Diagnosis and Management of acute coronary syndromes-latest guidelines (1).pptx

Diagnosis and Management of
acute coronary syndromes-
latest guidelines
Dr N ABHINAY REDDY
DM CARDIOLOGY RESIDENT
NIMS,PUNJAGUTTA

• Chest pain is ACUTE when it is new in onset or involves a change in
pattern, intensity, or duration compared with previous episodes in a
patient with recurrent symptoms.
• Chest pain is STABLE when symptoms are chronic and associated with
consistent precipitants such as exertion or emotional stress.
• Appropraite term to use is CHEST DISCOMFORT as many may not
describe it as pain
• Discourage the use of term atypical chest pain,
• Use “CARDIAC”, “POSSIBLY CARDIAC” , “NONCARDIAC” chest
discomfort

• Associated symptoms such as shortness of breath, nausea or vomiting,
lightheadedness, confusion, presyncope or syncope, or vague abdominal
symptoms are more frequent among patients with diabetes, women, and
the elderly.
• Most patients who present to the ED with chest pain are women,
particularly among those 65 years of age .
• The ISCHEMIA (International Study of Comparative Health Effectiveness
With Medical and Invasive Approaches) trial demonstrated that women
with moderate to-severe ischemia are more symptomatic than men.
• Women are less likely to have timely and appropriate care .
• This could be explained by the fact that women are more likely to
experience prodromal symptoms when they seek medical care .
• However, chest pain remains the predominant symptom reported by
women among those ultimately diagnosed with ACS, occurring with a
frequency equal to men

• The 12-lead ECG, which should be acquired and interpreted within 10
minutes of arrival to a medical facility , is pivotal in the evaluation
because of its capacity to identify and triage patients with STEMI to
urgent coronary reperfusion.

• cTn is organ-specific but not disease-specific.
• Numerous ischemic, noncoronary cardiac, and noncardiac causes of
cardiomyocyte injury can result in elevated cTn concentrations .
• Therefore, interpretation of cTn results requires integration with all
clinical information
• the time interval from onset of chest pain to a detectable concentration
at patient presentation is shorter with hs-cTn, affording more rapid rule-
in and rule-out algorithms.
• Comparative studies have confirmed the superiority of cTn over CK-MB
and myoglobin for diagnosis and prognosis of AMI .
• The addition of CK-MB or myoglobin to cTn for evaluation of patients
presenting with chest pain is not beneficial.

• A normal ECG may be associated with left circumflex or right coronary
artery occlusions and posterior wall ischemia, which is often
“electrically silent”; therefore, right-sided ECG leads should be
considered when such lesions are suspected.
• If the initial ecg is normal,serial ecgs are performed which is guided
by the patient symptoms,or a change a clinical situation occurs.

• Previously, the term known as CAD had been used to define those
with a significant obstructive stenosis (i.e., >50%).
• NOW the term “KNOWN CAD”is revised to include patients with prior
anatomic testing (invasive angiography or coronary computed
tomographic angiography [CCTA]) with identified” NONOBSTRUCTIVE
ATHEROSCLEROTIC PLAQUE”(<50% stenosis) and “OBSTRUCTIVE
CAD”(>50% stenosis).
• Added a term “HIGH RISK CAD” to denote left main stenosis >50%
stenosis or anatomically significant 3 vessel stenosis (>70%stenosis)

• Anatomical testing-CCTA(coronary computed tomographic
angiography) AND ICA(invasive coronary angiography)
• FUNCTIONAL TESTING-stress ecg , stress echo, stress MPI(myocardial
perfusion imaging), stress CMR(cardiac magnetic resonance),

Cardiac Testing Considerations for Women Who Are
Pregnant, Postpartum, or of Child-Bearing Age
• Elective and urgent cardiac testing, in both circumstances, imaging using ionizing
radiation during pregnancy or postpartum while breast feeding should generally
be avoided.
• When imaging is necessary to guide management, the risks and benefits of
invasive angiography, SPECT, PET, or CCTA should be discussed with the patient.
• In all cases for a test deemed clinically necessary, the lowest effective dose of
ionizing radiation should be used, including considerations for tests with no
radiation exposure (e.g., echocardiography, CMR imaging).
• Radiation risk to the fetus is very small. Iodinated contrast enters the fetal
circulation through the placenta and should be used with caution in a pregnant
woman.
• If contrast is needed for a postpartum woman, breastfeeding may continue
because <1% iodinated contrast is excreted into breast milk and absorbed into
infants intestinal tract
• The use of gadolinium contrast with CMR should be discouraged and used only
when necessary to guide clinical management and is expected to improve fetal or
maternal outcome

Patient-Centric Algorithms for
Acute Chest Pain:

Clinical Decision Pathways to Define Risk

• sex-specific considerations are not included in all scoring systems,
their effectiveness in men and women may not be equal.
• There are important differences in the performance of highly
sensitive and conventional cTn assays.
• hs-cTn assays may be used to guide disposition by repeat sampling at
1, 2, or 3 hours from ED arrival using the pattern of rise or fall.
• When using conventional cTn assays, the sampling timeframe is
extended to 3 to 6 hours from ED arrival.

