Acute Coronary Syndrome

In Clinical Practice

Firman B. Leksmono
Acute Coronary Syndrome

Acute coronary syndrome

(ACS) refers to any group of
symptoms attributed to
obstruction of the coronary
arteries.
Coronary Anatomy
Acute Coronary Syndrome
Acute Coronary Syndrome
Epidemiology
 CHD single leading cause of death in United
States
 452,327 deaths in the U.S. in 2004
 1,200,000 new & recurrent coronary
attacks per year
 38% of those who with coronary attack die
within a year of having it
 Annual cost > $300 billion
Epidemiology

Acute coronary syndrome

1,5 million hospital addmision - ACS

UA/ NSTEMI
STEMI

1,24 million 0,33 million

admission per admission per
year year

Heart disease and stroke statistic – 2007 update. Circulation 2007 , 155 : 69 – 171
Epidemiology

Guideline for the Management of STEMI. JACC 2013

Risk Factor
Non- Modifiable Modifiable

Gender  Hypertension
• Men > Women  Diabetes Mellitus
Age  Dyslipidemia
• Men, increased risk after age 45  Obesity
• Women, increased risk after age 55  Cigarette Smoking
Family History  Lack of physical activity
• Heart disease diagnosed before age 55 in father  Diet (high fat and high
or brother carbohidrat)
• Heart disease diagnosed before age 65 in mother  Stress
or sister  Novel Factors :
• Race Hiperhomocysteinemia, » CRP,
» Lipoprotein (a)
Diagnosis

At least 2 of the following (WHO criteria):

1. Ischemic Symptoms

2. Diagnostic ECG Changes

3. Serum Cardiac Marker

Diagnosis

Hamm CW et al. European Heart Journal 2011

ST-Elevation Myocardial Infarction

 There is a transmural infarction of the myocardium. Entire thickness

of the myocardium has undergone necrosis.

 Usually occurs when blood flow of artery coronary suddenly

decreased after occlusive thrombus on atherosclerotic plaque.

 Coronary plaques tend to rupture if it has a thin fibrous cap and a

lipid-rich core.

 Classical pathological picture consists of rich red fibrin thrombus,

which is believed to be the basis of so STEMI response to
thrombolytic therapy.
NSTEMI and Unstable Angina

 UA or NSTEMI is when there is a partial dynamic

block to coronary arteries (non-occlusive thrombus).

 There will be no ST elevation or Q waves on ECG, as

transmural infarction is not seen.

 The main difference between NSTEMI and unstable

angina is that in NSTEMI the severity of ischemia is
sufficient to cause cardiac enzyme elevation.
Pathophysiology
Pathophysiology
Pathophysiology
Pathophysiology
Pathophysiology
Clinical Manifestation

Ischemic symptoms
 Chest pain
 Dyspnea
 Diaphoresis
 Palpitation
 Nausea/vomiting
 Light headedness
Clinical Manifestation

Duration :Variable, often more than 30 minutes.

Quality : Feels squeezing, pressure like, tightness, heaviness, and burning.
Location : Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or
arms frequently on left.
Associated features : Not relieve with rest or nitrat
Electrocardiography

 STEMI  NSTEMI/UAP
Electrocardiography
Whole Anterior STEMI

Inferior STEMI
Biomarker
Biomarker
Biomarker
Biochemical marker for detection of myocardial necrosis
Enzyme Normal value First rise after Peak after Return to
AMI AMI normal

CK-MB < 5.0 ng/ml 4h 24 h 72 h

Myoglobin < 82 ng/ml 2h 6-8 h 24 h
Troponin T Negatif 4h 24 - 48 h 5 – 21 days
Troponin I Detection Limit = 0.5 ng/ml 3-4 h 24 – 36 h 5 – 14 days
Abnormal > 2.0 ng/ml
Borderline - Not detected
Decision Making of ACS
Cardiac Care Goals

 Decrease amount of myocardial necrosis

 Preserve LV function
 Prevent major adverse cardiac events
 Treat life threatening complications
 Chest pain suggestive of ischemia

Immediate assessment within 10 Minutes

Initial Labs Emergent History &
and Tests Care Physical

 12 lead ECG  IV access  Establish diagnosis

 Obtain initial cardiac  Cardiac monitoring  Read ECG
enzymes  Oxygen  Identify
 Electrolytes, cbc  Aspirin and CPG complications
lipids, bun/cr, glucose,  Nitrates  Assess for
coagulation reperfusion
 Morphin
 CXR
Basic Treatment
Basic Treatment
Invasive Strategy for UA-NSTEMI

Hamm CW et al. European Heart Journal 2011

Reperfussion Therapy of STEMI

Guideline for the Management of STEMI. JACC 2013

Reperfusion Therapy of STEMI

Guideline for the Management of STEMI. JACC 2013

Thrombolytic vs Primary PCI
Thrombolytic vs Primary PCI
Thrombolytic

 Streptokinase –1.5 million iu infusion over 30-60 min

in 100 ml D5w or 0,9% saline.
 rTPA – Accelerated infusion over 1.5 hrs - 15mg IV
bolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr.

Contraindication
 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
Primary PCI
Routine Medical Therapy
Routine Medical Therapy

Guideline for the Management of STEMI. JACC 2013

Prognosis
KILLIP Classification For STEMI

Class Description Mortality Rate (%)

I No clinical signs of heart failure 6

II Rales or crackles in the lungs, an S3, and 17

elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

IV Cardiogenic shock or hypotension (systolic 60 – 80

BP < 90 mmHg), and evidence of peripheral
vasoconstriction
TIMI Score for STEMI
TIMI Score for UA-NSTEMI

TIMI RISK SCORE – Increase in mortality with increasing score ~40% all cause
mortality at 14 days for patients requiring urgent revascularisation.
GRACE Score
Complication

 Sudden Death

 Arrhythmia (VT/VF)

 Ventricular Dysfunction (Heart Failure)

 Interventricular septum and myocardial wall rupture

 Hemodynamic Disturbances

 Cardiogenic shock

 Pericarditis
Secondary Prevention

 Disease
 Hypertension, Diabetes
Mellitus, Dislipidemia

 Behavioral
 Smoking, diet, physical activity,
weight

 Cognitive
 Education, cardiac rehab
program