The document discusses the current management of acute coronary syndrome in a non-interventional center. It outlines the definitions, processes of care, guidelines, and goals in diagnosing and treating ACS in the emergency department and hospital phases, including use of ECG, cardiac markers, medications, risk stratification, and addressing complications.

1. Current Management of Acute Coronary Syndrome in a Non- Interventional Center

3. Acute Coronary Syndromes Unstable Angina Ischemic Chest Discomfort No ST Elevation ST Elevation Non -ST Elevation MI ST Elevation MI ECG Cardiac markers – +

9. TRIAGE OF ACS Ischemic Chest Discomfort ST Elevation or New LBBB ECG s/o Ischemia ST dep, T inversion Non-diagnostic or Normal ECG Assess initial ECG Aspirin Baseline CK, CK-MB Assess C/I to thrombolysis Anti-ischemic therapy Reperfusion therapy [ thrombolyse or Primary PTCA ] Admit Anti-ischemic therapy Serial cardiac markers 2D Echo E/o ischemia / MI No Yes Discharge Admit Goal 10 minutes Goal < 30 min for STK or < 60 min for arrival in Cath Lab for PTCA

10. Criteria For The Diagnosis Of Acute Myocardial Infarction (AMI)  Biomarkers +  of the following Pathological findings of AMI Typical symptoms of AMI + one of the following Procedural myocardial damage Typical symptoms of myocardial ischemia No other findings required ST segment elevation in the ECG  cardiac biomarkers to prespecified levels; symptoms may be absent; ECG changes absent/nonspecific Q waves in the ECG Increased levels of cardiac biomarkers ST segment elevation or depression in the ECG Modified from Alpert J, Thygesen K, et al: Towards a new definition of myocardial infarction for the 21st century. J Am Coll Cardiol 2000, in press.

11. Initial Presentation

15. Electrocardiogram “standard of care”

16. ECG Patterns Normal 38% ST Depression 18% T Inversion 23% ST Elevation 11% LBBB 10% Hamm et al. NEJM 1997;337 ST Depression 57% Normal 13% T Inversion 13% ST Elevation 17% TIMI IIIb Investigators, Circulation 1994;89 In Acute Chest Pain In unstable angina