Warranty period of prior cardiac testing

Case 1
• A patient Mr.A ,50/M k/c/o T2DM for 5 years, developed acute onset
chest discomfort 12hours back ,initially went to a nearby hospital
where he was diagnosed as ACUTE INFERIOR WALL MYOCARDIAL
INFARCTION.
• He was given fibrinolysis by Tenecteplase,and other standard
guideline directed management.
• Later he was reffered to our hospital
• On examination his vitals were stable,physical examination is
unremarkable.

CASE 2
• A patient Mrs.X ,64/F with no h/o comorbities, came to ED with
complaints of acute onset chest discomfort of 12hours duration a/w
diaphoresis.
• On examination she was anxious, her vitals were stable,physical
examination is unremarkable
• ECG obtained immediately,suggestive of ST elevations in inferior
leads.
• She was taken to catheterisation laboratory and angioplasty was
done.

CASE REVIEW
• Mrs.X symptoms were s/o typical angina combined with significant
riskfactors, she was immediately ordered an ECG and diagnosed as
ACS-STEMI.
• She was immediately taken to cath lab as a part of PRIMARY PCI
STRATEGY and performed ICA followed by angioplasty of the INFARCT
RELATED ARTERY.
• Mr.A was diagnosed with ACS–STEMI initially presented to a non PCI
capable hospital where he was thrombolysed later he was shifted to
PCI capable hospital. He underwent pharmacoinvasive strategy of PCI.

• A 65-year-old gentleman Mr.Z presented to the emergency department with a
complaint of left-sided chest pain radiating to his left arm for last 4 hours.
• There were no alleviating factors.
• His past medical history included hypertension,diabetes mellitus,dyslipidemia.
• He denied any toxic habits.
• Upon presentation, vital signs were stable and the physical examination was
unremarkable.
• The chest pain was partially relieved by sublingual nitroglycerin.
• The 12-lead ECG showed T-wave inversions in the inferolateral leads.
• He was administered aspirin, and the chest pain resolved shortly thereafter.
• Subsequently, he was admitted for further evaluation and observation.
• His serial cardiac biomarkers were negative.
• He had recurrent chest pain and remained hemodynamically stable.
• How would you manage this case?
CASE 3

• Based on his history,riskfactors,and ECG he was stratified as a high
risk for short term MACE
• He was admitted to CCU underwent ICA followed angioplasty.

www.escardio.org/guidelines
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
©ESC
Figure 1
Diagnostic algorithm
and triage in acute
coronary syndrome.

©ESC
Figure 3 (1)
0 h/1 h rule-out and
rule-in algorithm using
high-sensitivity cardiac
troponin assays in
haemodynamically stable
patients presenting with
suspected non-ST-
segment elevation acute
coronary syndrome to the
emergency department.
aOnly applicable if CPO >3 h.

©ESC
Figure 4 (1) Timing of the
blood draws and clinical
decisions when using
the European Society
of Cardiology
0 h/1 h algorithm.

©ESC
Recommendations for diagnosis, risk stratification, imaging, and
rhythm monitoring in patients with suspected non-ST-segment
elevation acute coronary syndrome (1)
Recommendations Class Level
Diagnosis and risk stratification
It is recommended to base diagnosis and initial short-term risk stratification
on a combination of clinical history, symptoms, vital signs, other physical
findings, ECG, and laboratory results including hs-cTn.
I B
It is recommended to measure cardiac troponins with high-sensitivity assays
immediately after admission and obtain the results within 60 min of blood
sampling.
I B
It is recommended to obtain a 12-lead ECG within 10 min after first medical
contact and to have it immediately interpreted by an experienced physician.
I B
0 h = time of first blood test; 1 h, 2 h, 3 h = 1, 2, or 3 h after the first blood test.

