Acute Coronary Syndrome

Non ST Elevation MI

Muhammad Asim Rana

MBBS, MRCP, SF-CCM, EDIC, FCCP
Department of Critical Care Medicine
King Saud Medical City
Riyadh Saudi Arabia
 Disclosures

We are not
promotional speakers
for any company but
we do accept the
breakfast in our
presentations
(just for fun)

A very special man is here to see U doctor!!

 Session Objectives
 Utilize both clinical evaluation and risk scoring in
selecting the appropriate initial management
strategy for patients with UA/NSTEMI
 Identify potential updates to current UA/NSTEMI
critical pathways based on the latest ACC/AHA
UA/NSTEMI guidelines and recent UA/NSTEMI
clinical trial results
 Evaluate current approaches to discharge
planning and follow-up, and modify them as
necessary to promote adherence to medical and
rehabilitative therapies
 Deaths from ACS
others
23%

ACS
Hypertension 48%
5%

CHF
5%

Atherosclerosis
2%
0.5%

Stroke
0.5%
17%
 Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)

Acute Coronary
Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 million .33 million

Admissions per year Admissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171.
*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.
Ischemic Heart Disease Evaluation
Based on the patient’s

• History / Physical exam

• Electrocardiogram
• Biochemical markers

Patients are categorized into 2 groups

 Non Cardiac Chest Pain
 Pain cardiac in origin
USA/NSTEMI/STEMI
 Spectrum of Coronary Syndromes
Risk Factors + Hypertension
Endothelial Dysfunction
Atherosclerosis
IHD/Angina Pectoris
Myocardial Ischemia
Chronic Acute
Coronary Thrombosis Coronary
Coronary
Syndromes Myocardial Infarction Syndromes
Arrhythmia & Loss of Muscle

Remodeling
Ventricular Dilation
Congestive Heart Failure

Endstage Heart Disease

Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.
 Acute Coronary Syndrome
Definition
 The term ACS refers to a spectrum of
presentations caused by myocardial
ischemia that includes
 Unstable Angina
 Non ST elevation myocardial infarction
 ST elevation myocardial infarction
 Diagnosis
 Diagnosis requires a rise and/or fall in serum
levels (preferably troponin) together with:

 Evidence of Myocardial Ischaemia

 Defined clinically by patient history

 ECG (new ST-T wave changes, new left bundle
branch block or evolving pathological Q waves)
 Imaging evidence of new regional wall motion
abnormality.
 Acute Coronary Syndromes
Pathophysiology
 The
embracing term reflects the
common pathophysiology of
 Plaque disruption
 Intravascular thrombosis

 Impaired myocardial blood supply

 STEMI NSTEMI
Result of complete Incomplete &
epicardial occlusion transient epicardial
following plaque occlusion with
disruption & leads to
propagation of
platelet-rich &
thrombus & epicardial phasic distal
vasoconstriction embolisation
Pathophysiology
Summary of events & outcome
Acute ST Elevation MI
Normal ECG
Acute Coronary Syndrome
Clinical Diagnosis

MONA
Morphine
Oxygen
NTG
Aspirin

Blood Tests:
Troponin at 12 hours after
onset of pain, U&E, cholesterol,
FBC, coagulation
Admission or subsequent ECG
 High Risk ECG changes: High Risk Clinical
(2 or more contiguous leads)
features:
ST depression > 1mm
T inversion > 1mm
Ongoing rest pain.
Transient BBB Haemodynamic instability.
Minor/ transient ST elevation Arrythmias
NO

Troponin Elevated? Consider

NO investigations:
Perfusion scan
Low Risk Patient Angiography
Discharge Able to exercise ? NO Cardiology
YES Referral

ETT

ETT Normal ETT Inconclusive

 High Risk ECG changes: High Risk Clinical
(2 or more contiguous leads)
features:
ST depression > 1mm
T inversion > 1mm
Ongoing rest pain.
Transient BBB Haemodynamic instability.
Minor/ transient ST elevation Arrythmias
Troponin
Elevated

