MOCHAMMAD FATHONI

DEPART. OF CARDIOLOGY,
MEDICAL FACULTY,
SEBELAS MARET
UNIVERSITY,
Dr. MOEWARDI HOSPITAL,
SOLO

FAST RESPONSE OF

Acute Coronary
Syndrome

Acute Coronary
Syndrome
Clinical syndromes caused by acute myocardial

ischemia
Unstable angina
Angina at rest or new onset angina, accelerating
symptoms
No detectable increase of biomarkers
Non-ST-elevation MI
Angina at rest or new onset angina, accelerating
symptoms
Detectable release of biomarkers
ST-elevation MI
Clinical presentation of acute myocardial infarction
with EKG evidence of ST-segment elevation

Acute Coronary
Syndromes

Unstable Angina

Non-ST-Segment
Elevation MI
(NSTEMI)

ST-Segment
Elevation MI
(STEMI)

Similar
pathophysiology
Similar presentation
and early management
rules
STEMI requires
evaluation for acute
reperfusion and
intervention

Diagnosis of Acute MI
STEMI / NSTEMI

At least 2 of the
following
Ischemic
symptoms
Diagnostic ECG
changes
Serum cardiac
marker
elevations

Diagnosis of Angina

Typical angina : three of the following

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

Atypical angina

2 of the above criteria

Noncardiac chest pain

1 of the aboveTypical anginaAll

Diagnosis of Unstable
Angina

Patients with typical angina - An episode of

angina
Increased in severity or duration
Has onset at rest or at a low level of
exertion
Unrelieved by the amount of nitroglycerin
or rest that had previously relieved the pain
Patients not known to have typical angina
First episode with usual activity or at rest
within the previous two weeks
Prolonged pain at rest

U NSTABLE
ANGINA
Non
occlusive
thrombus
Non
specific
ECG

Normal
cardiac
enzymes

Occluding
thrombus
sufficient to
cause
tissue damage &
mild
myocardial
necrosis

NSTEMI

ST depression
+/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI

Complete thromb
occlusion

ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Ttt
Troponin
I rise

Expanding Risk Factors

Age-- > 45 for

Smoking
Hypertension
male/55 for
Diabetes Mellitus
female
Dyslipidemia
Chronic
Low HDL < 40
Kidney
Elevated LDL /
Disease
TG
Lack of
Family History
regular
event in first
physical
degree relative >55
activity
male/65 female

Take note of these common signs of an

acute coronary syndrome:
Chest pain or discomfort, which may
involve pressure, tightness or fullness
Pain or discomfort in one or both
arms, the jaw, neck, back or stomach
Shortness of breath
Feeling dizzy or lightheaded
Nausea
Sweating
These symptoms should be taken
seriously. If you experience chest pain
or other symptoms, call 118
immediately.

11
8

Acute
Management
Initial

evaluation &
stabilization
Efficient risk
stratification
Focused
cardiac care

Evaluation
Efficient

& direct historyOccurs

simultaneo
Initiate stabilization
usly
interventions
Plan for moving rapidly to
Directed Therapies
indicated
are
Time Sensitive!
cardiac care

Chest pain suggestive of

ischemia
Immediate assessment within 10
Initial
History
Minutes
Emergent

labs
and tests

12 lead ECG
Obtain initial
cardiac enzymes
electrolytes, cbc
lipids, bun/cr,
glucose, coags
CXR

care
IV access
Cardiac
monitorin
g
Oxygen
Aspirin
Nitrates

&
Physical
Establish
diagnosis
Read ECG
Identify
complicati
ons
Assess for
reperfusio

Focused History

Aid in diagnosis and rule

out other causes
Palliative/Provocative

factors
Quality of discomfort
Radiation
Symptoms associated
with discomfort
Cardiac risk factors
Past medical history
-especially cardiac

Reperfusion
questions
Timing

of
presentation
ECG c/w STEMI
Contraindication to
fibrinolysis
Degree of STEMI
risk

Targeted Physical

Examination
Vitals
Cardiovascul
ar system
Respiratory
system
Abdomen
Neurological
status