18. Risk of MI/Death during 1 yr Followup based on ECG on Admission The RISC Study Group . J.Intern.Med.1993;234

21. Cardiac Markers

22. TABLE 35-1 -- CAUSES OF MYOCARDIAL INFARCTION WITHOUT CORONARY ATHEROSCLEROSIS CORONARY ARTERY DISEASE OTHER THAN ATHEROSCLEROSIS Arteritis Luetic Granulomatous (Takayasu disease) Polyarteritis nodosa Mucocutaneous lymph node (Kawasaki) syndrome Disseminated lupus erythematosus Rheumatoid spondylitis Ankylosing spondylitis Trauma to coronary arteries Laceration Thrombosis Iatrogenic Radiation (radiation therapy for neoplasia) Coronary mural thickening with metabolic disease or intimal proliferative disease Mucopolysaccharidoses (Hurler disease) Homocysteinuria Fabry disease Amyloidosis Juvenile intimal sclerosis (idiopathic arterial calcification of infancy) Intimal hyperplasia associated with contraceptive steroids or with the postpartum period Pseudoxanthoma elasticum Coronary fibrosis caused by radiation therapy Luminal narrowing by other mechanisms Spasm of coronary arteries (Prinzmetal angina with normal coronary arteries) Spasm after nitroglycerin withdrawal Dissection of the aorta Dissection of the coronary artery EMBOLI TO CORONARY ARTERIES Infective endocarditis Nonbacterial thrombotic endocarditis Prolapse of mitral valve Mural thrombus from left atrium, left ventricle, or pulmonary veins Prosthetic valve emboli Cardiac myxoma Associated with cardiopulmonary bypass surgery and coronary arteriography Paradoxical emboli Papillary fibroelastoma of the aortic valve (&quot;fixed embolus&quot;) Thrombi from intracardiac catheters or guidewires CONGENITAL CORONARY ARTERY ANOMALIES Anomalous origin of left coronary from pulmonary artery Left coronary artery from anterior sinus of Valsalva Coronary arteriovenous and arteriocameral fistulas Coronary artery aneurysms MYOCARDIAL OXYGEN DEMAND-SUPPLY DISPROPORTION Aortic stenosis, all forms Incomplete differentiation of the aortic valve Aortic insufficiency Carbon monoxide poisoning Thyrotoxicosis Prolonged hypotension HEMATOLOGICAL (IN SITU THROMBOSIS) Polycythemia vera Thrombocytosis Disseminated intravascular coagulation Hypercoagulability, thrombosis, thrombocytopenic purpura MISCELLANEOUS Cocaine abuse Myocardial contusion Myocardial infarction with normal coronary arteries Complication of cardic catheterization Modified from Cheitlin M, et al: Myocardial infarction without atherosclerosis. JAMA 231:951, 1975. Copyright 1975, American Medical Association. MARKER MW (D) TIMES TO INITIAL ELEVATION (hr) MEAN TIME TO PEAK (NONTHROMBOLYSIS) TIME TO RETURN TO NORMAL RANGE MOST COMMON SAMPLING SCHEDULE hFABP 14,000-15,000 1.5 5-10 hr 24 hr On presentation, then 4 hr later Myoglobin 17,800 1-4 6-7 hr 24 hr Frequent; 1-2 hr after CP MLC 19,000-27,000 6-12 2-4 d 6-12 d Once at least 12 hr after CP cTnI 23,500 3-12 24 hr 5-10 d Once at least 12 hr after CP cTnT 33,000 3-12 12 hr-2 d 5-14 d Once at least 12 hr after CP MB-CK 86,000 3-12 24 hr 48-72 hr Every 12 hr×3 MM-CK tissue isoform 86,000 1-6 12 hr 38 hr 60-90 min after CP MB-CK tissue isoform 86,000 2-6 18 hr Unknown 60-90 min after CP Enolase 90,000 6-10 24 hr 48 hr Every 12 hr×3 LD 135,000 10 24-48 hr 10-14 d Once at least 24 hr after CP MHC 400,000 48 5-6 d 14 d Once at least >2 d after CP hFABP=heart fatty acid binding proteins; MLC=myosin light chain; cTnI=cardiac troponin I; cTnT=cardiac troponin T; MB-CK=MB isoenzyme of creatinine kinase (CK); MM-CK=MM isoenzyme of CK; LD=lactate dehydrogenase; MHC=myosin heavy chain; CP=chest pain

26. Clinical Status GISSI-1 (%) Killip Definition Incidence Control Lytic Class Mortality Mortality I No CHF 71 7.3 5.9 II S3 gallop or 23 19.9 16.1 basilar rales III Pulmonary edema 4 39.0 33.0 (rales >1/2 up) IV Cardiogenic shock 2 70.1 69.9 Killip T et al. Am J Cardiol 20:457;1967 GISSI. Lancet 1”397-401, 1986

27. Hospital Phase

29. Hemodynamic Classification Forrester J et al. NEJM 295:1356:1976

34. LV ANEURYSM MR CARDIAC RUPTURE VSD.

41. NITRATES IN ACS

42. Beta Blockers in ACS * Eur H Journal 1985;6 # Lancet 1986;ii

43. Calcium Ch. Blockers in ACS Salim Yusuf, BMJ 1989; 299

48. Role of Anticoagulants in ACS

49. New Anti coagulants in ACS

51. ESSENCE Trial incidence of death, MI, or recurrent angina N Eng J Med 1997;337:447-452 heparin enoxaparin Heparin enoxaparin n=1564 n=1607 n=1564 n=1607 19.8% 16.6% P=0.019 23.3% 19.8% P=0.016 Day 14 Day 30

55. Incidence of Ischemic Events No aspirin (early 1980s) Aspirin Aspirin + Heparin 16% 12% 9% Incidence of death and MI

58. Aspirin & Ticlopidine in ACS

67. Thrombotic Process – Pathophysiology Platelet Aggregation Ruptured Plaque Fibrinogen VWF VWF GP II b/ III a Receptor GP I b Receptor

75. Abciximab in ACS

88. POST INFARCT REMODELING Lessened Wall stress Increased Wall Stress No prevention LV dilation and remodeling LV failure WALL STRESS = Pressure x Radius 2 x (wall thickness) ACE inhibition Beta-blocker LV Smaller Less failure

