Treatmentof

Acute Coronary Syndrome

Ranjith R Thampi

I. Initial evaluation & stabilizationII. Optimized Anti-ischaemic & Anti-platelet therapyIII. Focused cardiac care

OBJECTIVES

Chest pain suggestive of

ischemia

12 lead ECG Obtain Initial

cardiac enzymes FBC,

Electrolytes, Urea, Creatinine, Coagulation Studies

CXR

Immediate assessment within 10 Minutes

Establish diagnosis

Read ECG Identify

complications

Assess for reperfusion

Initial labs

and tests

Emergent care

History &

Physical IV access Cardiac

monitoring Oxygen Nitrates Aspirin

ECG assessment

ST Elevation or new LBBBSTEMI

Non-specific ECGUnstable Angina

ST Depression or dynamicT wave inversions

NSTEMI

UNSTABLE

ANGINA

NSTEMI

General Measures Oxygen and ECG monitoring Oxygen 2-4 L/minPain Relief

5-10mg Morphine iv + 10mg Metoclopramide iv

Control Ischaemia Nitrates- GTN spray or Sublingual Tabs 0.3-0.6 mg/5

mins

i/v Nitroglycerin 10 mg/min -blockers/CCB’s

Therapeutic Goals PREVENT Re-thrombosis & Downstream Embolization Anti-platelet therapy

Aspirin upto 300 mg stat + 75 mg ODClopidogrel 300-600 mg 75 mg ODGlycoprotein IIB/IIIA inhibitors

Anti-coagulant therapyUFH or LMWH LMWH- Inj. Heparin s/c 1mg/kg 12hrlyUFH- Inj. Heparin 5000U i/v bolus + IVI

Therapeutic Goals

Relieve Obstruction

Cardiac catheterizationPercutaneous Coronary Interventions

Coronary Artery Bypass Graft

Based on Risk: (ACS Guidelines 2006)Low Risk: <2 % chance MI or Death within next 6 monthsHigh Risk: >10 % chance of Mortality in 6 months

High Risk:

H E A R T D O C

Unstable Angina/NSTEMI Focused Cardiac Care

Low Risk

UA/NSTEMI High Risk- Very Unstable

-Consider adding GP IIb/IIIa inhibitors (along with aspirin, clopidogrel and heparin)

-Urgent/ Immediate Cardiac Catheterization (<24 hrs) after starting UFH i/v-Consider use of Intra-Aortic Balloon Pump to stabilize patient prior to coronary angiography

Low & High RiskLongterm Therapy

Aspirin 75 mg Daily Clopidogrel 75 mg Daily Atorvastatin 80 mg Ramipril 10 mg Beta Blockade- Metoprolol/Atenolol Glycemic Control Life-style modification

NITRATES NITRATES

Low dose- VenodilatorHigh dose- Arteriolar dilatorReduces Preload/Afterload + MOD

MOA- Acts by releasing NO in vascular smooth muscleInhibits Platelet Aggregation

ADR- Throbbing Headache, Nausea, Dizziness, Hypotension, Reflex Tachycardia,

Tolerance develops over longterm use

C/I- Hypotension, Sildenafil Use(Viagra)

ANTIPLATELETS ASPIRIN

COX inhibitor- TXA2 synthesis by platelets fall Irreversible inhibition of platelet aggregation Stabilize plaque and arrest thrombus

CLOPIDOGREL Irreversible inhibition of platelet aggregation via inhibition of

ADP and fibrinogen by altering surface receptors Used in support of cath / PCI intervention or if unable to take

aspirin Course of 3-12 month duration depending on scenario

*NEWER ANTIPLATELETS Ticagrelor 50,100,200 mg Prasugrel 60 mg bolus + 10 mg (C/I: prior TIA, >75 yrs) i/v Cangrelor 180 mg loading + 90 mg BD

Platelet GP IIb/IIIa Receptor Inhibitors

-Inhibition of platelet aggregation at final common pathway

-Best for PCI, reduces ischemic complicationsADR- Hemorrhage, Thrombocytopenia, Arrhythmias, Constipation

Abciximab..pci Eptifibatide..acs Tirofiban..acs

Only through Parenteral Infusion

ANTICOAGULANTSHEPARIN MOA- Inhibition of Factor Xa and Thrombin

IIa mediated conversion of fibrinogen to fibrin ADR- Bleeding, Hypersensitivity reactions,

