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Dr Nurwahyudi, SpJP
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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
ST elevation ST depression
ECG ST segment
Diagnosis
UA
NSTEMI
STEMI
Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054, Davies MJ. Heart 2000;83:361–366 5
STEMI Management : Primary PCI or Fibrinolytic
Transfer
Intermediate Intermediate
Transfer
Optional
Low Low
Therapeutic Strategy
Immediate Non-invasive
invasive Early invasive invasive testing if
(< 2hr) (< 24hr) (< 72hr) appropriate
Pharmacotheraphy
Pharmacoterapy in ACS
• Fibrinolityc therapy
• Antiplatelet
• Anticoagulant
• Anti Ischemia
• Adjunctive Therapy
Pharmacotherapy
Ischemia:
Nitrat
Beta Blocker
Bleeding:
Anti Coagulant
Anti platelet
Fibrinolitic
Initial Treatment
Roffi M et al. Eur Heart J 2016;37(3):267-315; Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
Activated platelets are central to
thrombus formation in ACS
• Platelets do 3 things that promote thrombus
formaton Activated platelets aggregate
and assemble a critical mass
– Adhesion 3 of activated, pro-thrombotic
platelet membrane at the site
– Activation of injury
– Aggregation
Adherent platelet become activated
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1
Plaque rupture leads
to platelet adhesion
to the exposed
subendothelium
Vorchheimer DA, et al. Mayo Clin Proc. 2006;81:59-68; Davies MJ. Heart. 2000;83:361-366.
STEMI 2017 - Primary PCI
Ticagrelor preferred before clopidogrel
• The goal of antiplatelet therapy is to provide maximal protection
against thrombosis without increasing the risk of bleeding
DAPT (in the form of aspirin plus a P2Y12 inhibitor #) is indicated for up to 1
I C
year in patients undergoing fibrinolysis and subsequent PCI.
#Clopidogrel is the P2Y12 inhibitor of choice as co-adjuvant and after fibrinolysis, but 48 h
after fibrinolysis, switch to prasugrel/ticagrelor may be considered in patients who underwent
PCI
Reference: 1. Ibanez B et al. European Heart Journal 2017; 00; 1–66. 2. Windecker S. et al European Heart J. 2014; 1-12
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Fibrinolytic Therapy
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ESC NSTEACS 2015
Ticagrelor preferred before clopidogrel
• The time course of events following presentation with NSTE-ACS
necessitates immediate treatment with antiplatelet therapy,
once the diagnosis is made
• Antiplatelet therapy is necessary for the acute event, and
subsequent maintenance therapy
Ticagrelor is recommended, in the absence of
contraindications, for all patients at moderate-to-high risk of
ischaemic events (e.g. elevated cardiac troponins), regardless 1B
of initial treatment strategy and including those pretreated with
clopidogrel (which should be discontinued when ticagrelor is
started).
Hamm CW et al. Eur Heart J 2011;32:2999 – 3054; Amsterdam EA et al. J Am Coll Cardiol Sept 23, 2014 Epub ahead of print.
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DOI:10.1016/j.jack.2014.09.017; Kolh P et al. Eur Heart J August 29 2014; DOI:10.1093/eurheart/ehu278 [Epub ahead of print]
Anticoagulant
Primary PCI Fibrinolytic Therapy NSTEACS
• Routine use of UFH is • Enoxaparin i.v. followed by s.c. • Enoxaparin (1 mg/kg s.c. twice daily) or
recommended (1C) (preferred over UFH) (1A) UFH are recommended when
fondaparinux is not available. (1B)
• Enoxaparin should be considered as an
anticoagulant for PCI in patients
pretreated with s.c. enoxaparin. (IIaB)
• Routine use of enoxaparin • UFH given as a weight-adjusted • UFH 70–100 IU/kg i.v. (50–70 IU/kg if
i.v. should be i.v. bolus followed by infusion concomitant with GPIIb/IIIa inhibitors) is
• Considered (IIaA) (1B) recommended in patients undergoing PCI
who did not receive any anticoagulant.
(1B)
• Fondaparinux is not • In patients treated with • In patients on fondaparinux (2.5 mg s.c.
recommended for primary streptokinase: fondaparinux i.v. daily) undergoing PCI, a single i.v. bolus
PCI (IIIB) bolus followed by an s.c. dose 24 of UFH (70–85 IU/kg, or 50– 60 IU/kg in
h later (IIaB) the case of concomitant use of GPIIb/IIIa
inhibitors) is recommended during 19 the
procedure (1B)
Adjunctive Treatment
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STEMI Patients
STEMI Patients
STEMI Patients
Adjunctive Treatment in NSTEACS
It is recommended to start
high-intensity statin therapy as early as
possible, unless contraindicated, and
maintain it long term.
An ACE inhibitor is recommended in
patients with LVEF ≤40% or heart
failure, hypertension or diabetes,
unless contraindicated
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