ACUTE CORONARY

SYNDROME

Afdhalun Hakim,MD,FIHA,FASCC
Current Update
Acute Coronary Syndrom
Approach

Afdhalun Hakim,MD,FIHA,FASCC
PERKI BATAM
Introduction
Causes : Rupture of atherosclerosis plaque
Spectrum : STEMI, NSTEMI, & unstable angina.
US : ACS occurs every 25 seconds, 1,4 million patients/year are
hospitalized due to ACS
Mortality rate 30%, 25 30% mortality is occurred prehospital
(VT/VF)
Mortaility in Hospital (Cardiogenic Shock):
Without reperfusion therapy 15%
With fibrinolysis 5 6%
With PCI < 5%
Epidemiology
Worldwide, coronary artery disease (CAD) is the single most
frequent cause of death. Over seven million people every
year die from CAD, accounting for 12.8% of all deaths.
The mortality of STEMI is influenced by : age, Killip class,
time delay to treatment, mode of treatment, history of
prior MI, DM, renal failure, number of diseased coronary
arteries, EF, and treatment.
The in-hospital mortality of unselected STEMI patients in
the national registries of the ESC countries varies between
6% and 14%.
Universal definition of myocardial infarction

Detection of rise and/or fall of cardiac biomarker values (preferably troponin) with at
least one value above the 99th percentile of the upper reference limit and with at least
one of the following:
Symptoms of ischaemia;
New or presumably new significant ST-T changes or new LBBB;
Development of pathological Q waves in the ECG;
Imaging evidence of new loss of viable myocardium, or new regional wall motion abnormality;
Identification of an intracoronary thrombus by angiography or autopsy.
Cardiac death with symptoms suggestive of myocardial ischaemia, and presumably
new ECG changes or new LBBB, but death occurring before blood cardiac
biomarkers values are released or before cardiac biomarker values would be
increased.
Stent thrombosis associated with MI when detected by coronary angiography or
autopsy in the setting of myocardial ischaemia and with a rise and/or fall of cardiac
biomarker values with at least one value above the 99th percentile URL.
ACS-STEMI
Definition and Diagnosis STEMI is a
clinical syndrome defined by
characteristic symptoms of myocardial
ischemia in association with persistent
electrocardiographic (ECG) ST elevation
and subsequent release of biomarkers of
myocardial necrosis.
Emergency Care
History of chest pain lasting for 20 min or
more, not responding to nitrate.
Radiation of the pain to the neck, lower jaw
or left arm
Some patients present with less-typical
symptoms, such as nausea/vomiting,
shortness of breath, fatigue, palpitations
or syncope. (women, diabetic or elderly
patients)
Diagnosis

Clinical Presentation
Prolonged (>20 min) anginal pain at rest;
New onset (de novo) angina (class II / III of the CCS
Physical Examination
classification)
Frequently : normal
Recent destabilization of previously stable angina with at least
Sign
CCSofClass
HF / III Diagnostic
haemodynamic/ tools
electrical
angina characteristics instabilityangina);
(crescendo
Systolic
Post-MImurmur
angina. : mechanical complication
ECG Non-invasive imaging
Rule out other diagnosis
Biomarker Rule-in & rule-out algorithms
ECG
Even at an early stage, the ECG is seldom normal
ST-segment elevation, measured at the J point, should be
found in two contiguous leads
V2-V3: 0.25 mV in men < 40 years, 0.2 mV in men > 40
years, or 0.15 mV in women
0.1 mV in other leads (in the absence of LVH or LBBB)
Inferior myocardial infarction: record right precordial leads
(V3R and V4R) seeking ST elevation, in order to identify
concomitant right ventricular infarction
ST-segment depression in leads V1 V3 suggests
myocardial ischaemia, especially when the terminal T-
wave is positive (ST-elevation equivalent), and may be
confirmed by concomitant ST elevation 0.1 mV recorded
in leads V7 V9
Treatment
Relief pain, breathlessness, anxiety
Periprocedural antithrombotic medication
in primary percutaneous coronary
intervention
Reperfusion therapy
Importance of Rapid Reperfusion in STEMI

Expeditious restoration of flow in the

obstructed infarct artery after the onset of
symptoms in patients with STEMI is a key
determinant of short- and long-term
outcomes

30 minutes of delay = 8% increase in
relative risk of 1-year mortality

AntmanEM, Anbe DT, Armstrong PW, et al. Circulation.2004;110:e82-292.