Recognize factors tha

increase risk
Hypotension
Tachycardia
Pulmonary rales,
Pulmonary edema,
New murmurs/heart s
Diminished periphera
Signs of stroke

ECG assessment

ST Elevation or new LBBB

STEMI
ST Depression or dynamic
T wave inversions

NSTEMI
Non-specific ECG

Unstable Angina

Normal or nondiagnostic EKG

ST Depression or Dynamic
T wave Inversions

ST-Segment Elevation MI

Cardiac markers

Troponin ( T, I)
Very

specific and
more sensitive than
CK
Rises 4-8 hours after
injury
May remain elevated
for up to two weeks
Can provide
prognostic
information
Troponin T may be
elevated with renal
dz,
poly/dermatomyositis

CK-MB isoenzyme
Rises

4-6 hours
after injury and
peaks at 24 hours
Remains elevated
36-48 hours
Positive if CK/MB >
5% of total CK and
2 times normal
Elevation can be
predictive of
mortality
False positives with

Timing of Release of Various

Biomarkers After Acute Myocardial
Infarction

Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise
Textbook. 3rd ed. Rochester, MN: Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:77380.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1e157, Figure 5.

Risk Stratification

Based on initial
Evaluation, ECG, an
Cardiac markers

YES

- Assess

for
reperfusion
- Select &
implement
reperfusion
therapy

STEMI
Patient?

NO

UA or NSTEMI
- Evaluate

for
Invasive vs.
conservative
treatment
- Directed medical
therapy

Risk Stratification to Determine the

Likelihood of
Acute Coronary
Syndrome
Assessment
Findings
Findings
Findings

History

indicating HIGH
likelihood of ACS

indicating
INTERMEDIATE
likelihood of ACS
in absence of
high-likelihood
findings

indicating LOW
likelihood of ACS
in absence of
high- or
intermediatelikelihood findings

Chest or left arm

pain or
discomfort as
chief symptom
Reproduction of
previous
documented
angina
Known history of
coronary artery
disease,
including
myocardial
infarction

Chest or left arm

pain or
discomfort as
chief symptom
Age > 50 years

Probable ischemic
symptoms
Recent cocaine
use

Risk Stratification to Determine the Likelihood

of
Acute Coronary
Syndrome
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 Twave inversion
(> 0.2 mV) with
symptoms

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

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

Serum cardiac

Elevated

Normal

Normal

Table 1. Short-Term Risk of Death or Nonfatal MI in P

Feature

History

Intermediate Low Risk

Risk (No (No high- or
High Risk
high-risk intermediate
(At least 1 of feature but -risk feature
the following must have 1
but may
features
of the
have any of
must be
following the following
present)
features)
features)
Accelerating Prior MI,
tempo of
peripheral
ischemic
or
symptoms in cerebrovasc
preceding
ular disease,
48 hrs
or CABG;
prior aspirin

Table 1. Short-Term Risk of Death or Nonfatal MI in P

Intermediate Low Risk
Risk (No (No high- or
High Risk
high-risk intermediate
(At least 1 of feature but -risk feature
the following must have 1
but may
features
of the
have any of
must be
following the following
Feature
present)
features)
features)
Character of Prolonged
Rest angina New-onset
pain
ongoing
(<20 min or CCS Class
(>20 min)
relieved
III or IV
rest pain
with rest or angina in
no relieved sublingual the past 2
wk with
with rest or NTG

Intermediate
Risk (No high- Low Risk (No
high- or
High Risk (At risk feature
least 1 of the but must have intermediate-risk
feature but may
following
1 of the
have any of the
features must
following
following
Feature
be present)
features)
features)
ECG findings Angina at rest T-wave
Normal or
with transient inversions
unchanged
ST-segment
>0.2 mV
ECG during
changes
an episode of
>0.05 mV
chest
discomfort
BundlePathological Q
branch block, waves
new or

