Acute Coronary SyndromeIn Clinical PracticeFirman B. Leksmono

Acute Coronary SyndromeAcute coronary syndrome(ACS) refers to any group ofsymptoms attributed toobstruction of the coronaryarteries.

Coronary Anatomy

Acute Coronary Syndrome

Acute Coronary Syndrome

Epidemiology CHD single leading cause of death in United

States 452,327 deaths in the U.S. in 2004

1,200,000 new & recurrent coronaryattacks per year

38% of those who with coronary attack diewithin a year of having it

Annual cost > $300 billion

CHD single leading cause of death in UnitedStates 452,327 deaths in the U.S. in 2004

1,200,000 new & recurrent coronaryattacks per year

38% of those who with coronary attack diewithin a year of having it

Annual cost > $300 billion

Epidemiology

Acute coronary syndrome1,5 million hospital addmision - ACS

UA/ NSTEMIUA/ NSTEMI

1,24 millionadmission per

year

STEMI

0,33 millionadmission per

year

Heart disease and stroke statistic 2007 update. Circulation 2007 , 155 : 69 171

Epidemiology

Guideline for the Management of STEMI. JACC 2013

Risk FactorNon- Modifiable Modifiable

Gender Men > WomenAge Men, increased risk after age 45 Women, increased risk after age 55Family History Heart disease diagnosed before age 55 in father

or brother Heart disease diagnosed before age 65 in mother

or sister Race

Hypertension Diabetes Mellitus Dyslipidemia Obesity Cigarette Smoking Lack of physical activity Diet (high fat and high

carbohidrat) Stress Novel Factors :

Hiperhomocysteinemia, CRP, Lipoprotein (a)

Gender Men > WomenAge Men, increased risk after age 45 Women, increased risk after age 55Family History Heart disease diagnosed before age 55 in father

or brother Heart disease diagnosed before age 65 in mother

or sister Race

Hypertension Diabetes Mellitus Dyslipidemia Obesity Cigarette Smoking Lack of physical activity Diet (high fat and high

carbohidrat) Stress Novel Factors :

Hiperhomocysteinemia, CRP, Lipoprotein (a)

At least 2 of the following (WHO criteria):At least 2 of the following (WHO criteria):

Diagnosis

1. Ischemic Symptoms

2. Diagnostic ECG Changes

3. Serum Cardiac Marker

Diagnosis

Hamm CW et al. European Heart Journal 2011

ST-Elevation Myocardial Infarction There is a transmural infarction of the myocardium. Entire thickness

of the myocardium has undergone necrosis.

Usually occurs when blood flow of artery coronary suddenlydecreased after occlusive thrombus on atherosclerotic plaque.

Coronary plaques tend to rupture if it has a thin fibrous cap and alipid-rich core.

Classical pathological picture consists of rich red fibrin thrombus,which is believed to be the basis of so STEMI response tothrombolytic therapy.

There is a transmural infarction of the myocardium. Entire thicknessof the myocardium has undergone necrosis.

Usually occurs when blood flow of artery coronary suddenlydecreased after occlusive thrombus on atherosclerotic plaque.

Coronary plaques tend to rupture if it has a thin fibrous cap and alipid-rich core.

Classical pathological picture consists of rich red fibrin thrombus,which is believed to be the basis of so STEMI response tothrombolytic therapy.

NSTEMI and Unstable Angina UA or NSTEMI is when there is a partial dynamicblock to coronary arteries (non-occlusive thrombus).

There will be no ST elevation or Q waves on ECG, astransmural infarction is not seen.

The main difference between NSTEMI and unstableangina is that in NSTEMI the severity of ischemia issufficient to cause cardiac enzyme elevation.

UA or NSTEMI is when there is a partial dynamicblock to coronary arteries (non-occlusive thrombus).

There will be no ST elevation or Q waves on ECG, astransmural infarction is not seen.

The main difference between NSTEMI and unstableangina is that in NSTEMI the severity of ischemia issufficient to cause cardiac enzyme elevation.

