ACCp

1. Acute Coronary Syndromes
Done by :
Raniya.Khaled
@Rania199730
References:
ACCP Updates in Therapeutics® 2020 : Acute Care In Cardiology
Rxprep course book 2018 edition : Acute Coronary Syndromes

2. Acute coronary syndrome (ACS)
• Refers to a set of clinical conditions brought on by sudden,
reduced blood f low causing an imbalance between
myocardial oxygen supply and demand.
• This results from plaque buildup in the coronary arteries
(coronary atherosclerosis).
• These plaques are made up of fatty deposits that cause the
arteries to narrow, making blood flow more difficult. The
surface of the plaque can rupture, leading to clot format ion
and an acute reduction in blood flow (ischemia).
• Ischemia may ultimately lead to cardiac muscle cell death
(myocyte necrosis).
Raniya.Khaled
@Rania1997301

3. Acute coronary syndrome (ACS)
ACS can be divided into:
ST-segment elevation myocardial infarction (STEMI) and Non–ST-segment elevation acute coronary
syndrome (NSTE-ACS).
NSTE-ACS UA NSTEMI STEMI
Subjective Findings
Most commonly presents as a pressure- type chest pain that typically occurs at rest or with minimal exertion
Pain usually starts in the retrosternal area and can radiate to either or both arms, neck, or jaw
Pain may also present with diaphoresis, dyspnea, nausea, abdominal pain, or syncope
Unexplained new-onset or increased exertional dyspnea is the most common angina equivalent
Less common atypical symptoms (without chest pain) include epigastric pain, indigestion, nausea, vomiting,
diaphoresis, unexplained fatigue, and syncope
Classic symptoms include worsening of pain
or pressure in chest, characterized as viselike,
suffocating, squeezing, aching, gripping, and
excruciating, that may be accompanied by
radiation
Objective Findings
ST-segment depression, T-wave inversion, or transient or
nonspecific ECG changes can occur
No positive biomarkers for cardiac necrosis
ST-segment depression, T-wave inversion, or
transient or nonspecific ECG changes can
occur
Positive biomarkers (troponin I or T
elevation)
ST-segment elevation > 1 mm above baseline
on ECG in two or more contiguous leads
Positive biomarkers (troponin I or T
elevation)
Extent of Injury No myocardial injury; partial occlusion of coronary artery
Myocardial injury; partial occlusion of coronary
artery
Myocardial necrosis; total occlusion of
coronary artery
Raniya.Khaled
@Rania1997301

4. Acute coronary syndrome (ACS)
Acute coronary syndrome diagnosis and risk stratification.
Clinical suspicion of ACS
Obtain and interpret 12 lead ECG within 10
minutes Aspirin within 10 minutes
STEMI/ST Elevation
Trop (+)
Initiate immediate reperfusion
(PCI vs. fibrinolysis)
Primary PCI within 90 minutes Door to
needle time of 30 minutes if PCI not
available within 120 minutes
Begin adjunctive pharmacotherapy
Anticoagulation with UFH or
bivalirudin if primary PCI P2Y12
once anatomy verified
NSTE-ACS/ST Depression
Next page
Raniya.Khaled
@Rania1997301

5. Acute coronary syndrome (ACS)
Acute coronary syndrome diagnosis and risk stratification.
Clinical suspicion of ACS
Obtain and interpret 12 lead ECG within 10
minutes Aspirin within 10 minutes
NSTE-ACS/ST Depression
Unstable angina
Trop (-)
NSTEMI
Trop (+)Risk stratification Multi-lead continuous ECG monitoring
Obtain serial troponin
Low Risk
“Ischemia-guided approach”
Stress test to evaluate likelihood of CAD (before discharge)
Moderate and High Risk
“early invasive approach”
If negative, may rule out
cardiac origin
Positive Stress test?
Coronary angiography with
revascularization (PCI vs. CABG)
Begin adjunctive pharmacotherapy for NSTE-ACS based on risk
stratification Includes P2Y12 inhibitor and anticoagulant
Raniya.Khaled
@Rania1997301

