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Acute Coronary Acute Coronary SyndromeSyndrome
ObjectivesObjectives
Define & delineate acute coronary Define & delineate acute coronary syndromesyndrome
Review Management GuidelinesReview Management Guidelines Unstable Angina / NSTEMIUnstable Angina / NSTEMI STEMISTEMI
Review secondary prevention Review secondary prevention initiativesinitiatives
Scope of Problem Scope of Problem (2004 stats)(2004 stats)
CHD single leading cause CHD single leading cause of death in United Statesof death in United States 452,327 deaths in the U.S. in 452,327 deaths in the U.S. in
20042004
1,200,000 new & 1,200,000 new & recurrent coronary recurrent coronary attacks per year attacks per year
38% of those who with 38% of those who with coronary attack die within coronary attack die within a year of having ita year of having it
Annual cost > $300 billionAnnual cost > $300 billion
Expanding Risk FactorsExpanding Risk Factors
SmokingSmoking HypertensionHypertension Diabetes MellitusDiabetes Mellitus DyslipidemiaDyslipidemia
Low HDL < 40Low HDL < 40 Elevated LDL / TGElevated LDL / TG
Family History—Family History—event in first degree event in first degree relative relative >>55 male/65 55 male/65 femalefemale
Age-- Age-- >> 45 for 45 for male/55 for femalemale/55 for female
Chronic Kidney Chronic Kidney DiseaseDisease
Lack of regular Lack of regular physical activityphysical activity
ObesityObesity Lack of Etoh intakeLack of Etoh intake Lack of diet rich in Lack of diet rich in
fruit, veggies, fiberfruit, veggies, fiber
Acute Coronary Acute Coronary SyndromesSyndromes
Similar pathophysiologySimilar pathophysiology
Similar presentation and Similar presentation and early management rulesearly management rules
STEMI requires STEMI requires evaluation for acute evaluation for acute reperfusion interventionreperfusion intervention
Unstable AnginaUnstable Angina
Non-ST-Non-ST-Segment Segment Elevation MI Elevation MI (NSTEMI)(NSTEMI)
ST-Segment ST-Segment Elevation MI Elevation MI (STEMI)(STEMI)
Diagnosis of Acute MIDiagnosis of Acute MI STEMI / NSTEMI STEMI / NSTEMI
At least 2 of the At least 2 of the followingfollowing
Ischemic Ischemic symptomssymptoms
Diagnostic ECG Diagnostic ECG changeschanges
Serum cardiac Serum cardiac marker marker elevationselevations
Diagnosis of AnginaDiagnosis of Angina
Typical angina—All three of the Typical angina—All three of the followingfollowing
Substernal chest discomfortSubsternal chest discomfort Onset with exertion or emotional stressOnset with exertion or emotional stress Relief with rest or nitroglycerinRelief with rest or nitroglycerin
Atypical anginaAtypical angina 2 of the above criteria2 of the above criteria
Noncardiac chest painNoncardiac chest pain 1 of the above1 of the above
Diagnosis of Unstable Diagnosis of Unstable AnginaAngina
Patients with typical angina - An episode of Patients with typical angina - An episode of angina angina
Increased in severity or durationIncreased in severity or duration Has onset at rest or at a low level of exertionHas onset at rest or at a low level of exertion Unrelieved by the amount of nitroglycerin or Unrelieved by the amount of nitroglycerin or
rest that had previously relieved the painrest that had previously relieved the pain
Patients not known to have typical anginaPatients not known to have typical angina First episode with usual activity or at rest First episode with usual activity or at rest
within the previous two weekswithin the previous two weeks Prolonged pain at restProlonged pain at rest
Unstable Unstable AnginaAngina STEMISTEMI NSTEMINSTEMI
Non occlusive thrombus
Non specific ECG
Normal cardiac enzymes
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis
ST depression +/- T wave inversion on ECG
Elevated cardiac enzymes
Complete thrombus occlusion
ST elevations on ECG or new LBBB
Elevated cardiac enzymes
More severe symptoms
Acute ManagementAcute Management
Initial evaluation Initial evaluation & stabilization& stabilization
Efficient risk Efficient risk stratificationstratification
Focused cardiac Focused cardiac carecare
EvaluationEvaluation Efficient & direct history Efficient & direct history Initiate stabilization Initiate stabilization
interventionsinterventions
Plan for moving rapidly to Plan for moving rapidly to indicated cardiac care indicated cardiac care
Directed Therapies are
Time Sensitive!