Thrombocytopenia(HIT), Osteoporosis, Skin necrosis, Alopecia, Hypoaldosteronism

C/I- Bleeding disorders, SBE, Ocular & Neurosurgery, Chronic alcoholics, Cirrhosis, Renal Failure

HeparinTypes- UFH, LMWH

UFH 60 U/Kg iv bolus + M 16 U/Kg/hrLMWH Enox- 1 mg/Kg s/c Dalte- 120 IU/Kg Fondaparinux (Apixaban, Rivaroxaban) Bivalirudin

BD

Thrombus Formation and Agents Acting

ACE-inhibitors Captopril, Lisinopril , Ramipril, Perindopril MOA- Inhibits A1 pressor action, Reduced Aldosterone, Reduced vasoconstriction, reduced sodium retention Improves LV DysfunctionADR- Hypotension, Hyperkalemia, Dry Cough, Angioedema, Fetopathies, ARFC/I- Renal Failure, Renal Artery StenosisStart early and aim for highest doses Captopril - 50mg TDS, Lisinopril 20mg D, Ramipril 10mg D

Angiotensin Receptor BlockersLosartan, Temisartan, Candesartan, Olmesartan, ValsartanARB as substitute for patients unable to use ACE-I

MOA- AT2 receptor blockadePrevents: Vasoconstriction, sympathetic stimulation, Aldosterone and Adr release from adrenals, Salt & Water reabsorptionADR- Hypotension, Hyperkalemia, Fetopathies

STATINS- Atorvastatin, Simvastatin, Rosuvastatin

MOA- HMG CoA inhibition, blocks hepatic cholesterol synthesis, Increased LDL, VLDL blood clearanceADR- GI disturbances, Myopathies, Myalgia, HeadacheC/I- Liver Disease, Renal Impairment

Beta BlockersAtenolol, Carvedilol, Esmolol, Metoprolol, PindololMOA- Decreases HR, Force of contraction, Cardiac Output, Prolongs Systole, AntiarrhythmicADR- Ppts CHF, Carbohydrate Intolerance, Altered Lipid ProfileC/I- Bradycardia, Reactive airway disease, Sinus Node Dysfunction/AV block, Severe Heart failure*Diltiazem instead

Calcium Channel BlockersAmlodipine, Diltiazem, Nifedipine, Nimodipine, Verapamil

MOA- Smooth muscle relaxation & vasodilationSlows HR, Reduces: afterload, myocardial contractility, MODADR- Accentuates AV Block, CHF*Nifedipine causes abrupt changes in BP and HR occur without appropriate Beta Blockade

C/I- LV Dysfunction, Cardiogenic Shock, Sick Sinus Syndrome, Hepatic impairment

ECG assessment

ST Elevation or new LBBBSTEMI

Non-specific ECGUnstable Angina

ST Depression or dynamicT wave inversions

NSTEMI

STEMI

STEMI

2 situations when it becomes difficult to diagnose STEMI

Chronic or Rate Dependent LBBB Paced Rhythm

ACSClinical Diagnosis

ACSClinical Diagnosis

MONA:Morphine + antiemeticOxygenNitratesAspirin 300 mg statClopidogrel 600 mg stat

MONA:Morphine + antiemeticOxygenNitratesAspirin 300 mg statClopidogrel 600 mg stat

Blood Tests:Troponin at 12 hours after onset of pain, U&E, cholesterol, FBC, coagulationAdmission or subsequent ECG

Blood Tests:Troponin at 12 hours after onset of pain, U&E, cholesterol, FBC, coagulationAdmission or subsequent ECG

STEMI

Immediate Triage

Immediate Triage

12 Lead ECGShowing thrombolyseable

criteria

12 Lead ECGShowing thrombolyseable

criteria

ECG criteria-1 mm ST elevation in at least 2 limb leads-2 mm ST elevation in at least 2 precordial leads

-LBBB with typical clinical presentation

ECG criteria-1 mm ST elevation in at least 2 limb leads-2 mm ST elevation in at least 2 precordial leads

-LBBB with typical clinical presentation

Extra ECG requirements

Inferior ST elevation Do Rpt ECGPosterior changes Deep ST-elevation + tall R waves in V1- V3