6. Treatment
Raniya.Khaled
@Rania1997301

7. 2=O -
Oxygen
1=M- Morphine
or other narcotic
analgesic
Acute coronary syndrome (ACS)
Mnemonic: MONA
M
O
N
A3-N =
Nitroglycerin
4-A =
Aspirin
Raniya.Khaled
@Rania1997301

8. Treatment
Initial Anti-ischemic and Analgesic Therapies for ACS..1
Therapy M = Morphine or other narcotic analgesic O = Oxygen N = Nitroglycerin
Comments
Provides analgesia and decreased pain-induced
sympathetic/adrenergic tone
Commonly used because it can also induce
vasodilation and mediate some degree of afterload
reduction
Morphine 1–5 mg IV every 5–30 min is
reasonable if symptoms are not relieved despite
maximally tolerated anti-ischemic medications
Can help attenuate anginal pain
secondary to tissue hypoxia
Consider supplemental oxygen if
Sao2 < 90%, respiratory distress,
or high-risk features of hypoxemia
Facilitates coronary vasodilation and may also
be helpful in severe cardiogenic pulmonary
edema caused by venous capacitance
NTG spray or sublingual tablet (0.3–0.4 mg)
every 5 min for up to three doses to relieve
acute chest pain
Contraindications:
Sildenafil or vardenafil (use within 24 hr) or
tadalafil (use within 48 hr);
SBP < 90 mm Hg or ≥ 30 mm Hg below
baseline, HR < 50 beats/min, HR > 100
beats/min in absence of symptomatic HF or
right ventricular infarction
Raniya.Khaled
@Rania1997301

9. Treatment
Initial Anti-ischemic and Analgesic Therapies for ACS..2
Therapy
A = Aspirin β-Blocker
Comments
Inhibits platelet activation
Mortality-reducing therapy
Use Clopidogrel if aspirin allergy
Decrease myocardial ischemia, reinfarction, and frequency of dysrhythmias and
increase long-term survival
Oral β-blocker should be initiated within 24 hr in patients who do not have signs
of HF, evidence of low-output state, increased risk of cardiogenic shock, or other
contraindications to β-blockade (e.g., PR interval > 0.24 s, second- or third-
degree heart block, active asthma, or reactive airway disease)
Use metoprolol succinate, carvedilol, or bisoprolol in concomitant stabilized HFrEF ;
add cautiously in decompensated HF
Avoid agents with intrinsic sympathomimetic activity (acebutolol, pindolol,
penbutolol)
IV β-blocker is potentially harmful in patients with risk factors for shock (age >
70 yr, HR > 110 beats/min, SBP < 120 mm Hg, and late presentation)
Raniya.Khaled
@Rania1997301

10. Treatment
Long term
management after
ACS
(Secondary
prevention)
Aspirin
Indefinitely ,
unless contraindicated
P2Y12 Inhibitor:
Medical Therapy Patients:
ticagrelor or clopidogrel with
aspirin for at least 12 months
■ PCI-Treated Patients :
clopidogrel, prasugrel or
ticagrelor with aspirin for at least
12 months
Nitroglycerin
Indefinitely
(SL tabs or spray PRN) Beta Blocker
3 years; continue indefinitely if HF or if
needed for management of HTN
ACE Inhibitor
Indefinitely if EF < 40%, HTN, CKD
or diabetes; consider for all Ml
patients with no contraindications
Aldosterone Antagonist
■ Indefinitely if EF < 40% and either
symptomatic HF or DM receiving
target doses of an ACE inhibitor and
beta blocker
■ Contraindications: significant renal
impairment (SCr > 2.5 mg/dL in men,
SCr > 2 mg/dL in women) or
hyperkalemia(K> 5 mEq/L)
Statin
■ Patients < 75 years of age, use high-
intensity statin therapy
■ Patients > 75 years of age, use
moderate-intensity statin therapy
Raniya.Khaled
@Rania1997301