High Risk
UnStable High Risk
High Risk Stable
Ongoing pain 1. LMWH
ECG changes 2. Clopidogrel 300 stat, 75mg OD Cardiac Cath.
GPIIbIIIa 3. Aspirin 75 mg OD pre-morbid
4. Beta Blockers: (metopr)25 mg tds
Urgent cath. 5. Hyperglycaemic control DIGAMI
state and
pre-morbidity protocol, if RBS > 10 mmol suitability
suitability for 6. Morphine and / or IV nitrates if
for revasc.
revasc. continuing pain, titrate to pain and
blood pressure.
What is UA/NSTEMI Patients Risk
of inpatient Cardiac Mortality and
ischemic events?
Variables Used in the TIMI Risk Score
• Age ≥ 65 years =1 point
• At least 3 risk factors for CAD =1 point
• Prior coronary stenosis of ≥ 50% =1 point
• ST-segment deviation on ECG presentation =1 point
• At least 2 anginal events in prior 24 hours =1 point
• Use of aspirin in prior 7 days =1 point
• Elevated serum cardiac biomarkers =1 point

The TIMI risk score is determined by the sum of the presence of the above 7 variables at
admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more
remained relatively insensitive to missing information and remained a significant predictor
of events. Antman EM, et al. JAMA 2000;284:835–42.
TIMI = Thrombolysis in Myocardial Infarction.
 TIMI Risk Score
TIMI All-Cause Mortality, New or Recurrent MI, or Severe
Risk Recurrent Ischemia Requiring Urgent
Score Revascularization Through 14 Days After
Randomization %
0-1 4.7
2 8.3
3 13.2
4 19.9
5 26.2
6-7 40.9

Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American
Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.
 GRACE Risk Score
Variable Odds ratio
Older age 1.7 per 10 y
Killip class 2.0 per class
Systolic BP 1.4 per 20 mm Hg ↑
ST-segment deviation 2.4
Cardiac arrest during presentation 4.3
Serum creatinine level 1.2 per 1-mg/dL ↑
Positive initial cardiac biomarkers 1.6
Heart rate 1.3 per 30-beat/min
↑
The sum of scores is applied to a reference monogram to determine the corresponding all-cause
mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRACE
clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157.
GRACE = Global Registry of Acute Coronary Events.
Why R U Confusing us?
 UA/NSTEMI Hospital Care

Let’s Start with the Basics! Assuming the

NSTEMI has been our diagnosis
 ACC/AHA Guidelines
ACS Treatment Overview: UA/NSTEMI
Diagnosis of UA or NSTEMI is likely or definite

Aspirin or clopidogrel
Initial conservative (if patient is aspirin intolerant)
management
Initial invasive
management
Medical Diagnostic
PCI or CABGa
therapy angiography

Evaluation of LV
Function in pt Long-term medical management:
Clopidogrel, aspirin, β-blocker, ACEI,
with ischemia
statin

aIf possible, clopidogrel should be withheld for 5-7 days prior to the procedure.
Anderson JL, et al. Circulation. 2007;116:803-877.
 Selection of Initial Treatment

Wright RS et al. Circ 2011;123;2022-2060.

 Early Treatment
Class I Indications
 Bed rest with continuous ECG Monitoring
 O2 therapy if saturation <90%, respiratory
distress, or other high-risk features for
hypoxemia
 SL NTG 0.4 mg q5min x3 then assessment of
need for IV NTG
 IV NTG indicated first 48 hours for treatment of
persistent ischemia, CHF or HTN; should not
preclude Rx with beta-blockers or ACE

Wright RS et al. Circ 2011;123;2022-2060.

 Early Treatment
Class I Indications

 Oral Beta-Blocker in first 24 hours for pt who do not

have
 Signs of CHF

 Low out-put state

 Increased risk of cardiogenic shock

 Contraindication to Beta blockers/heart block/COPD

 If Beta-Blockers are contraindicated a

nondihydropyridine calcium channel blocker may be used
if no LV dysfunction

Wright RS et al. Circ 2011;123;2022-2060.

 Early Treatment (Cont.)
 ACE inhibitor within 24 hours with pulmonary congestion or
LVEF < 40% in the absence of hypotension or
contraindication
 Because of the increased risk of mortality, reinfarction, HTN,
CHF, and myocardial rupture NSAIDS except for ASA should
be discontinued at presentation
Class II indications:
 It is reasonable to admin O2 to all UA/NSTEMI pts in first 6
hours. IIa
 Morphine (1-5 mg IV) remains Class I for STEMI although
may increase adverse events in UA/NSTEMI (1,2)
 It is reasonable to administer morphine sulfate IV if there
is uncontrolled ischemic Chest Pain despite NTG. IIa

1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.