Feature
Cardiac
markers

Intermediate
Risk (No high- Low Risk (No
high- or
High Risk (At risk feature
least 1 of the but must have intermediate-risk
feature but may
following
1 of the
have any of the
features must
following
following
be present)
features)
features)
Markedly
Slightly
Normal
elevated (eg, elevated (eg,
TnI >0.1
Tn I >0.01 but
ng/mL)
<0.1 ng/mL)

Cardiac Care
Goals
Decrease

amount of
myocardial necrosis
Preserve LV function
Prevent major adverse
cardiac events
Treat life threatening
complications

STEMI CARDIAC CARE

Assessment

Time since onset of symptoms

90 min for PCI / 12 hours for fibrinolysis

Is this high risk STEMI?

KILLIP classification
If higher risk may manage with more
invasive rx

Determine if fibrinolysis candidate

Meets criteria with no contraindications

Determine if PCI candidate

Based on availability and time to balloon rx

Fibrinolysis
indications
ST

segment elevation >1mm

in two contiguous leads
New LBBB
Symptoms consistent with
ischemia
Symptom onset less than 12
hrs prior to presentation

Absolute contraindications for

fibrinolysis
therapy
in
patients
Any prior ICH
with acute STEMI

Known structural cerebral vascular lesion

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 mont.

Relative contraindications for

fibrinolysis 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)

Relative contraindications
for fibrinolysis therapy in
patients with acute STEMI
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

SUMMARY

ACS includes UA, NSTEMI, and STEMI

Assesment the diagnosis of ACS

Management guideline focus

Immediate assessment/intervention (MONA+BAH)

Risk stratification (UA/NSTEMI vs. STEMI)
RAPID reperfusion for STEMI (PCI vs.

Thrombolytics)

Conservative vs Invasive therapy for

UA/NSTEMI

Aggressive attention to secondary

prevention initiatives for ACS patients

Beta blocker, ASA, ACE-I, Statin

SUMMARY
STEMI CARE CVICU
Monitor for complications:

Review guidelines for specific management

of complications & other specific clinical
scenarios

recurrent ischemia, cardiogenic shock, ICH,

arrhythmias

PCI after fibrinolysis, emergent CABG, etc

Decision making for risk stratification at

hospital discharge and/or need for CABG

THANK YOU
FOR YOUR
ATTENTION

STEMI cardiac care

STEP 2: Determine preferred reperfusion strategy

Fibrinolysis
preferred if:

<3 hours from onset

PCI not
available/delayed
door to balloon >
90min
door to balloon
minus door to
needle > 1hr
Door to needle goal
<30min

PCI preferred if:

PCI available
Door to balloon <
90min
Door to balloon
minus door to
needle < 1hr
Fibrinolysis
contraindications
Late Presentation >
3 hr
High risk STEMI

Comparing outcomes

Medical Therapy
MONA + BAH

Morphine

Oxygen (2-4 liters/minute) (class I, level C)

(class I, level C)
Analgesia 2-5 mg , maximum 20 mg /day
Reduce pain/anxietydecrease sympathetic
tone, systemic vascular resistance and oxygen
demand
Careful with hypotension, hypovolemia,
respiratory depression

Up to 70% of ACS patient demonstrate

hypoxemia
May limit ischemic myocardial damage by
increasing oxygen delivery/reduce ST elevation

Nitroglycerin (class I, level B)

Analgesiatitrate infusion to keep patient pain
free
Dilates coronary vesselsincrease blood flow
Reduces systemic vascular resistance and preload
Careful with hypotension, bradycardia,
tachycardia, RV infarction

Aspirin (160-325mg chewed & swallowed) (class I,

level A)
Irreversible inhibition of platelet aggregation
Stabilize plaque and arrest thrombus
Reduce mortality in patients with STEMI
Careful with active PUD, hypersensitivity, bleeding
disorders

Beta-Blockers (class I, level A)

14% reduction in mortality risk at 7 days at 23%
long term mortality reduction in STEMI
Approximate 13% reduction in risk of
progression to MI in patients with threatening or
evolving MI symptoms
Be aware of contraindications (CHF, Heart block,
Hypotension)

