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• ACS
• Revascularization
• Risk stratification
• Medication
Fourth Universal Definition of Myocardial Infarction
MI caused by atherothrombotic CAD and usually precipitated by
Type 1
atherosclerotic plaque rupture or erosion.
ACS
Fourth universal definition of myocardial infarction 2018. European Heart Journal (2019) 40, 237–269
PRESENTATION
WORKING
DIAGNOSIS
12-LEADS ECG
&
SERIAL
CARDIAC
BIOMARKER
FINAL DIAGNOSIS
NSTEMI / UA (NSTE-ACS) STEMI
N Engl J Med 2017;376:2053-64.
Diagnostic
algorithm and
triage in ACS
©ESC 2020
2020 ESC Guidelines for the management of acute
coronary syndromes in patients presenting without
persistent ST-segment elevation
Diagnostic
algorithm and
triage in ACS
©ESC 2020
2020 ESC Guidelines for the management of acute
coronary syndromes in patients presenting without
persistent ST-segment elevation
Typical angina
✤ Chest discomfort: diffuse, not localized, not affected by movement
✤
!แห$ง&'อาการ: chest, upper extremity, mandible, epigastrium
✤
อาการมาก-นเ0อ Exertion/stress
✤
ระยะเวลา&'อาการ > 20 นา5
✤
อาการ&เ6ด8วมไ:: diaphoresis, nausea, syncope
•Cardiac arrest
•Peripheral embolization
•Fatigue
การ;กประ=>?@วย
การ$กประ'()*วย
1.อาการเAบหCอแ$นหDาอก (character), ความFนแรง (severity/pain score), และ
เวลา&เGม'อาการ (onset)
ความเQยงWอการเ6ด GI bleeding
• Lungs: rales
• Systemic hypoperfusion
Table 4 Differential diagnoses of acute coronary syndromes in the
setting of acute chest pain
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
ECG Changes
in STEMI
Isoelectric Line
ECG in STEMI
LM
RCA
LCX
LAD
Myocardial ischemia, injury, and infarction
Ischemia:
T inversion
Injury:
ST elevation
Infarction:
Q wave
Reciprocal:
ST depression
Acute inferior wall MI (+ RV infarction)
V4R
V3R
Acute Myocardial Infarct- Inferior wall, with
Advanced Heart Block-likely Mobitz type I
Inferior wall MI
ST elevation in lead II, III, aVF
LCX lesions
• Posterior MI (RCA/LCX)
STE: V7-9
ST E M I
EC Gi n STD: V1-2 (R:S≥1)
• Posterolateral MI (LAD/LCX)
STE: V7-9,I,aVL,V5-6
STD: V1-2
RCA lesions • Inferoposterior MI (RCA/LCX)
• Inferior MI (RCA distal to RV) STE: II,III,aVF,V7-9
STE: II, III, aVF STD: V1-2 (R:S≥1)
STD: aVL
• Inferior & RV MI (RCA proximal to RV) LAD lesions
STE: II, III, aVF, I, V4R
• Septal MI
• Inferolateral MI (LAD/LCX) STE: V1-2
STE: II, III, aVF, I,V5-6 ±V4R
• Anterior MI
• Inferoposterior MI (RCA/LCX) STE: V3-4
STE: II, III, aVF,V7-9
• Lateral MI
STD: V1-2 (R:S≥1)
STE: V5-6, I, aVL
Horizontal Down-sloping
Inverted T
ST-depression ST-depression
ECG
Changes in
NSTE-ACS
99th
SC/ACC/AHA/WHF 2018
percentile
URL
Time from onset of symptoms (hours) European Heart Journal (2019) 40, 237–269
Fathil, M. F. et al. “Diagnostics on acute myocardial infarction: Cardiac troponin biomarkers.” Biosensors & bioelectronics 70 (2015): 209-20 .