Occurs Occurs simultaneosimultaneo
uslyusly
Chest pain suggestive of Chest pain suggestive of ischemiaischemia
12 lead ECG12 lead ECG Obtain initial Obtain initial
cardiac cardiac enzymesenzymes
electrolytes, cbc electrolytes, cbc lipids, bun/cr, lipids, bun/cr, glucose, coagsglucose, coags
CXRCXR
Immediate assessment within 10 Minutes
Establish Establish diagnosisdiagnosis
Read ECGRead ECG Identify Identify
complicaticomplicationsons
Assess for Assess for reperfusioreperfusionn
Initial Initial labslabs
and testsand tests
Emergent Emergent carecare
History History & &
PhysicalPhysical IV accessIV access Cardiac Cardiac
monitorinmonitoringg
OxygenOxygen AspirinAspirin NitratesNitrates
Focused HistoryFocused History Aid in diagnosis and Aid in diagnosis and
rule out other rule out other causescauses
Palliative/Provocative Palliative/Provocative factorsfactors
Quality of discomfortQuality of discomfort RadiationRadiation Symptoms associated Symptoms associated
with discomfortwith discomfort Cardiac risk factorsCardiac risk factors Past medical history -Past medical history -
especially cardiacespecially cardiac
Reperfusion Reperfusion questionsquestions
Timing of Timing of presentationpresentation
ECG c/w STEMI ECG c/w STEMI Contraindication Contraindication
to fibrinolysisto fibrinolysis Degree of STEMI Degree of STEMI
riskrisk
Targeted PhysicalTargeted Physical Recognize factors Recognize factors
that increase riskthat increase risk HypotensionHypotension TachycardiaTachycardia Pulmonary rales, Pulmonary rales,
JVD, pulmonary JVD, pulmonary edema,edema,
New murmurs/heart New murmurs/heart soundssounds
Diminished Diminished peripheral pulsesperipheral pulses
Signs of strokeSigns of stroke
ExaminationExamination VitalsVitals Cardiovascular Cardiovascular
systemsystem Respiratory Respiratory
systemsystem AbdomenAbdomen Neurological Neurological
statusstatus
ECG assessmentECG assessment
ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI
Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina
ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions
NSTEMINSTEMI
Normal or non-Normal or non-diagnostic EKGdiagnostic EKG
ST Depression or Dynamic T wave ST Depression or Dynamic T wave InversionsInversions
ST-Segment Elevation MIST-Segment Elevation MI
New LBBBNew LBBB
QRS > 0.12 secL Axis deviationProminent R wave V1-V3Prominent S wave 1, aVL, V5-V6 with t-wave inversion
Cardiac markersCardiac markers Troponin ( T, I)Troponin ( T, I)
Very specific and more Very specific and more sensitive than CKsensitive than CK
Rises 4-8 hours after Rises 4-8 hours after injuryinjury
May remain elevated May remain elevated for up to two weeksfor up to two weeks
Can provide Can provide prognostic informationprognostic information
Troponin T may be Troponin T may be elevated with renal dz, elevated with renal dz, poly/dermatomyositispoly/dermatomyositis
CK-MB isoenzymeCK-MB isoenzyme
Rises 4-6 hours after Rises 4-6 hours after injury and peaks at 24 injury and peaks at 24 hourshours
Remains elevated 36-Remains elevated 36-48 hours48 hours
Positive if CK/MB > Positive if CK/MB > 5% of total CK and 2 5% of total CK and 2 times normaltimes normal
Elevation can be Elevation can be predictive of mortalitypredictive of mortality
False positives with False positives with exercise, trauma, exercise, trauma, muscle dz, DM, PEmuscle dz, DM, PE
Prognosis with TroponinPrognosis with Troponin
1.01.7
3.4 3.7
6.0
7.5
0
1
2
3
4
5
6
7
8
0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0
Cardiac troponin I (ng/ml)
Mo
rtal
ity
at 4
2 D
ays
831 174 148 134 50 67
%%
%%
%
%
Risk StratificationRisk Stratification
UA or NSTEMIUA or NSTEMI- Evaluate for - Evaluate for
Invasive vs. Invasive vs. conservative conservative treatmenttreatment
- Directed medical - Directed medical therapytherapy
Based on initialBased on initialEvaluation, ECG, andEvaluation, ECG, and
Cardiac markersCardiac markers
- Assess for - Assess for reperfusionreperfusion
- Select & - Select & implement implement reperfusion reperfusion therapytherapy
- Directed medical - Directed medical therapytherapy
STEMI Patient?