Patophysiology

Patophysiology

Patophysiology

Clinical ManifestationIschemic symptoms Prolonged pain (usually >20 mins), constricting,

crushing, squeezing Usually retrosternal location, radiating to left

chest, left arm, can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness

Ischemic symptoms Prolonged pain (usually >20 mins), constricting,

crushing, squeezing Usually retrosternal location, radiating to left

chest, left arm, can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness

Clinical Manifestation

Duration :Variable, often more than 30 minutes.Quality : Feels squeezing, pressurelike, tightness, heaviness, and burning.Location : Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, orarms frequently on left.Associated features : Not relieve with rest or nitrat

Electrocardiography

STEMI NSTEMI/UAP

Electrocardiography

Whole Anterior STEMI

Inferior STEMI

Biomarker

Biomarker

BiomarkerBiochemical marker for detection of myocardial necrosis

Enzyme Normal value First rise afterAMI

Peak afterAMI

Return tonormal

CK-MB < 5.0 ng/ml 4 h 24 h 72 hMyoglobin < 82 ng/ml 2 h 6-8 h 24 hTroponin T Negatif 4 h 24 - 48 h 5 21 daysTroponin T Negatif 4 h 24 - 48 h 5 21 daysTroponin I Detection Limit = 0.5 ng/ml

Abnormal > 2.0 ng/mlBorderline - Not detected

3-4 h 24 36 h 5 14 days

Decission Making of ACS

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

Chest pain suggestive of ischemia

12 lead ECG Obtain initial cardiac

enzymes Electrolytes, cbc

lipids, bun/cr, glucose,coagulation

CXR

Immediate assessment within 10 Minutes

Establish diagnosis Read ECG Identify

complications Assess for

reperfusion

InitialInitial LabsLabsandandTestsTests

EmergentEmergentCareCare

History &History &PhysicalPhysical

IV access Cardiac monitoring Oxygen Aspirin and CPG Nitrates Morphin

12 lead ECG Obtain initial cardiac

enzymes Electrolytes, cbc

lipids, bun/cr, glucose,coagulation

CXR

Establish diagnosis Read ECG Identify

complications Assess for

reperfusion

IV access Cardiac monitoring Oxygen Aspirin and CPG Nitrates Morphin

Basic Treatment

Basic Treatment

Invasive Strategy for UA-NSTEMI

Hamm CW et al. European Heart Journal 2011

Reperfussion Therapy of STEMI

Guideline for the Management of STEMI. JACC 2013

Reperfussion Therapy of STEMI

Guideline for the Management of STEMI. JACC 2013

Trombolytic vs Primary PCI

Trombolytic vs Primary PCI

Trombolytic Streptokinase 1.5 million iu infusion over 30-60 minin 100 ml D5w or 0,9% saline.

rTPA Accelerated infusion over 1.5 hrs - 15mg IVbolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr.

Streptokinase 1.5 million iu infusion over 30-60 minin 100 ml D5w or 0,9% saline.

rTPA Accelerated infusion over 1.5 hrs - 15mg IVbolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr.

Contraindication Any prior ICH Known structural cerebral vascular lesion (e.g., AVM) 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 months

Primary PCI

Routine Medical Therapy

Routine Medical Therapy

Guideline for the Management of STEMI. JACC 2013

Class Description Mortality Rate (%)I No clinical signs of heart failure 6II Rales or crackles in the lungs, an S3, and

elevated jugular venous pressure17

KILLIP Classification For STEMI

Prognosis

Rales or crackles in the lungs, an S3, andelevated jugular venous pressure

III Acute pulmonary edema 30 - 40IV Cardiogenic shock or hypotension (systolic

BP < 90 mmHg), and evidence of peripheralvasoconstriction

60 80

TIMI Score for STEMI

TIMI Score for UA-NSTEMI

TIMI RISK SCORE Increase in mortality with increasing score ~40% all causemortality at 14 days for patients requiring urgent revascularisation.

GRACE Score

Sudden Death

Arrhythmia (VT/VF)

Ventricular Dysfunction (Heart Failure)

Interventricular septum and myocardial wall rupture

Hemodynamic Disturbances

Cardiogenic shock

Pericarditis

Complication

Sudden Death

Arrhythmia (VT/VF)

Ventricular Dysfunction (Heart Failure)

Interventricular septum and myocardial wall rupture

Hemodynamic Disturbances

Cardiogenic shock

Pericarditis

Secondary Prevention Disease

Hypertension, DiabetesMellitus, Dislipidemia

Behavioral Smoking, diet, physical activity,

weight

Cognitive Education, cardiac rehab

program

Disease Hypertension, Diabetes

Mellitus, Dislipidemia

Behavioral Smoking, diet, physical activity,

weight

Cognitive Education, cardiac rehab

program