Table 1 Clinical implications of high-sensitivity cardiac troponin
assays (cTn) (2)
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Value
Figure of of
2 Value high-sensitivity cardiac
high-sensitivity cardiac troponin
troponin.
©ESC
between 1 ng/L and 5 ng/L. Similarly, the 99th percentile varies
among the different hs-cTn assays, mainly being between 10 ng/L
and 20 ng/L.
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Table 1 Reasons for the elevation of cardiac troponin Increased .. myocardial oxygen demand, e.g.
• .
.
Sustained the discomfort
tachyarrhythmia is diffuse; not localized, nor positi
Reasons for the elevation of cardiac troponin values
values because of myocardial injury .. movement
• Severe because
hypertension of the
withof myocardial
region.
or without However,
left ventricular theseinjury sympt
..hypertrophy
.. for myocardial ischaemia and can be observed
Myocardial injury related to acute myocardial ischaemia Other
.
.. causes such as of gastrointestinal,
myocardial injury neurological, pulmonary
.. complaints. MI may occur with atypical symptom
Atherosclerotic plaque disruption with thrombosis. Cardiac .
. conditions, e.g.
12
• Heart .. orfailure cardiac arrest, or even without symptoms.
Myocardial injury related to acute myocardial ischaemia
.
.. of ischaemia too short to cause necrosis can als
• Myocarditis
because of oxygen supply/demand imbalance .
• Cardiomyopathy
. and
(any type)
elevations. The involved myocytes can subs
..
• Takotsubo syndrome
Reduced myocardial perfusion, e.g.
• Coronary .
. apoptosis. 42
revascularization procedure
• Cardiac .. procedure other than revascularization
If myocardial ischaemia is present clinically o
• Coronary artery spasm, microvascular dysfunction • Catheter .
. ablation
• Coronary embolism .
.. changesshocks
• Defibrillator together with myocardial injury, manife
• Coronary artery dissection • Cardiac .. or falling contusion pattern of cTn values, a diagnosis of acu
• Sustained bradyarrhythmia .. If myocardial ischaemia is not present clinically, th
• Hypotension or shock Systemic .
.. els conditions, e.g.
• Respiratory failure
• Sepsis, . may be
infectious indicative
disease of acute myocardial injury if
• Chronic .. kidneyand/or
diseasefalling, or related to more chronic
• Severe anaemia . is rising
• Stroke, .. subarachnoid haemorrhage
©ESC/ACC/AHA/WHF 2018
14
• Pulmonary . pattern is unchanging. Similar
embolism, pulmonary hypertension considerations
Increased myocardial oxygen demand, e.g. .
.. evaluating
• Infiltrative events
diseases, that are potentially
e.g. amyloidosis, sarcoidosisrelated to p
• Sustained tachyarrhythmia • Chemotherapeutic .. agents
. cause myocardial injury and/or MI. Additional eva
• Severe hypertension with or without left ventricular • Critically .. ill patients
hypertrophy • Strenuous .. a needexercise
for the initial diagnosis to be revised.
.. Patients with suspected acute coronary syndr
Other causes of myocardial injury . European Heart Journal (2019) 40, 237–269
Initial Assessment & Management in ACS
1. Triage to an ACS pathway
*ในสถานพยาบาลทีมีอปุ กรณ์พร้อม
** ข้อห้ามสําคัญ เช่น RV infarction ได้รบั ยากลุ่ม PDE-5 inhibitors ความดันโลหิตตําอยู่แล้ว
7
Importance of Time-to-Treatment
Mortality at 6 months in 10 RCT’s Meta-analysis
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
STEMI Treatment Guidelines
Reperfusion
Strategies
2017 ESC Guidelines for the
management of acute myocardial
infarction in patients presenting with
ST-segment elevation
คําแนะนําการรักษาโดยการเปิ ดหลอดเลือดหัวใจ STEMI
8
“Important Time Target”
Modes of Patient presentation, components of ischemic time and flowchart for reperfusion strategy selection
Non-PCI Center
Maximum expected delay from
STEMI Dx-PPCI ≤ 120 min ? Transferred Patient:
Maximum time from STEMI Dx-
PPCI (wire crossing) ≤ 90 min
Maximum time from
PCI Center
PCI Center:
Maximum time from STEMI Dx-
PPCI (wire crossing) ≤ 60 min
European Heart Journal (2018) 39, 119–177
9
Maximum target times according to repercussion strategy selection in patients presenting via EMS or non-PCI center
“Fibrinolysis
Strategy”
• Ventricular arrhythmias
Reperfusion
arrhythmias
• Accelerated idioventricular rhythm (AIVR)
• Non-sustained bradycardia
Reperfusion
Accelerated idioventricular rhythm (AIVR)
Circulation. 2004;110:e82.