Antman E, Morrow DA. ST-segment elevation myocardial infarction: management. In: Bonow RO, Mann DL, Zipes P, et al, eds.
Braunwald's Heart Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011:1111-1177.
Reperfusion and Revascularization
Reperfusion: restoration of blood supply to a
tissue or organ to relieve ischemia
Fibrinolysis
PCI
Revascularization: restoration of flow
through part of the vascular system
PCI
CABG
Improving Door-to-Device Times
Strategy
Contraindications for Fibrinolysis

Absolute contraindications Relative contraindications

History of chronic, severe, poorly controlled
Any prior intracranial hemorrhage hypertension

Known cerebral lesions Severe uncontrolled hypertension on presentation

(SBP >180 mm Hg or DBP >110 mm Hg)
(structural or cancer) History of prior ischemic stroke, dementia, or
known intracranial pathology not covered in
Ischemic stroke within 3 months contraindications
(unless within 3 hours) Recent (<3 weeks) traumatic or prolonged (>10
minutes) CPR or major surgery
Suspected aortic dissection Recent internal bleeding (within 24 weeks)

Active bleeding (excluding Noncompressible vascular punctures

menses) Prior exposure (>5 days ago) or prior allergic

reaction to certain fibrinolytic agents
Significant closed-head or facial Pregnancy

trauma within 3 months Active peptic ulcer

Current use of anticoagulants

AntmanEM, Anbe DT, Armstrong PW, et al.

Circulation.2004;110:e82-292.
CASE 1 Mrs. J/ 53 y.o
STEMI INFERIOR KILLIP I
One hour Post PCI
CASE 2
Mrs. L/ 70 y.o
ACS STEMI INFERIOR KILLIP IV
Post Cardiac-Arrest
CASE 3
Mrs. S/ 57 y.o
AP CCS III ec CAD
Mr. H/ 56 y.o
NSTEMI Very High Risk (GRACE 177)
NSTEMI - Update
Diagnosis
2015
2011
High-sensitive cardiac
Conventional troponin
troponin (hsTrop) assays
What
New is new
cardiac in??
biomarker!!!
detection of lower ranges of circulating troponin levels
a higher negative predictive value
reduce the troponin-blind interval leading to earlier
detection of ACS
hsTrop assays are currently recommended over
conventional ones (I,A)
Pharmacological Antithrombotic Therapy &
2015 Revascularisation

Dual antiplatelet
(1,A) treatment (DAPT) : aspirin + P2Y12 inhibitor

2011 are preferred over

Newer P2Y12 inhibitors (ticagrelor, prasugrel) I,B
clopidogrel because of improved ischaemic outcomes (I,B)
I,B
Preloading with prasugrel (prior to coronary angiography) in NSTE-
ACS is not recommended based on excess bleeding risks documentedI,A
in the
(I,B)ACCOAST trial (III,B). I,B

II,B
Cangrelor and vorapaxar have recently received marketing
authorisation by
(I,B) the EMA, but the guideline task force thought it

premature to make any recommendation based on limited and

somewhat controversial published data.
(I,B)
Invasive Coronary Angiography
Invasive coronary angiography revascularization as the
routine approach in NSTE-ACS, intermediate - and
high-risk patients
The timing depends on the
severity & risk
Immediate invasive Early invasive strategy
strategy (< 24 hours of presentation)
(< 2 hrs of presentation)
Very high-risk criteria High-risk criteria
(shock, cardiac arrest, life- Rise / fall in troponin, dynamic
threatening arrhythmias, etc.) (I,C) ST- / T-wave changes, and/or
a GRACE score >140 (I,A)

