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ANGINA PECTORIS
ACUTE CORONARY SYNDROME
MANAGEMENT
Pathway Aspirin
Beta blockers
Nitrates
Antithrombin regimen
GP IIb/IIIa inhibitor
Monitoring (rhythm and ischemia)
Evaluate LV
Function
EF <.40 EF >.40
Stress Test
Follow on
Medical Rx
Is it ACUTE CORONARY SYNDROME?
Location of chest pain
14
R
I
S
K
F
A
C
T
O
R
S
Evolution of the atherosclerotic Plaque
Traditional risk factors Emerging risk factors
- Dyslipidemia - Homocystein
- Hypertension - CRP
- Smoking - Fibrinogen
- DM - etc
Likelihood That Signs and Symptoms
Represent an ACS Secondary to CAD
MB2/MB1
Myoglobin
048 16 24 36 48
Hour post-AMI
Acute Coronary Syndrome
• ST-segment elevation MI (STEMI)
• Non ST-segment elevation MI (NSTEMI)
• Unstable Angina
Treatment of ACS
A. Anti IschemicTherapy
• b-Blockers
• Nitrates
• Calcium channel blockers
B. Antiplatelet agents
• Aspirin
• P2Y12 receptor inhibitors (Clopidogrel, Ticagrelor, Prasugrel (not
available in Indonesia))
• Glycoprotein IIb/IIIa receptor inhibitors
C. Anticoagulants
• Indirect inhibitors of the coagulation cascade (Fondaparinux, LMWH,
UFH)
• Direct inhibitors of coagulation (Direct factor Xa inhibitors, Direct
thrombin inhibitors )
THERAPY
General Therapy (MONACT)
Beta-blockers
Reperfusion
Facilitated PCI
Risk Factors
Complications
Antithrombotic
Ticlopidin,
Clopidogrel,
Prasugrel
Ticagrelor
PATHOGENESIS THERAPY
- PLATELET ADHESION
ANTIPLATELET
-PLATELET AGGREGATION
-THROMBOSIS THROMBOLYTIC
Hospital care
A. Anti Ischemic Therapy
Bed rest with continuous ECG monitoring
Supplemental O2 to maintain SaO2 > 90%
Morphine iv. (for pain, anxiety, Pulmonary congestion)
Nitrate (oral or iv.)
Betablockers if no contraindication
Non dihydropyridine calcium antagonis (Diltiazem
or Verapamil) if Betablockers contraindicated and
no severe LV dysfunction.
Ace inhibitors for hypertension LV dysfunction
after MI
Hospital care
B. Anti Thrombotic Therapy
Clopidogrel
+
Clopidogrel
Hospital care