Made by Ranjith R Thampi. This was a powerpoint I had made for a Cardiology Seminar during internship. Got it checked by cardiologists, all approved. Covers management of UA, NSTEMI and STEMI. This was my favorite topic. I think the flowcharts will be clear to the point. Kindly comment and let me know.

1. Treatment
of
Acute Coronary
Syndrome
Ranjith R Thampi

2. OBJECTIVES
I. Initial evaluation
& stabilization
II. Optimized
Anti-ischaemic
&
Anti-platelet therapy
III. Focused cardiac
care

3. Chest pain suggestive
of ischemia
Immediate assessment within 10 Minutes
Initial labs Emergent History &
and tests care Physical
 12 lead ECG  IV access  Establish
 Obtain Initial  Cardiac diagnosis
cardiac enzymes monitoring  Read ECG
 FBC, Electrolytes,  Oxygen  Identify
Urea, Creatinine,  Nitrates complications
Coagulation  Aspirin  Assess for
Studies reperfusion
 CXR

4. ECG assessment
Non-specific ECG
Unstable Angina
ST Depression or dynamic
T wave inversions
NSTEMI
ST Elevation or new LBBB
STEMI

5. UNSTABLE
ANGINA NSTEMI

8. General Measures
 Oxygen and ECG monitoring
 Oxygen 2-4 L/min
 Pain 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 g/min
 -blockers/CCB’s

9. Therapeutic Goals
 PREVENT
Re-thrombosis & Downstream Embolization
 Anti-platelettherapy
 Aspirin upto 300 mg stat + 75 mg OD
 Clopidogrel 300-600 mg 75 mg OD
 Glycoprotein IIB/IIIA inhibitors
 Anti-coagulant therapy
 UFH or LMWH
LMWH- Inj. Heparin s/c 1mg/kg 12hrly
UFH- Inj. Heparin 5000U i/v bolus + IVI

10. Therapeutic Goals
 Relieve Obstruction
 Cardiac catheterization
 Percutaneous Coronary Interventions
 Coronary Artery Bypass Graft

11. Unstable Angina/NSTEMI
Focused Cardiac Care
 Based on Risk: (ACS Guidelines 2006)
Low Risk: <2 % chance MI or Death within
next 6 months
High Risk: >10 % chance of Mortality
in 6 months
 High Risk:
H E A R T D O C

12. Low Risk

13. 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

21. Low & High Risk
Longterm Therapy
 Aspirin 75 mg Daily
 Clopidogrel 75 mg Daily
 Atorvastatin 80 mg
 Ramipril 10 mg
 Beta Blockade- Metoprolol/Atenolol
 Glycemic Control
 Life-style modification

22. NITRATES
 NITRATES
Low dose- Venodilator
High dose- Arteriolar dilator
Reduces Preload/Afterload + MOD
MOA- Acts by releasing NO in vascular smooth
muscle
Inhibits Platelet Aggregation
ADR- Throbbing Headache, Nausea, Dizziness,
Hypotension, Reflex Tachycardia,
Tolerance develops over longterm use
C/I- Hypotension, Sildenafil Use(Viagra)

23. 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

24. Platelet GP IIb/IIIa Receptor Inhibitors
-Inhibition of platelet aggregation at final
common pathway
-Best for PCI, reduces ischemic complications
ADR- Hemorrhage, Thrombocytopenia,
Arrhythmias, Constipation
 Abciximab..pci
Only through
 Eptifibatide..acs Parenteral Infusion
 Tirofiban..acs

26. ANTICOAGULANTS
HEPARIN
 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

27. Heparin
 Types-
UFH, LMWH
UFH 60 U/Kg iv bolus + M 16 U/Kg/hr
LMWH Enox- 1 mg/Kg s/c
BD
Dalte- 120 IU/Kg
Fondaparinux
(Apixaban, Rivaroxaban)
Bivalirudin

29. Thrombus Formation
and Agents Acting

30. ACE-inhibitors
Captopril, Lisinopril , Ramipril, Perindopril
MOA- Inhibits A1 pressor action, Reduced
Aldosterone, Reduced vasoconstriction, reduced
sodium retention Improves LV Dysfunction
ADR- Hypotension, Hyperkalemia,
Dry Cough, Angioedema, Fetopathies, ARF
C/I- Renal Failure, Renal Artery Stenosis
Start early and aim for highest doses
Captopril - 50mg TDS, Lisinopril 20mg D, Ramipril
10mg D

31. Angiotensin Receptor Blockers
Losartan, Temisartan, Candesartan, Olmesartan, Valsartan
ARB as substitute for patients unable to use ACE-I
MOA- AT2 receptor blockade
Prevents: Vasoconstriction, sympathetic stimulation,
Aldosterone and Adr release from adrenals, Salt & Water
reabsorption
ADR- Hypotension, Hyperkalemia, Fetopathies
STATINS-
Atorvastatin, Simvastatin, Rosuvastatin
MOA- HMG CoA inhibition, blocks hepatic cholesterol
synthesis, Increased LDL, VLDL blood clearance
ADR- GI disturbances, Myopathies, Myalgia, Headache
C/I- Liver Disease, Renal Impairment

