Acute Coronary SyndromesMagdy El-Masry.

Prof. of Cardiology.

Tanta University.

What Do the Guidelines Say ?

Acute Coronary Syndromes Guidelines : Are the US and Europe in Harmony ?

STEMI

NSTEmi

Based on the ECG, two groups of patients should be differentiated:

(1)Patients with acute chest pain and persistent (>20 min) ST-segment elevation (ST-elevation ACS )

(2) Patients with acute chest pain but no persistent ST-segment elevation (Non-ST-elevation ACS) ECG changes may include transient ST-segment elevation,

persistent or transient ST-segment depression, T-wave inversion, flat T waves or pseudo-normalization of T waves or the ECG may be normal.

The leading symptom that initiates the diagnostic and therapeutic cascade in patients with suspected acute coronary syndromes is chest pain.

Initial assessment of patients with suspected acute coronary syndromes

“Other cardiac” includes, among other, myocarditis, Tako-Tsubo cardiomyopathy, or tachyarrhythmias. “Non-cardiac” refers to thoracic diseases such as pneumonia or pneumothorax. . If the initial evaluation suggests aortic dissection or pulmonary embolism, D-dimers and MDCT angiography are recommended

Differential diagnoses of acute coronary syndromes in the setting of

acute chest pain

Differential diagnoses of acute coronary syndromes in the setting

of acute chest pain

STEMI

Reperfusion goals:

Door-to-balloon inflation(pPCI)goal of 90 minutes

Door-to-needle (fibrinolysis)goal of 30 minutes

STEMI time delays (Time is Myocardium ) “You may delay, but time will not, and lost time is never found again.”

Patient Delay System Delay

FMC

door-to-balloon time

door-to-needle time

STEMI diagnosis

Primary PCI capable center

Primary - PCI

Non primary-PCI capable center

PCI possible <120 min? Yes

Primary - PCI

Transfer to PCI center

DIDO time

STEMI diagnosisNon primary-PCI capable

center

PCI possible <120 min? No

Thrombolytic Therapy

Failed or Reocclusion Successful

Rescue PCICoronary angiography

NSTEmi

Initial risk stratification

Initial risk stratification

Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification.

A few words about antiplatelet therapy

Pathophysiology of ACS: The Role of Platelets

Rivaroxaban

Antiplatelet Agents—Oral P2Y12 Inhibitors

++ +++

+ Bleeding Risk

Ischemic RiskBleeding Risk

Balanced Benefit/Risk Ratio

Tailoring antiplatelet therapy : a step toward individualized therapy to improve clinical outcome?

Thus, the thousand dollar question is : Where is the sweet spot between

ischaemia and bleeding?

A call for individualised medicine

One Size Does Not Fit All

Precision medicine ( Personalized medicine )

Factors for physicians to consider in determining the optimal duration of DAPT after DES implantation for individual patients

Eisen, A. & Bhatt, D. L. (2015) Defining the optimal duration of DAPT after PCI with DES Nat. Rev. Cardiol. doi:10.1038/nrcardio.2015.87