2. Meine T el al. Am Heart J 2005;149:1043- 9
Rx for all NSTEMI
Early Hospital Care
2011 Focused update Antiplatelet therapy

 ASA should be administered to USA/NSTEMI as

soon as possible after hospital presentation and
continued indefinitely (LOE A)
 Clopidogrel (loading dose followed by
maintenance dose) should be administered to
USA/NSTEMI patients who are unable to take
ASA because of hypersensitivity or major
gastrointestinal intolerance (LOE B)

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Look who is sleeping
 Conservative Rx
Hospital Care
2011 Focused update Antiplatelet therapy

 For USA/NSTEMI patients in whom an

initial conservative strategy is selected
clopidogrel (loading dose followed by
maintenance dose) should be added to
ASA and anticoagulant therapy as soon as
possible after admission and administered
for at least 1 month and ideally up to 1
year

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

 Conservative Rx Hospital Care
Initial Conservative Strategy:
Anticoagulant Therapy
 Anticoagulant therapy should be added to antiplatelet
therapy in UA/NSTEMI patients as soon as possible after
presentation.
 For patients in whom a conservative strategy is selected,
regimens using either enoxaparin* or UFH (LOE A) or
fondaparinux (LOE: B) have established efficacy.

 In patients in whom a conservative strategy is selected

and who have an increased risk of bleeding,
fondaparinux is preferable.

*Limited data are available for the use of other low-

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367 molecular-weight heparins (LMWHs), e.g., dalteparin.
 Time to use your grey matter
 An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
 Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponin is mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are not
contraindicated:
a. Clopidogrel
b. Prasugrel
c. Enoxaparin
d. Eptifibatide
e. An intravenous fibrinolytic drug
 Time to use your grey matter
 An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
 Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponin is mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are
most appropriate
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel 75 mg daily
c. Intravenous unfractionated heparin
d. ASA 325 mg daily and Intravenous heparin
e. ASA 325 mg OD & Clopidogrel 75mg OD & IV heparin
 Time to use your grey matter
 An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
 Her ECHO showed EF 30% & small pericardial effusion.
 Which of the following drugs should be discontinued?
a. Metoprolol
b. Diltiazem
c. Hydralazine
d. Lisinopril
 Time to use your grey matter
 Oral beta blockers should be initiated within first 24 hrs
for those pts who do not have
 1) Signs of heart failure
 2) Evidence of low output state
 3) Increased risk of cardiogenic shock
 4) other contraindications to beta blockers

 Risk Factors for Cardiogenic Shock

 Age > 70yrs
 BP <120
 Heart rate >110 or < 60
 Increased time since onset of symptoms
Time to use your grey matter
 Time to use your grey matter
 An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
 Her ECHO showed EF 30% & small pericardial effusion.
 Which of the following is indicated?
a. Transe-esophageal echo
b. Biventricular pacing
c. Implantable cardioverter defibrillator
d. Cardiac catheterization
 Initial Conservative strategy
Additional Management considerations
 Conservative Rx Hospital Care
2011 Focused update

 For USA/NSTEMI patients in whom an

initial conservative strategy is selected if
recurrent symptoms/ischemia, CHF, or
serious arrhythmias subsequently appear,
then diagnostic angiography should be
preformed

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

 Conservative Rx
Hospital Care
2011 Focused update

 For patients with USA/NSTEMI treated

conservatively without recurrent symptoms, CHF
or arrhythmia a stress test should be performed
 If the pt is not classified as low risk after the
stress test then angiography should be
performed

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

 Conservative Rx
Hospital Care
2011 Focused update

 If at low risk Post Stress Test:

 Continue ASA
 Continue clopidogrel for at least 1 month and
ideally up to 1 year
 Discontinue GP IIb/IIIa inhibitor if started
 Continue UFH for 48 hours or administer
enoxaparin or fondaparinux for the duration
of hospitalization up to 8 days and then
discontinue
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Pharao gets prescription
 Time to use your grey matter
 An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
 Physical exam is normal , ECG is below

What would you recommend?

a. A resting sistamibi scan
b. A nuclear stress test
c. Intravenous fibrinolytic drug
d. Cardiac Cath
 Selection of Initial Treatment

Wright RS et al. Circ 2011;123;2022-2060.