32. Beta Blockers
Atenolol, Carvedilol, Esmolol, Metoprolol, Pindolol
MOA- Decreases HR, Force of contraction, Cardiac Output,
Prolongs Systole, Antiarrhythmic
ADR- Ppts CHF, Carbohydrate Intolerance, Altered Lipid
Profile
C/I- Bradycardia, Reactive airway disease, Sinus Node
Dysfunction/AV block, Severe Heart failure
*Diltiazem instead
Calcium Channel Blockers
Amlodipine, Diltiazem, Nifedipine, Nimodipine, Verapamil
MOA- Smooth muscle relaxation & vasodilation
Slows HR, Reduces: afterload, myocardial contractility, MOD
ADR- 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

33. ECG assessment
Non-specific ECG
Unstable Angina
ST Depression or dynamic
T wave inversions
NSTEMI
ST Elevation or new LBBB
STEMI

34. STEMI

35. STEMI
 2 situations when it becomes difficult to
diagnose STEMI
 Chronic or Rate Dependent LBBB
 Paced Rhythm

36. ACS
Clinical Diagnosis
MONA:
Morphine + antiemetic
Oxygen
Nitrates
Aspirin 300 mg stat
Clopidogrel 600 mg stat
Blood Tests:
Troponin at 12 hours after
onset of pain, U&E, cholesterol,
FBC, coagulation
Admission or subsequent ECG

37. Immediate
ECG criteria Triage
-1 mm ST elevation in
at least 2 limb leads
-2 mm ST elevation in at
least 2 precordial leads 12 Lead ECG
Showing thrombolyseable
criteria Ix on admission
-LBBB with typical
clinical presentation
U&E, FBC, Cholest,
coagulation
Repeat
Definite STEMI 12 hrs Troponin,
ECG
Extra ECG Control RBS
requirements
Inferior ST elevation Primary PCI
Tenectoplase (TKN-tPA)
Do Rpt ECG Drug of choice with LMWH for
Posterior changes Thrombolysis pts <75 yrs independent of site
Deep ST-elevation + (if PCI unavailable immediately) of infarct
Target < 30 min
tall R waves in V1- V3 Streptokinase (SK)
Door-needle time in > 75%
patients Consider for pts > 75 yrs due to
lower incidence of ICH
Repeat ECG 90 min from comencement of lytic
Aim: > 50% reduction in peak ST segment elevation

38. REASSESS
Risk assessment & secondary prevention
Aspirin
Statin
Early beta blockade
Ace- inhibitors
Angiogram Pre discharge
Rehablitation
Consider patient’s pre morbid state & suitability
for revascularisation
Failed Reperfusion
Haemodynamics compromise
Continuing pain
Discuss suitability for rescue PCI

39. THROMBOLYSIS
 Lyses fibrin thrombi and reduces
clot-caused infarct size allowing reperfusion
D2N Time- <30 mins
Best Time- Upto 12 hrs from Onset of symptoms
Primary PCI
 Usually done under anticoagulant cover
Coronary recanalization is done with
Angioplasty and commonly Stenting
Best D2B Time- <90 mins

40. 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 paramedics
Indication: Ant. Wall MI, Previous SK use
SBP< 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

41. Thrombus Formation
and Agents Acting

42. 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

43. Contraindications to thrombolysis
 ABSOLUTE  RELATIVE
 Active GI Bleed  Traumatic CPR
 Aortic Dissection  Surgery<10 days
 Previous ICH  Arterial Puncture<24 hrs
 Stroke<2 months  SBP>180
 Intracranial aneurysm/  Bleeding Tendency
neoplasm  Trauma
 Head injury<2 months  Pregnancy
 Pericarditis  Bacterial Endocarditis
 Pancreatitis
 Warfarin/INR>3
Contraindications vary slightly between thrombolytics

44. 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.

45. Primary PCI
 Facilitated 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.

46. Primary PCI
 Rescue PCI
Performed 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.

47. 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

48. COMPLICATIONS

49. 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

51. Admit to CCU & Monitor closely
KILLIP Pulmonary edema
Class 3+4 O2 2-4 L, aim for SaO2 >95% +
Treatment Cardiogenic Shock
ANALGESIA
2.5-5mg 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)

52. PCWP
PCWP <15 mm Hg PCWP >15 mm Hg
fluid load
Plasma Expander 100mL every 15 mins iv Inotropic support
Aim for PCWP of 15-20 mm Hg eg: Dobutamine 2.5-10 g/kg/min ivi
Aim for SBP >80 mm Hg
Consider ‘renal dose’ dopamine 2-5 g/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
Look for and treat any reversible cause:
MI or PE- Consider Thrombolysis;
Surgery for: a/c VSD, MR, AR

54. 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 STEMI
Obstruction is by Thrombus

55. Prevention

56. Secondary Prevention
 Comorbid Diseases
 HTN, DM, Dyslipidemia
 Behavioral
 smoking, diet, physical activity, weight redn
 Cognitive
 Education, cardiac rehab program

57. Secondary Prevention
Comorbid 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%

58. Secondary prevention
Behavioral 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

59. 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)

60. 
Thank You