Comparison of Approved Fibrinolytic Agents
Parameter Streptokinase (SK) TNK t-PA Alteplase (t-PA) Reteplase (rPA)
30-50 mg
Up to 100 mg in 90 min 10 U × 2 (30 min apart)
Dose 1.5. MU in 30-60 min
(based on weight) (based on weight) each over 2 min
Inform consent:
• Disease
Vital signs
Absolute contraindication for fibrinolysis
Prior intracranial hemorrhage (ICH)
• Pregnancy
• Current use of anticoagulants: the higher the INR (INR > 1.7 or PT > 15 sec)
ระหว่างให้ Fibrinolysis during เตรียมอะไรบ้าง
Medical team: doctor, nurse (ACLS)
Set emergency (prepare for resuscitation)
Defibrillator, AED
Monitor & record clinical, V/S, ECG
Ambulance (Telemetry), refer team
How to manage hypotension during SK infusion
Figure 13
Central illustration.
Choice of Figure
Management strategy for
non-ST-segment elevation
antithrombotic acute coronaryCentra
syndrome
treatment patients. Manag
non-ST
Invasive vs acute c
Selective invasive
strategy
patien
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting wit
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
2020 ESC Guidelines for the management
2020ofESC
acute coronary syndromes
Guidelines in patients presenting
for the management of acutewithout
coronarypersistent ST-segment
syndromes elevation
in patients presenting
withou
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575
Figure 3 (1)
0 h/1 h rule-out and
rule-in algorithm using
high-sensitivity cardiac
troponin assays in
haemodynamically stable
patients presenting with
suspected non-ST-
segment elevation acute
coronary syndrome to the
emergency department.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Supplementary Figure 3
Global
Clinical Registry
scores for risk of
assessment.
Acute Coronary
Syndrome (GRACE)
©ESC
The figure shows a nomogram for calculation of the GRACE
risk score and was adapted by Granger et al.
207
Selection of NSTEMI treatment strategy & time according to initial risk stratification
Invasive vs Selective
invasive strategy
PCI center EMS or Non-PCI center
Figure 9
non-ST-s
elevatio
coronar
treatme
timing a
initial
risk stra
คําแนะนําการฉีดสี หลอดเลือดหัวใจในผ้ ูป่วย NSTE-ACS
** โดยเร็ว ในสถานพยาบาลทีมีความพร้อม
32
Initial Assessment & Management in ACS
1. Triage to an ACS pathway
2020 ESC Guidelines for the management of acute coronary syndromes in patients pr
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eu
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
Algorithms for Reperfusion Therapy of ACS: Initiate DAPT & Anticoagulant Therapy
STEMI NSTE-ACS
Fibrinolytic PPCI Ischemia-Guided
Invasive Stratigy
Strategy Strategy Strategy
-Enoxaparin (Class I, A) or
- UFH (Class I,C)
- UFH (Class I,C) or - Fondaparinux with UFH - Fondaparinux or
-UFH (Class I, B) or
600 mg
(PPCI)
Clopidogerl 75 mg/day
300 mg
Prasugrel 60 mg
(5 mg in BW ≤ 60 kg) • Generally not recommended in patients ≥ 75
years (but dose 5 mg/d should be used if
necessary)
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
Dose of Anticoagulant Co-therapies in ACS
Anticoagulant Bolus dose Maintenance Dose Caution
60 IU IV bolus
12 IU/kg IV infusion
• Target aPTT 50-70 sec or 1.5-2.0 times
UFH (maximum 4000 IU) (maximum 1000 IU/hr) for 24-48 hr (monitored at 3, 6, 12, and 24 hr)
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation
Table 7 P2Y12 receptor inhibitors for use in non-ST-segment
elevation acute coronary syndrome patients (3)
Oral administration i.v. administration
Clopidogrel Prasugrel Ticagrelor Cangrelor
Delay to 5 days 7 days 5 days No significant delay
surgery
Kidney No dose No dose No dose No dose
failure adjustment adjustment adjustment adjustment
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Figure 13 (1) Central illustration. Management strategy
Figure 13 (4) Central illustration. Management strategy
for non-ST-segment elevation acute coronary syndrome
for non-ST-segment
patients. elevation acute coronary syndrome
patients.