 Time to use your grey matter
 An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
 Physical exam is normal.
 Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9
 Which of the following therapies are most appropriate?
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel 75 mg daily
c. ASA 325 mg daily and prasugrel 10 mg OD
e. Clopidogrel 75mg OD & IV eptifabatide
Medium to High
Risk patients…..
Early Hospital Care
2011 Focused update Antiplatelet therapy

 Pt with definite USA/NSTEMI at medium or

high risk and in whom an initial invasive
strategy is selected should receive dual-
antiplatelet therapy on presentation (LOE A)
 ASA on presentation
 The second should be given before PCI as
follows…..

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

 Medium to High
Risk patients…..
Early Hospital Care
2011 Focused update Antiplatelet therapy

Before PCI:
 Clopidogrel (LOE B)

 An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide

or tirofiban are the preferred agents
At the time of PCI:
 Clopidogrel if not started before PCI (LOE A)

 Prasugrel (LOE B)

 An IV GP IIb/IIIa inhibitor (LOE A)

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

 Time to use your grey matter
 An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
 Physical exam is normal.
 Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9
 Which of the following therapies are not appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin
Initial Invasive Strategy
Anticoagulation
Continue Smiling
 Time to use your grey matter
 An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
 Physical exam is normal.
 Labs: RBS 150 mg%, CBC Normal, Creatinin clearance is <30
ml/min, CTn 2.9
 Which of the following therapies are not appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin
 Time to use your grey matter
 An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
 Physical exam is normal.
 Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin normal but
there is history of heparin induced thrombocytopenia
 Which of the following therapies is appropriate?
a. IV unfractionated heparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin
 Hospital Care
2011 Focused update
 For patients with USA/NSTEMI in whom CABG is
selected post angiography
 Continue ASA
 Discontinue IV GP IIb/IIIa inhibitor 4 hours before
CABG
 Continue UFH
 Discontinue enoxaparin 12-24 hours before CABG and
dose with UFH per institution practice
 Discontinue fondaparinux 24 hours before CABG and
dose with UFH per institution practice
 Discontinue bivalirudin 3 hours before CABG and dose
with UFH per institution practice
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
 Hospital Care
2011 Focused update
 In patients taking thienopyridine in whom
CABG is planned and can be delayed…
 Discontinue clopidogrel for at least 5 days
 Discontinue prasugrel for at least 7 days

Unless the need for revascularization and or

the net benefit of the thienopyridine
outweighs the potential risks of excess
bleeding… (LOE C)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
 ACC/AHA Guidelines update 2011
UA/NSTEMI: Long-Term Medical Management
UA or NSTEMI at hospital discharge

Inhospital management with Inhospital therapy with

Inhospital therapy with bare-
medical therapy (without drug-eluting stent
metal stent implantation
stenting) implantation

Aspirina 162-325 mg/d for at

Aspirina 75-162 mg/d
indefinitely plus
clopidogrelb 75 mg/d for at
least 1 mo, ideally up to 1 yr
Aspirina
162-325 mg/d for at
least 3 mo with Sirolimus and
least 1 mo, then
6 mo paclitaxel, then
75-162 mg/d indefinitely plus
75-162 mg/d indefinitely plus
clopidogrelb 75 mg/d or
clopidogrelb 75 mg/d or
prasugrel 10 mg/d for at
prasugrel 10 mg/d for at
least12 months*
least 12 mo

aIfpatient is allergic
to aspirin, use Is an indication for
clopidogrel alone anticoagulation present? cContinue aspirin indefinitely
(indefinitely) or try aspirin
and warfarin long term, if
desensitization. indicated for specific conditions.
dIfwarfarin is added to aspirin
bIf If yes: add If no: continue dual
patient is allergic to clopidogrel, and clopidogrel, the
use ticlodipine 250 mg PO bid. warfarinc,d antiplatelet therapy recommended INR is 2.0-2.5.
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Dear Doctor!
 Evaluating Recurrent Risk
Secondary Prevention Strategies
Broad Goals during Hospital discharge phase
 Prepare the patient for normal activities
 Use the acute event as an opportunity to
reevaluate the plan of care - lifestyle and
risk factor modification

Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Can U Revise
 Evidence based medicine

Take all these pills daily until a new clinical

trial is published
 Questions?
No questions?
Good!
Then let’s go home
& try some herbal Rx