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Outline
Presentation of ACS
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand
guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.
2012 National Heart Foundation of Australia
References
1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.
2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.
2012 National Heart Foundation of Australia
smoking
gender
poor diet
age
high cholesterol
physical inactivity
diabetes
being overweight
Myocardial infarction (MI) occurs when the blood supply to the heart muscle is
interrupted due to partial or complete occlusion (thrombus) of the coronary
artery. As a result, some of the heart muscle becomes infarcted (dies).
Reference
1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1S14.
Acute
presentation
of
ACS
Critical factors to timely
treatment:
recognition
time
Heart attack
The pain may spread to other parts of the upper body, including:
recent research shows that women, the elderly and people with
diabetes are less likely to experience chest pain as a symptom.
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the
management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.
2012 National Heart Foundation of Australia
Early response
insert cannulae
pain relief
blood tests.
All PCI facilities should be able to perform primary angioplasty within 90 minutes of
patient presentation.
Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S929.
2012 National Heart Foundation of Australia
high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75
mg/day for at least 12 months) (Grade B)
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for
the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.
2012 National Heart Foundation of Australia
Bleeding risk
The following risk factors should be considered when assessing bleeding risk and
choosing antithrombotic therapies in patients with ACS (Grade B):
age > 75 years
female
history of bleeding
history of stroke or transient ischaemic attack (TIA)
creatinine clearance rate < 60 mL/min
diabetes
heart failure
tachycardia
blood pressure < 120 mmHg or 180 mmHg
peripheral vascular disease (PVD)
anaemia
concomitant use of GP IIb/IIIa inhibitor
enoxaparin 48 hours prior
switching between unfractionated heparin and enoxaparin
procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart
catheterisation).
2012 National Heart Foundation of Australia
Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots
in the coronary vessels to restore blood flow to the heart muscle. 1
Absolute contraindications
Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm.
Accessed 7 August 2011.
2012 National Heart Foundation of Australia
Fibrinolysis
Relative contraindications
Current use of anticoagulants.
Non-compressible vascular punctures.
Recent major surgery (< 3 weeks).
Traumatic or prolonged (> 10 mins) CPR.
Recent internal bleeding (within 4 weeks).
Active peptic ulcer.
History of chronic, severe, poorly controlled hypertension.
Severe uncontrolled hypertension on presentation (systolic 180 mmHg or
All patients with NSTEACS should have their risk stratified to direct
management decisions.
Stratify risk.
NO
YES
Stress test (e.g. exercise
ECG) using treadmill.
NO
Proceed to discharge patient with
urgent cardiac follow-up (on
upgraded medical therapy)
according to long-term
management after control of
myocardial ischaemia.
When additional agents are needed, substitute rather than add (Grade B).
5.
Long-term
management
Before discharging a patient:
smoking cessation
managing depression
Medication regimen
Continued antiplatelet therapies for 12 months for all patients with stents (Grade A).
In addition:
aspirin
beta-blockers
ACE inhibitors
statins
warfarin
nitrates
insulin/oral hypoglycaemics
aldosterone antagonists.
Concluding remarks
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resulting from the reliance on the content, or for its accuracy, currency and completeness. The information is obtained and developed from a variety of sources including,
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