Radial access resulted in lower bleeding rate and significant reductions

in total mortality compared to femoral access (I,A)
Mode of revascularisation

PCI VS Surgical

Depends on
clinical condition of the patient, comorbidities, &
disease severity
no randomised trials have ever compared
PCI with CABG in the NSTE-ACS setting

In multivessel disease, the revascularisation strategy

(ad hoc culprit-lesion PCI, staged CABG, multivessel PCI,
or multivessel CABG) should be discussed according to
the local heart-team protocol (I, C).
Definition
Patients with acute chest pain but no persistent ST-
segment elevation

Transient ST-segment elevation

Persistent / transient ST-segment depression
T-wave inversion
ECG changes
Flat T waves
Pseudonormalization of T waves
Normal ECG
Biomarker
0 h/3 h rule-out algorithm of non-ST-elevation acute coronary
syndromes using high-sensitivity cardiac troponin assays.
GRACE SCORE :
Risk Calculator for 6-Month Post-Discharge Mortality After
Hospitalization for ACS
Invasive coronary angiography & revascularization

Risk criteria mandating invasive

strategy in NSTE-ACS

Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS)

treatment strategy & timing according to initial risk stratification
Complications of ACS
Arrhythmias
Hemodynamic disturbances
Mechanical damage
Recurrent chest pain
Ischemic stroke
Deep venous thrombosis
Pulmonary embolism
Arrhythmias: Fibrillation and Tachycardia

Common early after STEMI

Ventricular fibrillation
Uncoordinated signals; no effective pumping
Occurs in 3%5% of patients after STEMI; may cause sudden
death if not treated effectively

Tachycardia
Abnormally fast heart rate (>100 bpm)

Treatment
Countershock in hemodynamically significant arrhythmias
(cardioversion vs.. defibrillation, dependent on rhythm and
whether a pulse is present), possibly with medical therapy

AntmanEM, Anbe DT, Armstrong PW, et al. Circulation.2004;110:e82-292.

Arrhythmias: Bradycardias and Conduction Abnormalities

Arrhythmia Description Incidence

Bradycardia Abnormally slow heart rate 30%40% of MI-

associated
arrhythmias
Heart block Impaired signal transmission 6%14% of
of signals between the atria STEMI
and the ventricles More common in
inferior
infarctions
Intraventricular Delayed signal transmission 10%20% of
conduction delay through 1 or both bundle STEMI
branches
Related to the extent of ischemia and infarction
Treatment: observation, pharmacologic therapy (atropine), or electronic
pacing AntmanEM, Anbe DT, Armstrong PW, et al. Circulation.2004;110:e82-292.
Heart Failure
Failure to pump blood with normal efficiency
Low cardiac output
Usually estimated using the left ventricular ejection
fraction (LVEF)

Pulmonary edema/congestion
Fluid in the lungs because of increased ventricular
pressure

Cardiogenic shock
Inability to supply enough blood to support organ function
Medical emergency requiring prompt treatment
Summary
Early diagnosis and risk stratification are
essential to determine the decision of
treatment, especially reperfusion therapy
Importance of recognizing atypical
presentations
Delays must be recorded and monitored
Prasurgrel or Ticagrelor preferred over
clopidogrel as adjunct to aspirin.
Treat the complication of ACS
comprehensively
Other Complications of ACS
Mechanical damage Weakened necrotic tissue may fail
Papillary muscles: mitral regurgitation
Septal defect: opening between the left
and right ventricles
Free wall rupture: opening in the heart
wall, causes tamponade
Right ventricular infarction Necrosis may affect the right ventricle
Recurrent chest pain after Recurrent ischemia or infarction
STEMI Pericarditis
Ischemic stroke 0.75%1.2% of MIs; especially with atrial
fibrillation
Deep venous thrombosis and Bed rest and heart failure promote
pulmonary embolism thrombus formation in the veins; thrombi
may cause pulmonary embolism