWH or UFH (max 4000u bolus, 1000u/hr)(max 4000u bolus, 1000u/hr)

Indirect inhibitor of thrombinIndirect inhibitor of thrombin less supporting evidence of benefit in era of less supporting evidence of benefit in era of

reperfusionreperfusion Adjunct to surgical revascularization and Adjunct to surgical revascularization and

thrombolytic / PCI reperfusionthrombolytic / PCI reperfusion 24-48 hours of treatment24-48 hours of treatment Coordinate with PCI team (UFH preferred)Coordinate with PCI team (UFH preferred) Used in combo with aspirin and/or other platelet Used in combo with aspirin and/or other platelet

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

Additional medication therapyAdditional medication therapy ClopidodrelClopidodrel (class I, level B)(class I, level B)

Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregation Used in support of cath / PCI intervention or Used in support of cath / PCI intervention or

if unable to take aspirinif unable to take aspirin 3 to 12 month duration depending on 3 to 12 month duration depending on

scenario scenario

Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors (class IIa, level B)(class IIa, level B)

Inhibition of platelet aggregation at final Inhibition of platelet aggregation at final common pathwaycommon pathway

In support of PCI intervention as early as In support of PCI intervention as early as possible prior to PCIpossible prior to PCI

Additional medication therapyAdditional medication therapy

Aldosterone blockersAldosterone blockers (class I, level A)(class I, level A) Post-STEMI patients Post-STEMI patients

no significant renal failure (cr < 2.5 men or no significant renal failure (cr < 2.5 men or 2.0 for women)2.0 for women)

No hyperkalemis > 5.0No hyperkalemis > 5.0 LVEF < 40%LVEF < 40% Symptomatic CHF or DMSymptomatic CHF or DM

STEMI care CCUSTEMI care CCU

Monitor for complications: Monitor for complications: recurrent ischemia, cardiogenic shock, ICH, recurrent ischemia, cardiogenic shock, ICH,

arrhythmiasarrhythmias

Review guidelines for specific Review guidelines for specific management of complications & other management of complications & other specific clinical scenariosspecific clinical scenarios

PCI after fibrinolysis, emergent CABG, etc…PCI after fibrinolysis, emergent CABG, etc…

Decision making for risk stratification at Decision making for risk stratification at hospital discharge hospital discharge and/orand/or need for CABG need for CABG

Unstable angina/NSTEMI Unstable angina/NSTEMI cardiac carecardiac care

Evaluate for conservative vs. invasive Evaluate for conservative vs. invasive therapy based upon:therapy based upon:

Risk of actual ACSRisk of actual ACS TIMI risk scoreTIMI risk score ACS risk categories per AHA guidelinesACS risk categories per AHA guidelines

LowLowIntermediateIntermediate

HighHigh

Assessment Findings indicating

HIGH likelihood of ACS

Findings indicating

INTERMEDIATE likelihood of ACS in absence of high-likelihood findings

Findings indicating

LOW likelihood of ACS in absence of high- or intermediate-likelihood findings

History Chest or left arm pain or discomfort as chief symptomReproduction of previous documented anginaKnown history of coronary artery disease, including myocardial infarction

Chest or left arm pain or discomfort as chief symptomAge > 50 years

Probable ischemic symptomsRecent cocaine use

Physical examination

New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales

Extracardiac vascular disease

Chest discomfort reproduced by palpation

ECG New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms

Fixed Q wavesAbnormal ST segments or T waves not documented to be new

T-wave flattening or inversion of T waves in leads with dominant R wavesNormal ECG

Serum cardiac markers

Elevated cardiac troponin T or I, or elevated CK-MB

Normal Normal

Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome

TIMI Risk ScorePredicts risk of death, new/recurrent MI, need for urgent

revascularization within 14 days

ACS risk criteriaACS risk criteria

Low Risk ACS

No intermediate or high risk factors

<10 minutes rest pain

Non-diagnositic ECG

Non-elevated cardiac markers

Age < 70 years

Intermediate Risk ACS

Moderate to high likelihood of CAD

>10 minutes rest pain, now resolved

T-wave inversion > 2mm

Slightly elevated cardiac markers

High Risk ACS

Elevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery

Low risk

High risk

ConservaConservative tive

therapytherapy

Invasive Invasive therapytherapy

Chest Pain Chest Pain centercenter

Intermediate risk

Invasive therapy option Invasive therapy option UA/NSTEMIUA/NSTEMI

Coronary angiography and revascularization within 12 to 48 hours after presentation to ED