YESYES NONO
Cardiac Care Goals Cardiac Care Goals
Decrease amount of myocardial Decrease amount of myocardial necrosisnecrosis
Preserve LV functionPreserve LV functionPrevent major adverse cardiac Prevent major adverse cardiac events events
Treat life threatening Treat life threatening complicationscomplications
STEMI cardiac care STEMI cardiac care STEP 1STEP 1: Assessment: Assessment
Time since onset of symptomsTime since onset of symptoms 90 min for PCI / 12 hours for fibrinolysis90 min for PCI / 12 hours for fibrinolysis
Is this high risk STEMI?Is this high risk STEMI? KILLIP classificationKILLIP classification If higher risk may manage with more If higher risk may manage with more
invasive rxinvasive rx
Determine if fibrinolysis candidateDetermine if fibrinolysis candidate Meets criteria with no contraindicationsMeets criteria with no contraindications
Determine if PCI candidateDetermine if PCI candidate Based on availability and time to balloon Based on availability and time to balloon
rxrx
Fibrinolysis indicationsFibrinolysis indications
ST segment elevation >1mm in two ST segment elevation >1mm in two contiguous leadscontiguous leads
New LBBBNew LBBB Symptoms consistent with ischemiaSymptoms consistent with ischemia Symptom onset less than 12 hrs Symptom onset less than 12 hrs
prior to presentationprior to presentation
Absolute contraindications for fibrinolysis Absolute contraindications for fibrinolysis therapy in patients with acute STEMI therapy in patients with acute STEMI
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
Relative contraindications for fibrinolysis Relative contraindications for fibrinolysis therapy in patients with acute STEMI therapy in patients with acute STEMI
History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP
greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months,
dementia, or known intracranial pathology not covered in contraindications
Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)
Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than
5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the
higher the risk of bleeding
STEMI cardiac careSTEMI cardiac care STEP 2STEP 2: Determine preferred reperfusion strategy: Determine preferred reperfusion strategy
FibrinolysisFibrinolysis preferred if:preferred if: <<3 hours from onset3 hours from onset PCI not PCI not
available/delayedavailable/delayed door to balloon > door to balloon >
90min90min door to balloon door to balloon
minus door to minus door to needle > 1hrneedle > 1hr
Door to needle goal Door to needle goal <30min<30min
No contraindicationsNo contraindications
PCIPCI preferred if:preferred if: PCI availablePCI available Door to balloon < Door to balloon <
90min90min Door to balloon Door to balloon
minus door to minus door to needle < 1hrneedle < 1hr
Fibrinolysis Fibrinolysis contraindicationscontraindications
Late Presentation > Late Presentation > 3 hr3 hr
High risk STEMIHigh risk STEMI Killup 3 or higherKillup 3 or higher
STEMI dx in doubtSTEMI dx in doubt
Comparing outcomesComparing outcomes
Comparing outcomesComparing outcomes
Medical TherapyMedical TherapyMONA + BAHMONA + BAH
MorphineMorphine (class I, level C)(class I, level C) AnalgesiaAnalgesia Reduce pain/anxiety—decrease sympathetic Reduce pain/anxiety—decrease sympathetic
tone, systemic vascular resistance and oxygen tone, systemic vascular resistance and oxygen demanddemand
Careful with hypotension, hypovolemia, Careful with hypotension, hypovolemia, respiratory depressionrespiratory depression
OxygenOxygen (2-4 liters/minute) (class I, level C)(2-4 liters/minute) (class I, level C) Up to 70% of ACS patient demonstrate Up to 70% of ACS patient demonstrate
hypoxemiahypoxemia May limit ischemic myocardial damage by May limit ischemic myocardial damage by