D/C & post D/C
management
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
2020 ESC Guidelines for the management of acute coronary syndromes in patients prese
Long Term Therapy
Long Term Therapy
Medication
RAAS Inhibitors
Beta-blockers
©ESC
goal of <1.0 mmol/L (<40 mg/dL) may be considered.
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
ACE inhibitors or ARBs
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
LDL-C goal
for LDL-C • SCORE <1%
cardiovascular risk
The Task Force for the management of dyslipidaemias of the
European Society of Cardiology (ESC) and European
• SCORE ≥1% and <5% Atherosclerosis Society (EAS)
• Young patients (T1DM <35 years;
T2DM <50 years) with DM durationAuthors/Task Force Members: François Mach* (Chairperson) (Switzerland),
3.0 mmol/L Colin Baigent* (Chairperson) (United Kingdom), Alberico L. Catapano1*
(116 mg/dL)
Low <10 years without other risk factors(Chairperson) (Italy), Konstantinos C. Koskinas (Switzerland),
1
Manuela Casula1
(Italy), Lina Badimon (Spain), M. John Chapman (France), Guy G. De Backer
(Belgium), Victoria Delgado (Netherlands), Brian A. Ference (United Kingdom),
Ian M. Graham (Ireland), Alison Halliday (United Kingdom), Ulf Landmesser
(Germany), Borislava Mihaylova (United Kingdom), Terje R. Pedersen (Norway),
• SCORE ≥5% and <10%
Gabriele Riccardi1 (Italy), Dimitrios J. Richter (Greece), Marc S. Sabatine (United
2.6 mmol/L • Markedly elevated single risk factors, in
States of America), Marja-Riitta Taskinen1 (Finland), Lale Tokgozoglu1 (Turkey),
BP ≥180/110 mmHg
Fax: þ41 223 727 229, Email: francois.mach@hcuge.ch. Colin Baigent, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Roosevelt Drive,
Oxford OX3 7LF, United Kingdom. Tel: þ44 1865 743 741, Fax: þ44 1865 743 985, Email: colin.baigent@ndph.ox.ac.uk. Alberico L. Catapano, Department of Pharmacological
and Biomolecular Sciences, University of Milan, Via Balzaretti, 9, 20133 Milan, and Multimedica IRCCS, Milan, Italy. Tel: þ39 02 5031 8401, Fax: þ39 02 5031 8386,
1.8 mmol/L
the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to
High
Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permissions@oxfordjour-
nals.org).
• ASCVD (clinical/imaging)
(70 mg/dL)
Disclaimer. The ESC/EAS Guidelines represent the views of the ESC and EAS, and were produced after careful consideration of the scientific and medical knowledge, and the
• SCORE ≥10%
evidence available at the time of their publication. The ESC and EAS is not responsible in the event of any contradiction, discrepancy, and/or ambiguity between the ESC/EAS
& ≥50%
Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic
from
medical devices at the time of prescription.