Extra ECG requirements

Inferior ST elevation Do Rpt ECGPosterior changes Deep ST-elevation + tall R waves in V1- V3

Definite STEMI

Thrombolysis(if PCI unavailable immediately)

Target < 30 minDoor-needle time in > 75% patients

Thrombolysis(if PCI unavailable immediately)

Target < 30 minDoor-needle time in > 75% patients

Primary PCIPrimary PCI

Repeat ECG 90 min from comencement of lytic Aim: > 50% reduction in peak ST segment elevation

Repeat ECG 90 min from comencement of lytic Aim: > 50% reduction in peak ST segment elevation

Tenectoplase (TKN-tPA)Drug of choice with LMWH for pts <75 yrs independent of site

of infarctStreptokinase (SK)

Consider for pts > 75 yrs due to lower incidence of ICH

Tenectoplase (TKN-tPA)Drug of choice with LMWH for pts <75 yrs independent of site

of infarctStreptokinase (SK)

Consider for pts > 75 yrs due to lower incidence of ICH

Ix on admissionU&E, FBC, Cholest, coagulation

Repeat12 hrs Troponin, ECGControl RBS

Ix on admissionU&E, FBC, Cholest, coagulation

Repeat12 hrs Troponin, ECGControl RBS

Risk assessment & secondary preventionAspirin StatinEarly beta blockade Ace- inhibitorsAngiogram Pre discharge RehablitationConsider patient’s pre morbid state & suitability for revascularisation

Risk assessment & secondary preventionAspirin StatinEarly beta blockade Ace- inhibitorsAngiogram Pre discharge RehablitationConsider patient’s pre morbid state & suitability for revascularisation

REASSESS

Failed Reperfusion

Haemodynamics compromiseContinuing pain

Discuss suitability for rescue PCI

Failed Reperfusion

Haemodynamics compromiseContinuing pain

Discuss suitability for rescue PCI

Primary PCI Usually done under anticoagulant

cover Coronary recanalization is done with Angioplasty and commonly Stenting Best D2B Time- <90 mins

THROMBOLYSIS Lyses fibrin thrombi and reduces

clot-caused infarct size allowing reperfusion D2N Time- <30 minsBest Time- Upto 12 hrs from Onset of symptoms

THROMBOLYSIS Streptokinase & Urokinase[1.5 MU in 100 ml NS

ivi/1 hr]S/E: Nausea, Vomiting, Haemorrhage, Stroke

Tenectaplase [0.5 mg/Kg over 10 seconds]Bolus Injection best for paramedicsIndication: Ant. Wall MI, Previous SK useSBP< 100 mm Hg, New LBBB

Alteplase Reteplase[2 iv boluses 2hrs apart]

[10 MU bolus/2mins + 10 MU bolus after 30 mins]*Patients with STEMI who have not received reperfusion therapy should be treated with fondaparinux immediately

Thrombus Formation and Agents Acting

THROMBOLYSIS

ECG is done after 1 hr and assessed: Successful Thrombolysis

-Reperfusion Arrhythmias(Accelerated idioventricular rhythm)-Persistent Ventricular ectopics-Alleviation of chest pain

Failed Thrombolysis- Uncontrolled pain(Persistent Angina)- Continuing ST- elevation- Absent VTc, Absent Idioventricular arrhythmias

Consider re-thrombolysis with rt-PA, Tenecteplase, Rescue PCI

ABSOLUTE Active GI Bleed Aortic Dissection Previous ICH Stroke<2 months Intracranial

aneurysm/ neoplasm Head injury<2

months Pericarditis Pancreatitis Warfarin/INR>3

ABSOLUTE Active GI Bleed Aortic Dissection Previous ICH Stroke<2 months Intracranial

aneurysm/ neoplasm Head injury<2

months Pericarditis Pancreatitis Warfarin/INR>3

RELATIVE Traumatic CPR Surgery<10 days Arterial Puncture<24

hrs SBP>180 Bleeding Tendency Trauma Pregnancy Bacterial Endocarditis

RELATIVE Traumatic CPR Surgery<10 days Arterial Puncture<24

hrs SBP>180 Bleeding Tendency Trauma Pregnancy Bacterial Endocarditis

Contraindications vary slightly between thrombolytics

Contraindications to thrombolysis

Primary PCI

Current primary PCI strategy: Initiate Glycoprotein IIb/IIIa inhibitor in ED, together with Aspirin+Heparin, followed by rapid application of coronary angioplasty with stenting

Operator and institutional experience is an issue more important to outcomes with primary PCI than fibrinolysis.