increasing oxygen delivery/reduce ST elevationincreasing oxygen delivery/reduce ST elevation
NitroglycerinNitroglycerin (class I, level B)(class I, level B) Analgesia—titrate infusion to keep patient pain Analgesia—titrate infusion to keep patient pain
freefree Dilates coronary vessels—increase blood flowDilates coronary vessels—increase blood flow Reduces systemic vascular resistance and Reduces systemic vascular resistance and
preloadpreload Careful with recent ED meds, hypotension, Careful with recent ED meds, hypotension,
bradycardia, tachycardia, RV infarctionbradycardia, tachycardia, RV infarction
AspirinAspirin (160-325mg chewed & swallowed) (class (160-325mg chewed & swallowed) (class I, level A)I, level A)
Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregation Stabilize plaque and arrest thrombusStabilize plaque and arrest thrombus Reduce mortality in patients with STEMIReduce mortality in patients with STEMI Careful with active PUD, hypersensitivity, Careful with active PUD, hypersensitivity,
bleeding disordersbleeding disorders
Beta-BlockersBeta-Blockers (class I, level A)(class I, level A) 14% reduction in mortality risk at 7 days at 23% 14% reduction in mortality risk at 7 days at 23%
long term mortality reduction in STEMIlong term mortality reduction in STEMI Approximate 13% reduction in risk of Approximate 13% reduction in risk of
progression to MI in patients with threatening or progression to MI in patients with threatening or evolving MI symptomsevolving MI symptoms
Be aware of contraindications (CHF, Heart block, Be aware of contraindications (CHF, Heart block, Hypotension)Hypotension)
Reassess for therapy as contraindications resolveReassess for therapy as contraindications resolve
ACE-Inhibitors / ARBACE-Inhibitors / ARB (class I, level A)(class I, level A) Start in patients with anterior MI, pulmonary Start in patients with anterior MI, pulmonary
congestion, LVEF < 40% in absence of congestion, LVEF < 40% in absence of contraindication/hypotensioncontraindication/hypotension
Start in first 24 hoursStart in first 24 hours ARB as substitute for patients unable to use ACE-ARB as substitute for patients unable to use ACE-
II
HeparinHeparin (class I, level C to class IIa, level C) (class I, level C to class IIa, level C) LMWH or UFHLMWH or UFH (max 4000u bolus, 1000u/hr)(max 4000u bolus, 1000u/hr)
Indirect inhibitor of thrombinIndirect inhibitor of thrombin less supporting evidence of benefit in era of less supporting evidence of benefit in era of
reperfusionreperfusion Adjunct to surgical revascularization and Adjunct to surgical revascularization and
thrombolytic / PCI reperfusionthrombolytic / PCI reperfusion 24-48 hours of treatment24-48 hours of treatment Coordinate with PCI team (UFH preferred)Coordinate with PCI team (UFH preferred) Used in combo with aspirin and/or other platelet Used in combo with aspirin and/or other platelet
inhibitorsinhibitors Changing from one to the other not recommendedChanging from one to the other not recommended
Additional medication therapyAdditional medication therapy ClopidodrelClopidodrel (class I, level B)(class I, level B)
Irreversible inhibition of platelet aggregationIrreversible inhibition of platelet aggregation Used in support of cath / PCI intervention or Used in support of cath / PCI intervention or
if unable to take aspirinif unable to take aspirin 3 to 12 month duration depending on 3 to 12 month duration depending on
scenario scenario
Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors (class IIa, level B)(class IIa, level B)
Inhibition of platelet aggregation at final Inhibition of platelet aggregation at final common pathwaycommon pathway