ACE-Inhibitors / ARB

(class I, level A)
Start in patients with anterior MI, pulmonary
congestion, LVEF < 40% in absence of
contraindication/hypotension
Start in first 24 hours
ARB as substitute for patients unable to use
ACE-I

Heparin (class I, level C to class IIa, level C)

LMWH or UFH

(max 4000u bolus, 1000u/hr)

Indirect inhibitor of thrombin

less supporting evidence of benefit in era of
reperfusion
Adjunct to surgical revascularization and
thrombolytic / PCI reperfusion
Coordinate with PCI team (UFH preferred)
Used in combo with aspirin and/or other platelet
inhibitors
Changing from one to the other not recommended

Additional medication therapy

Clopidogrel (class I, level B)

Irreversible inhibition of platelet aggregation
Used in support of cath / PCI intervention or
if unable to take aspirin
3 to 12 month duration depending on
scenario

Glycoprotein IIb/IIIa inhibitors

(class IIa, level B)
Inhibition of platelet aggregation at final
common pathway
In support of PCI intervention as early as
possible prior to PCI

Additional medication therapy

Aldosterone blockers (class I, level A)

Post-STEMI patients
No

significant renal failure (cr

< 2.5 men or 2.0 for women)
No hyperkalemis > 5.0
LVEF < 40%
Symptomatic CHF or DM

STEMI care CCU

Monitor for complications:

Review guidelines for specific

management of complications & other
specific clinical scenarios

recurrent ischemia, cardiogenic shock, ICH,

arrhythmias

PCI after fibrinolysis, emergent CABG, etc

Decision making for risk stratification at

hospital discharge and/or need for CABG

Unstable angina/NSTEMI
cardiac care

Evaluate for conservative vs. invasive

therapy based upon:
Risk

of actual ACS
TIMI risk score
ACS risk categories per AHA guidelines

Low

Intermediate

High

TIMI Risk Score

Predicts risk of death, new/recurrent MI, need for
urgent revascularization within 14 days

ACS 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 markers
New or presumed new ST depression
Recurrent ischemia despite therapy
Recurrent ischemia with heart failure
High risk findings on non-invasive stress test
Depressed systolic left ventricular function
Hemodynamic instability
Sustained Ventricular tachycardia
PCI with 6 months
Prior Bypass surgery

Low
risk

Intermediate

risk

High
risk

Chest Pain
center

Conserva
tive
therapy

Invasive
therapy

Invasive therapy option

UA/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
months

Glycoprotein IIb/IIIa inhibitors

Conservative Therapy for

UA/NSTEMI

Early revascularization or PCI not

planned
MONA + BAH (LMW or UFH)
Clopidogrel
Glycoprotein IIb/IIIa inhibitors

Only in certain circumstances (planning PCI,

elevated TnI/T)

Surveillence in hospital

Serial ECGs
Serial Markers

Secondary Prevention

Disease

Behavioral

HTN, DM, HLP

smoking, diet, physical activity, weight

Cognitive

Education, cardiac rehab program

Secondary Prevention
disease management

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

Lipids
LDL < 100 (70) ; TG < 200
Maximize use of statins; consider
fibrates/niacin first line for TG>500;
consider omega-3 fatty acids

Diabetes

A1c < 7%

Secondary prevention
behavioral intervention

Smoking cessation

Cessation-class, meds, counseling

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

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

Medication Checklist
after ACS

Antiplatelet agent

Aspirin* and/or Clopidorgrel

Lipid lowering agent

Statin*
Fibrate / Niacin / Omega-3

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

Summary

ACS includes UA, NSTEMI, and STEMI

Management guideline focus

Immediate assessment/intervention (MONA+BAH)
Risk stratification (UA/NSTEMI vs. STEMI)
RAPID reperfusion for STEMI (PCI vs. Thrombolytics)
Conservative vs Invasive therapy for UA/NSTEMI

Aggressive attention to secondary prevention

initiatives for ACS patients

Beta blocker, ASA, ACE-I, Statin

THANK YOU
FOR YOUR
ATTENTION