Primary PCIFacilitated PCI Facilitated PCI is the use of

pharmacological reperfusion treatment delivered prior to a planned PCI. *There is no evidence of a significant clinical benefit and so facilitated PCI is currently not recommended.

Primary PCI

Rescue PCIPerformed on a coronary artery which remains occluded despite fibrinolytic therapy. *Associated with significant reduction in heart failure & reinfarction

Indication:-Evidence of failed fibrinolysis based on clinical signs and insufficient ST-segment resolution-Clinical or ECG evidence of a large infarct-If can be performed <12 hours after the onset of symptoms.

Primary PCI Preferred When:

-Diagnosis in doubt-Cardiogenic Shock-Increased Bleeding-Symptoms for 2-3 hrs, clot more mature, less chance for lysis

DISADVANTAGES:-Cost-Trained Personnel-Facilities

COMPLICATIONS

Complications ISCHAEMIC- Angina, Reinfarction,

Infarct Extension MECHANICAL- LVD, Cardiogenic

Shock, CHF, MV Dysfunction, Aneurysm, Cardiac Rupture

ARRHYTHMIAS- Atrial, Ventricular, SA/AV Node Dysfunction

THROMBOSIS & EMBOLIC- CNS, Peripheral embolisation, Pericarditis

PSYCHOSOCIAL- Depression *Dressler’s Syndrome

Admit to CCU & Monitor closely

O2 2-4 L, aim for SaO2 >95%

ANALGESIA2.5-5mg Morphine iv+ 10mg

Metoclopramide iv

INVESTIGATIONS and close monitoring

Correct arrhythmias, U&E abnormalities or acid-base

disturbance

Optimize filling pressure,if available, measure Pulmonary Capillary Wedge

Pressure(PCWP)

Pulmonary edema+

Cardiogenic Shock

KILLIP Class 3+4 Treatmen

t

PCWP

Plasma Expander 100mL every 15 mins iv

Aim for PCWP of 15-20 mm Hg

Consider ‘renal dose’ dopamine 2-5 mg/kg/min iv initially(via central line

only)

Consider intra-aortic balloon pump if expecting condition to improve, or time is required while

awaiting surgery

PCWP <15 mm Hg fluid load

PCWP >15 mm Hg

Inotropic supporteg: Dobutamine 2.5-10

mg/kg/min iviAim for SBP >80 mm Hg

Look for and treat any reversible cause:MI or PE- Consider Thrombolysis;

Surgery for: a/c VSD, MR, AR

Why Thrombolyse only STEMI?

UA/ NSTEMI- Plaque stabilization to prevent progression of disease is required. More risk of bleeding complications.In UA/NSTEMI Obstruction is caused by plaque(platelet-rich)In STEMIObstruction is by Thrombus

Prevention

Secondary Prevention

Comorbid Diseases HTN, DM, Dyslipidemia

Behavioral smoking, diet, physical activity,

weight redn

Cognitive Education, cardiac rehab program

Secondary PreventionComorbid Disease

management Blood Pressure Goals < 140/90 or <130/80 in DM

/CKD Maximize use of beta-blockers & ACE-I

Lipids LDL < 100 mg/dl ; TG < 200 mg/dl Maximize use of statins; consider

fibrates/niacin first line for TG>500; consider omega-3 fatty acids

Diabetes HbA1c < 7%

Secondary preventionBehavioral intervention

Smoking cessation Cessation-class, meds, counseling

Physical Activity Goal 30 - 60 minutes daily Risk assessment prior to initiation

Diet Fiber diet, omega-3 fatty acids <7% total calories from saturated

fats

Medication Checklist after ACS

Antiplatelet agent Aspirin* and/or Clopidorgrel GP Inhibitors*

Lipid lowering agent Statins* Fibrate / Niacin / Omega-3 FAs

Antischaemic & LV remodelling Prevention Beta blocker* ACE-I*/ARB Aldactone (as appropriate)

Thank You