In support of PCI intervention as early as In support of PCI intervention as early as possible prior to PCIpossible prior to PCI
Additional medication therapyAdditional medication therapy
Aldosterone blockersAldosterone blockers (class I, level A)(class I, level A) Post-STEMI patients Post-STEMI patients
no significant renal failure (cr < 2.5 men or no significant renal failure (cr < 2.5 men or 2.0 for women)2.0 for women)
No hyperkalemis > 5.0No hyperkalemis > 5.0 LVEF < 40%LVEF < 40% Symptomatic CHF or DMSymptomatic CHF or DM
STEMI care CCUSTEMI care CCU
Monitor for complications: Monitor for complications: recurrent ischemia, cardiogenic shock, ICH, recurrent ischemia, cardiogenic shock, ICH,
arrhythmiasarrhythmias
Review guidelines for specific Review guidelines for specific management of complications & other management of complications & other specific clinical scenariosspecific clinical scenarios
PCI after fibrinolysis, emergent CABG, etc…PCI after fibrinolysis, emergent CABG, etc…
Decision making for risk stratification at Decision making for risk stratification at hospital discharge hospital discharge and/orand/or need for CABG need for CABG
Unstable angina/NSTEMI Unstable angina/NSTEMI cardiac carecardiac care
Evaluate for conservative vs. invasive Evaluate for conservative vs. invasive therapy based upon:therapy based upon:
Risk of actual ACSRisk of actual ACS TIMI risk scoreTIMI risk score ACS risk categories per AHA guidelinesACS risk categories per AHA guidelines
LowLowIntermediateIntermediate
HighHigh
Assessment Findings indicating
HIGH likelihood of ACS
Findings indicating
INTERMEDIATE likelihood of ACS in absence of high-likelihood findings
Findings indicating
LOW likelihood of ACS in absence of high- or intermediate-likelihood findings
History Chest or left arm pain or discomfort as chief symptomReproduction of previous documented anginaKnown history of coronary artery disease, including myocardial infarction
Chest or left arm pain or discomfort as chief symptomAge > 50 years
Probable ischemic symptomsRecent cocaine use
Physical examination
New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales
Extracardiac vascular disease
Chest discomfort reproduced by palpation
ECG New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms
Fixed Q wavesAbnormal ST segments or T waves not documented to be new
T-wave flattening or inversion of T waves in leads with dominant R wavesNormal ECG
Serum cardiac markers
Elevated cardiac troponin T or I, or elevated CK-MB
Normal Normal
Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome
TIMI Risk ScorePredicts risk of death, new/recurrent MI, need for urgent
revascularization within 14 days
ACS risk criteriaACS risk criteria
Low Risk ACS
No intermediate or high risk factors
<10 minutes rest pain
Non-diagnositic ECG
Non-elevated cardiac markers
Age < 70 years
Intermediate Risk ACS
Moderate to high likelihood of CAD
>10 minutes rest pain, now resolved
T-wave inversion > 2mm
Slightly elevated cardiac markers
High Risk ACS
Elevated cardiac markersNew or presumed new ST depressionRecurrent ischemia despite therapyRecurrent ischemia with heart failureHigh risk findings on non-invasive stress testDepressed systolic left ventricular functionHemodynamic instabilitySustained Ventricular tachycardiaPCI with 6 monthsPrior Bypass surgery
Low risk
High risk
ConservaConservative tive
therapytherapy
Invasive Invasive therapytherapy
Chest Pain Chest Pain centercenter
Intermediate risk
Invasive therapy option Invasive therapy option UA/NSTEMIUA/NSTEMI
Coronary angiography and revascularization within 12 to 48 hours after presentation to ED
For high risk ACS (class I, level A) MONA + BAH (UFH) Clopidogrel
20% reduction death/MI/Stroke – CURE trial 1 month minimum duration and possibly up to 9 1 month minimum duration and possibly up to 9