For high risk ACS (class I, level A) MONA + BAH (UFH) Clopidogrel

20% reduction death/MI/Stroke – CURE trial 1 month minimum duration and possibly up to 9 1 month minimum duration and possibly up to 9

monthsmonths

Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors

Conservative Therapy for Conservative Therapy for UA/NSTEMIUA/NSTEMI

Early revascularization or PCI Early revascularization or PCI notnot plannedplanned

MONA + BAMONA + BAHH (LMW or UFH)(LMW or UFH) ClopidogrelClopidogrel Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors

Only in certain circumstances (planning PCI, Only in certain circumstances (planning PCI, elevated TnI/T)elevated TnI/T)

Surveillence in hospitalSurveillence in hospital Serial ECGsSerial ECGs Serial MarkersSerial Markers

Secondary PreventionSecondary Prevention

DiseaseDisease HTN, DM, HLPHTN, DM, HLP

BehavioralBehavioral smoking, diet, physical activity, weightsmoking, diet, physical activity, weight

Cognitive Cognitive Education, cardiac rehab programEducation, cardiac rehab program

Secondary PreventionSecondary Preventiondisease managementdisease management

Blood PressureBlood Pressure Goals < 140/90 or <130/80 in DM /CKDGoals < 140/90 or <130/80 in DM /CKD Maximize use of beta-blockers & ACE-IMaximize use of beta-blockers & ACE-I

LipidsLipids LDL < 100 (70) ; TG < 200LDL < 100 (70) ; TG < 200 Maximize use of statins; consider Maximize use of statins; consider

fibrates/niacin first line for TG>500; fibrates/niacin first line for TG>500; consider omega-3 fatty acidsconsider omega-3 fatty acids

DiabetesDiabetes A1c < 7%A1c < 7%

Secondary preventionSecondary preventionbehavioral interventionbehavioral intervention

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

Physical ActivityPhysical Activity Goal 30 - 60 minutes dailyGoal 30 - 60 minutes daily Risk assessment prior to initiationRisk assessment prior to initiation

DietDiet DASH diet, fiber, omega-3 fatty acidsDASH diet, fiber, omega-3 fatty acids <7% total calories from saturated <7% total calories from saturated

fatsfats

Thinking outside the box…Thinking outside the box…

Or maybe just move….Or maybe just move….

Secondary preventionSecondary preventioncognitivecognitive

Patient educationPatient education In-hospital – discharge –outpatient In-hospital – discharge –outpatient

clinic/rehabclinic/rehab

Monitor psychosocial impactMonitor psychosocial impact Depression/anxiety assessment & Depression/anxiety assessment &

treatmenttreatment Social support systemSocial support system

Medication Checklist Medication Checklist after ACSafter ACS

Antiplatelet agentAntiplatelet agent AspirinAspirin** and/or Clopidorgrel and/or Clopidorgrel

Lipid lowering agentLipid lowering agent StatinStatin** Fibrate / Niacin / Omega-3 Fibrate / Niacin / Omega-3

Antihypertensive agentAntihypertensive agent Beta blockerBeta blocker** ACE-IACE-I**/ARB/ARB Aldactone Aldactone (as appropriate)(as appropriate)

Prevention news…Prevention news…From 1994 to 2004 the death

rate from coronary heart disease declined 33%...

But the actual number of deaths declined only 18% 

Getting better with treatment…

But more patients developing disease –need for primary

prevention focus

SummarySummary

ACS includes UA, NSTEMI, and STEMIACS includes UA, NSTEMI, and STEMI

Management guideline focusManagement guideline focus Immediate assessment/intervention Immediate assessment/intervention (MONA+BAH)(MONA+BAH) Risk stratification Risk stratification (UA/NSTEMI vs. STEMI)(UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI RAPID reperfusion for STEMI (PCI vs. (PCI vs.

Thrombolytics)Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMIConservative vs Invasive therapy for UA/NSTEMI

Aggressive attention to secondary Aggressive attention to secondary prevention initiatives for ACS patients prevention initiatives for ACS patients

Beta blocker, ASA, ACE-I, StatinBeta blocker, ASA, ACE-I, Statin