ACC/AHA

ESC

Acute Coronary Syndromes:

Incorporating Guidelines and Recent Trial Data into Clinical Practice

ACC/AHA and ESC Guidelines: Established Points

Modified from Libby P Circ 104:365,2001

Acute Coronary Syndrome

Superficial Erosion

Ruptured Fibrous Cap

Hamm Lancet 358:1533,2001

Presentation Working Dx

Ischemic Discomfort Acute Coronary Syndrome

Davies MJ Heart 83:361, 2000

ECG

No ST Elevation NSTEMI

ST Elevation

Biochem. Marker Final Dx Unstable Angina

Myocardial Infarction NQMI Qw MI

Use of Cardiac Markers in ACS

URL = 99th %tile of Reference Control Group

50
Multiples of the URL

20 10 5 2 1 0 1
Upper reference limit

Cardiac troponin after classical AMI CK-MB after AMI Cardiac troponin after microinfarction

2 3 4 5 6 Days After Onset of AMI

Modified from: ESC/ACC Comm MI redefined JACC 36: 959,2000

Wu AH et al. Clin Chem 1999;45:1104.

Troponins for Evaluation and Management of ACS

Advantages
Risk Stratificaton Sens/Spec > CKMB Detect Recent MI Selection of Rx Detect Reperfusion

Disadvantages
Low sens. early (< 6h) Repeat at 8-12 h if neg. Limited ability to detect late minor reinfarction

Recommendation Useful as single test to efficiently Dx NSTEMI Clinicians should familiarize themselves with Dx cutoffs in local lab

Acute Coronary Syndrome No ST Elevation

NSTEMI

ST Elevation

Uns Angina

Myocardial Infarction NQMI Qw MI Dx: Reinfarction Prognosis Assess Reperfusion

Serum Cardiac Markers Dx: MI Prognosis Selection of Rx

Acute Coronary Syndrome No ST Elevation ST Elevation

Risk Stratification
Purposes Triage / Transfer for Tertiary Care Resource Allocation Selection of Rx Strategy

Prognosis

Continuous Process Presentation: History, ACS features, Biomarkers, PEx In Hospital: Events, Response to Rx Discharge: LV Function, Arrhythmias, Ischemia

TIMI Risk Score For UA/NSTEMI

D/MI/Urg Revasc (%)
Age > 65 y > 3 CAD Risk Factors Prior Stenosis > 50 % ST deviation > 2 Anginal events < 24 h ASA in last 7 days Elev Cardiac Markers
26.2 13.2 14.1 19.9 14.9 20

UFH ENOX
40.9 28.8

50 40 30 20 10 0

4.7 3.5

8.3 8.6

0/1

6/7

Number of Risk Factors

Antman et al JAMA 284 : 835, 2000

Acute Coronary Syndrome No ST Elevation

NSTEMI

ST Elevation

Uns Angina

Myocardial Infarction NQMI Qw MI

Fibrinolytics Antiplatelet Rx Antithrombin Rx

MA of RCTs of Antiplatelet Rx for Prevention of Death,MI, Stroke in Hi Risk Pts

Antithrombotic Trialists Collaboration BMJ 324: 71, 2002

Symptoms suggestive of ACS

Rapid Triage Obtain Biomarkers

Assess 12 lead ECG

Goal = 10 min

Non Cardiac Diagnosis

Chronic Stable Angina

Possible ACS ASA

Definite ACS

As Per Other Dx

Medical Rx

Antithrombin Beta Blocker ACS Protocol

Symptoms Suggestive of ACS Possible ACS No ST elev. < 12h Lytic eligible Lytic
(D-N < 30 m)

Definite ACS ST elev. > 12h Not a reperfusion candidate

Consider Reperfusion for Symptoms

Lytic ineligible PCI*

(D-B < 90)
Consider: GP IIb/IIIa + stent

Medical Rx
(ACEI)

*Skilled Oper./Team Rapidly Available

Symptoms Suggestive of ACS

Possible ACS No ST elev. Definite ACS ST elev. Evaluate for reperfusion

Non dx ECG Neg. card. markers Observe f/u studies Neg Neg Outpt f/u Stress Pos Pos

ST-Tw changes Ongoing pain Positive card markers Hemodynamic abnl.

Dx of ACS confirmed Admit to hospital Acute ischemia pathway

Preparation for Discharge

Education: TNG, symptoms Antiplatelet Rx
ASA 75 - 325 mg/day Clopidogrel 75 mg/day if ASA intolerant

LDL < 100 mg/dL BP: target 135/85 (JNC VI) Diabetics: Hb A1c < 7.0% (ADA) Smoking cessation ACEI (especially if DM, HF, EF < 40%,HTN)

AHA/ACC Scientific Statement: Prevention of MI in Pts with Athero. CVD Circ 104: 1577, 2001

Chronology of Atherosclerotic Vascular Disease Process

Development of atherosclerosis and vulnerable plaque Acute Coronary Syndrome Secondary Prevention

Ischemic Heart Disease Cerebrovascular Disease Peripheral Vascular Disease

Modified from Libby P Circ 104:365,2001