monthsmonths
Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors
Conservative Therapy for Conservative Therapy for UA/NSTEMIUA/NSTEMI
Early revascularization or PCI Early revascularization or PCI notnot plannedplanned
MONA + BAMONA + BAHH (LMW or UFH)(LMW or UFH) ClopidogrelClopidogrel Glycoprotein IIb/IIIa inhibitorsGlycoprotein IIb/IIIa inhibitors
Only in certain circumstances (planning PCI, Only in certain circumstances (planning PCI, elevated TnI/T)elevated TnI/T)
Surveillence in hospitalSurveillence in hospital Serial ECGsSerial ECGs Serial MarkersSerial Markers
Secondary PreventionSecondary Prevention
DiseaseDisease HTN, DM, HLPHTN, DM, HLP
BehavioralBehavioral smoking, diet, physical activity, weightsmoking, diet, physical activity, weight
Cognitive Cognitive Education, cardiac rehab programEducation, cardiac rehab program
Secondary PreventionSecondary Preventiondisease managementdisease management
Blood PressureBlood Pressure Goals < 140/90 or <130/80 in DM /CKDGoals < 140/90 or <130/80 in DM /CKD Maximize use of beta-blockers & ACE-IMaximize use of beta-blockers & ACE-I
LipidsLipids LDL < 100 (70) ; TG < 200LDL < 100 (70) ; TG < 200 Maximize use of statins; consider Maximize use of statins; consider
fibrates/niacin first line for TG>500; fibrates/niacin first line for TG>500; consider omega-3 fatty acidsconsider omega-3 fatty acids
DiabetesDiabetes A1c < 7%A1c < 7%
Secondary preventionSecondary preventionbehavioral interventionbehavioral intervention
Smoking cessationSmoking cessation Cessation-class, meds, counselingCessation-class, meds, counseling
Physical ActivityPhysical Activity Goal 30 - 60 minutes dailyGoal 30 - 60 minutes daily Risk assessment prior to initiationRisk assessment prior to initiation
DietDiet DASH diet, fiber, omega-3 fatty acidsDASH diet, fiber, omega-3 fatty acids <7% total calories from saturated <7% total calories from saturated
fatsfats
Thinking outside the box…Thinking outside the box…
Or maybe just move….Or maybe just move….
Secondary preventionSecondary preventioncognitivecognitive
Patient educationPatient education In-hospital – discharge –outpatient In-hospital – discharge –outpatient
clinic/rehabclinic/rehab
Monitor psychosocial impactMonitor psychosocial impact Depression/anxiety assessment & Depression/anxiety assessment &
treatmenttreatment Social support systemSocial support system
Medication Checklist Medication Checklist after ACSafter ACS
Antiplatelet agentAntiplatelet agent AspirinAspirin** and/or Clopidorgrel and/or Clopidorgrel
Lipid lowering agentLipid lowering agent StatinStatin** Fibrate / Niacin / Omega-3 Fibrate / Niacin / Omega-3
Antihypertensive agentAntihypertensive agent Beta blockerBeta blocker** ACE-IACE-I**/ARB/ARB Aldactone Aldactone (as appropriate)(as appropriate)
Prevention news…Prevention news…From 1994 to 2004 the death
rate from coronary heart disease declined 33%...
But the actual number of deaths declined only 18%
Getting better with treatment…
But more patients developing disease –need for primary
prevention focus
SummarySummary
ACS includes UA, NSTEMI, and STEMIACS includes UA, NSTEMI, and STEMI
Management guideline focusManagement guideline focus Immediate assessment/intervention Immediate assessment/intervention (MONA+BAH)(MONA+BAH) Risk stratification Risk stratification (UA/NSTEMI vs. STEMI)(UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI RAPID reperfusion for STEMI (PCI vs. (PCI vs.
Thrombolytics)Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMIConservative vs Invasive therapy for UA/NSTEMI
Aggressive attention to secondary Aggressive attention to secondary prevention initiatives for ACS patients prevention initiatives for ACS patients
Beta blocker, ASA, ACE-I, StatinBeta blocker, ASA, ACE-I, Statin