89. ACE INHIBITORS Dzau-Braunwald model RISK FACTORS Hypertension LVH Atheroma Ischemia Thrombosis Sudden Death Infarction Reinfarction Loss of muscle Remodeling LV Failure - - - - - - - = ACE inhibitor effect

94. PTCA in ACS VANQWISH TRIAL 916 Pts. Of UA Early Invasive Conservative 24 % 19% 1 yr Mortality or Reinf

95. PTCA in ACS FRISC 2 2457 Pts of ACS Early Invasive Tt Selective Invasive Tt 9.5 % 12 % 6 Mo Death or Reinf. Procedural 1.2 % 0.4 % Mortality

96. CABG in ACS

98. EMERGENCY ROOM PROTOCOL FOR ACUTE CHEST PAIN

99. Phases & Lesion Morphology of Atherosclerosis American Heart Assn. Committee on Vascular Lesions

100. AMI: Parameters influencing prognosis Acute MI At Presentation In Hospital At Discharge Size of infarct Recurrent ischemia LV systolic dysfunction Diastolic dysfunction Mechanical complications Residual ischemia LV dysfunction Risk of arrhythmia Age Gender ECG features Concomitant Risk factors Clinical status

106. TIMI myocardial perfusion grade and mortality

107. Second International Study of Infarct Survival (ISIS-2).

108. Mortality differences during days 0 to 35 subdivided by presentation features in nine trials of thrombolytic therapy

109. TIMI Risk Score for STEMI for predicting 30-day mortality

112. Acute Coronary Syndromes Spectrum Acute Coronary Syndromes No ST elevation ST elevation Enzymes not  Enzymes  USA NSTEMI STEMI

116. Antithrombotic Drug Therapy Abciximab (ReoPro) with unfractionated heparin and aspirin 0.25-mg/kg intravenous bolus followed by an infusion of 0.125 μg/kg/min for 12–24 h up to 10 mg/min Eptifibatide (Integrilin) with unfractionated heparin and aspirin 180-μg/kg bolus followed by an infusion of 2 μg/kg/min up to 72 h for intervention. Max 15 mg/h Tirofiban (Aggrastat) with unfractionated heparin and aspirin 0.4 μg/kg/min × 30 min 0.1-μg/kg/min infusion × 48 h up to 108 h (PRISM-Plus) Enoxparin (clexane) 1 mg/kg q12 h Clopidogrel (Plavix) 300 mg initially, followed by 75 mg/d

118. Predictive Value of Troponins in ACS

119. Initial Presentation : Clinical The GUSTO Pyramid: 30 Day Mortality Model Lee et al. Circulation 1995;91:1659-1668 Influence of Clinical characteristics on 30 day mortality in thrombolyzed patients with STEMI Age (31%) Systolic Blood Pressure (24%) Killip Class (15%) Heart Rate (12%) MI Location (6%) Prior MI (3%) Age x Killip (1.3%) Height (1.1%) Diabetes (1%) Time-to-Rx (1%) Smoker (0.8%) Weight (0.8%) Accel t-PA (0.8%) Prior CABG (0.8%) HTN (0.6%) H/o CV D (0.4%)

120. Initial Presentation TIMI Risk Score for STEMI Morrow et al. In TIME II substudy. Circulation 2000; 102:2031-2037 1 Yr Mortality Score 0 - 1%; Score >8 - 17%

122. ECG : prognostication GUSTO I outcome based on ECG 6.7%  ST II, III, aVF only distal RCA or LCx br. Small inferior 10.2%  ST V 1-4 or  ST I, aVL, V 5-6 beyond / in diagonal LAD (Distal) / diagonal 12.4%  ST V 1-6 , I, aVL before diagonal LAD (Mid) 25.6%  ST V 1-6 , I, aVL, fascicular or BBB before septal LAD (Prox) 8.4%  ST II, III, aVF and V 1 ,V 3 R,V 4 R or V 5-6 or R >S V 1-2 proximal RCA or LCX Moderate-to- large inferior (post, lat, RV) 1-Year mortality ECG Occlusion Site Category

123. Admission ECG Prognostic Value for Triaging GUSTO IIb Trial Eur H. J 1997