Acute Coronary Syndrome
In Clinical Practice
Firman B. Leksmono
Acute Coronary Syndrome
Acute coronary syndrome
(ACS) refers to any group of
symptoms attributed to
obstruction of the coronary
arteries.
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 coronary
attacks per year
38% of those who with coronary attack die
within a year of having it
Annual cost > $300 billion
Epidemiology
Acute coronary syndrome
1,5 million hospital addmision - ACS
UA/ NSTEMI
1,24 million
admission per
year
STEMI
0,33 million
admission per
year
Heart disease and stroke statistic 2007 update. Circulation 2007 , 155 : 69 171
Epidemiology
Guideline for the Management of STEMI. JACC 2013
Risk Factor
Non- Modifiable
Gender
Men > Women
Age
Modifiable
Hypertension
Diabetes Mellitus
Dyslipidemia
Men, increased risk after age 45
Obesity
Women, increased risk after age 55
Cigarette Smoking
Family History
Heart disease diagnosed before age 55 in father
or brother
Lack of physical activity
Diet (high fat and high
carbohidrat)
Heart disease diagnosed before age 65 in mother
Stress
or sister
Novel Factors :
Race
Hiperhomocysteinemia, CRP,
Lipoprotein (a)
Diagnosis
At least 2 of the following (WHO criteria):
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 suddenly
decreased after occlusive thrombus on atherosclerotic plaque.
Coronary plaques tend to rupture if it has a thin fibrous cap and a
lipid-rich core.
Classical pathological picture consists of rich red fibrin thrombus,
which is believed to be the basis of so STEMI response to
thrombolytic therapy.
NSTEMI and Unstable Angina
UA or NSTEMI is when there is a partial dynamic
block to coronary arteries (non-occlusive thrombus).
There will be no ST elevation or Q waves on ECG, as
transmural infarction is not seen.
The main difference between NSTEMI and unstable
angina is that in NSTEMI the severity of ischemia is
sufficient to cause cardiac enzyme elevation.
Patophysiology
Patophysiology
Patophysiology
Clinical Manifestation
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, or
arms frequently on left.
Associated features : Not relieve with rest or nitrat
Electrocardiography
STEMI
NSTEMI/UAP
Electrocardiography
Whole Anterior STEMI
Inferior STEMI
Biomarker
Biomarker
Biomarker
Biochemical marker for detection of myocardial necrosis
Enzyme
Normal value
First rise after
AMI
Peak after
AMI
Return to
normal
CK-MB
< 5.0 ng/ml
4h
24 h
72 h
Myoglobin
< 82 ng/ml
2h
6-8 h
24 h
Troponin T
Negatif
4h
24 - 48 h
5 21 days
Troponin I
Detection Limit = 0.5 ng/ml
Abnormal > 2.0 ng/ml
Borderline - 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
Immediate assessment within 10 Minutes
Initial Labs
and Tests
12 lead ECG
Obtain initial cardiac
enzymes
Electrolytes, cbc
lipids, bun/cr, glucose,
coagulation
CXR
Emergent
Care
IV access
Cardiac monitoring
Oxygen
Aspirin and CPG
Nitrates
Morphin
History &
Physical
Establish diagnosis
Read ECG
Identify
complications
Assess for
reperfusion
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 min
in 100 ml D5w or 0,9% saline.
rTPA Accelerated infusion over 1.5 hrs - 15mg IV
bolus, 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
Prognosis
KILLIP Classification For STEMI
Class
Description
Mortality Rate (%)
No clinical signs of heart failure
II
Rales or crackles in the lungs, an S3, and
elevated jugular venous pressure
17
III
Acute pulmonary edema
30 - 40
IV
Cardiogenic shock or hypotension (systolic
BP < 90 mmHg), and evidence of peripheral
vasoconstriction
60 80
TIMI Score for STEMI
TIMI Score for UA-NSTEMI
TIMI RISK SCORE Increase in mortality with increasing score ~40% all cause
mortality at 14 days for patients requiring urgent revascularisation.
GRACE Score
Complication
Sudden Death
Arrhythmia (VT/VF)
Ventricular Dysfunction (Heart Failure)
Interventricular septum and myocardial wall rupture
Hemodynamic Disturbances
Cardiogenic shock
Pericarditis
Secondary Prevention
Disease
Behavioral
Hypertension, Diabetes
Mellitus, Dislipidemia
Smoking, diet, physical activity,
weight
Cognitive
Education, cardiac rehab
program