1.4 mmol/L
For permissions please email: journals.permissions@oup.com.
baseline
(55 mg/dL)
Very High major risk factors; or early onset of
T1DM of long duration (>20 years)
European Heart Journal (2019) 00, 1-178 Low Moderate High Very high CV Risk
2018 AHA/ACC (updated): Secondary Prevention
Clinical ASCVD
Healthy Lifestyle
Fluvastatin XL – 80 mg –
Fluvastatin – 40 mg bid 20–40 mg
Pitvastatin – 2–4 mg 1 mg
Bold: Statins and doses evaluated in RCTs
Italics: Statins and doses approved by US FDA but not tested in RCTs reviewed Stone NJ, et al. J Am Coll Cardiol 2013 Nov 7. Epub ahead of print
*Should be used in patients unable to tolerate moderate-to high-intensity therapy Reproduced with kind permission from American College of Cardiology Jan 2014
Asian ancestry may modify the statin dose prescribed
Recommendations for pharmacological long-term management
after non-ST-segment elevation acute coronary syndrome
(excluding antithrombotic treatments) (2)
Recommendations Class Level
Lipid-lowering drugs (continued)
If the current NSTE-ACS episode is a recurrence within less than 2 years of a
first ACS, while taking maximally tolerated statin-based therapy, an LDL-C IIb B
goal of <1.0 mmol/L (<40 mg/dL) may be considered.
ACE inhibitors or ARBs
ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are
recommended in patients with heart failure with reduced LVEF (<40%),
diabetes, or CKD unless contraindicated (e.g. severe renal impairment, I A
hyperkalaemia, etc.) in order to reduce all-cause and cardiovascular mortality
and cardiovascular morbidity.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Recommendations for pharmacological long-term management
after non-ST-segment elevation acute coronary syndrome
(excluding antithrombotic treatments) (3)
Recommendations for pharmacological long-term management
Recommendations
after non-ST-segment elevation acute coronary syndrome Class Level
(excluding
Beta-blockersantithrombotic treatments) (2)
Recommendations
Beta-blockers are recommended in patients with systolic LV dysfunction or Class Level
I A
heart failure with reduced LVEF
Lipid-lowering drugs (continued)(<40%).
In patients with prior MI, long-term oral treatment with a beta-blocker
If the current NSTE-ACS episode is a recurrence within less than 2 years of a
should be considered in order to reduce all-cause and cardiovascular
first ACS, while taking maximally tolerated statin-based therapy, an LDL-C IIa
IIb BB
mortality and cardiovascular morbidity.
goal of <1.0 mmol/L (<40 mg/dL) may be considered.
ACE inhibitors or ARBs
ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are
recommended in patients with heart failure with reduced LVEF (<40%),
diabetes, or CKD unless contraindicated (e.g. severe renal impairment, I A
©ESC
hyperkalaemia, etc.) in order to reduce all-cause and cardiovascular mortality
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
and cardiovascular morbidity. persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
www.escardio.org/guidelines
ESC
Recommendations for pharmacological long-term management
after non-ST-segment elevation acute coronary syndrome
(excluding antithrombotic treatments) (4)
Recommendations Class Level
MRAs
MRAs are recommended in patients with heart failure with reduced LVEF
(<40%) in order to reduce all-cause and cardiovascular mortality and I A
cardiovascular morbidity.
Proton pump inhibitors
Concomitant use of a proton pump inhibitor is recommended in patients
receiving aspirin monotherapy, DAPT, DAT, TAT, or OAC monotherapy who
I A
are at high risk of gastrointestinal bleeding in order to reduce the risk of
gastric bleeds.
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
Lifestyle Interventions & Risk Factor Control
Smoking cessation
Resumption of activities