©ESC
Diagnosis and risk stratification (continued)
It is recommended to obtain an additional 12-lead ECG in case of recurrent
symptoms or diagnostic uncertainty.
I C
The ESC 0 h/1 h algorithm with blood sampling at 0 h and 1 h is
recommended if an hs-cTn test with a validated 0 h/1 h algorithm is
available.
I B
Additional testing after 3 h is recommended if the first two cardiac troponin
measurements of the 0 h/1 h algorithm are not conclusive and the clinical
condition is still suggestive of ACS.
I B

©ESC
Diagnosis and risk stratification (continued)
As an alternative to the ESC 0 h/1 h algorithm, it is recommended to use the
ESC 0 h/2 h algorithm with blood sampling at 0 h and 2 h, if an hs-cTn test with
a validated 0 h/2 h algorithm is available.
I B
Additional ECG leads (V3R, V4R, V7–V9) are recommended if ongoing
ischaemia is suspected when standard leads are inconclusive.
I C
As an alternative to the ESC 0 h/1 h algorithm, a rapid rule-out and rule-in
protocol with blood sampling at 0 h and 3 h should be considered, if a high-
sensitivity (or sensitive) cardiac troponin test with a validated 0 h/3 h
algorithm is available.
IIa B

©ESC
Imaging
In patients presenting with cardiac arrest or haemodynamic instability of
presumed cardiovascular origin, echocardiography is recommended and
should be performed by trained physicians immediately following a 12-lead
ECG.
I C
In patients with no recurrence of chest pain, normal ECG findings, and
normal levels of cardiac troponin (preferably high sensitivity), but still with a
suspected ACS, a non-invasive stress test (preferably with imaging) for
inducible ischaemia or CCTA is recommended before deciding on an invasive
approach.
I B

©ESC
Imaging (continued)
Echocardiography is recommended to evaluate regional and global LV
function and to rule in or rule out differential diagnoses.a
I C
CCTA is recommended as an alternative to ICA to exclude ACS when there is
a low-to-intermediate likelihood of CAD and when cardiac troponin and/or
ECG are normal or inconclusive.
I A
aDoes not apply to patients discharged the same day in whom NSTEMI has been ruled out.

©ESC
Recommendations on biomarker measurements for prognostic
stratification (1)
Beyond its diagnostic role, it is recommended to measure hs-cTn serially for
the estimation of prognosis.
I B
Measuring BNP or NT-proBNP plasma concentrations should be considered
to gain prognostic information.
IIa B
The measurement of additional biomarkers, such as midregional pro-A-type
natriuretic peptide, high-sensitivity C-reactive protein, midregional pro-
adrenomedullin, GDF-15, copeptin, and h-FABP is not recommended for
routine risk or prognosis assessment.
III B

Recommendations for Low-Risk Patients With Acute Chest Pain
There is no evidence to support routine admission or cardiac testing for chest pain
patients who are low risk, although outpatient CAC (coronary artery calcium)
scanning can provide additional information for longer-term risk stratification.

• For this low-risk subset patients who have chest pain, there is no
evidence that stress testing or cardiac imaging within 30 days of the
index ED visit improves their outcomes .
• This represents a change from previous guidelines where stress
testing within 72 hours was broadly recommended for patients with
acute chest pain.
• However, many of these patients have baseline cardiac risk factors
that need to be managed.
• Pathways to facilitate outpatient follow-up for further evaluation and
guideline-directed management of cardiac risk factors should be
considered

Recommendations for Intermediate-Risk Patients With Acute Chest Pain

Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD

Recommendations for Intermediate-Risk Patients With No Known CAD

Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With Known CAD

Recommendations for Intermediate-Risk Patients With Acute Chest Pain and Known
CAD

Recommendations for High-Risk Patients With Acute Chest Pain

Acute chest pain in Prior CABG surgery
patients
CCTA has a great degree of accuracy with a sensitivity and specificity of
detecting complete graft occlusions, 99% and 99%, respectively, when
compared with the standard of ICA

Evaluation of Acute Chest Pain in Patients
With Cocaine and Methamphetamine Use
• In patients presenting with acute chest pain, it is reasonable to
consider cocaine and methamphetamine use as a cause of their
symptoms
• General principles for risk stratification of patients with chest pain
apply to patients with cocaine or methamphetamine use.
• A person’s urine typically tests positive for cocaine or
methamphetamine within 1 to 4 hours of consuming the drug and
will continue to test positive for 2 to 4 days.

Recommendations for Acute Chest Pain With Suspected Pulmonary embolism

Recommendations for Acute Chest Pain With Suspected Myopericarditis

CASE 4
• Mr. B 54/M who is a known type 2 diabetic,hypertensive came to OPD
with complaints of typical chest pain on exertion which is subsiding
on taking rest for the past 6months.he doesn’t have any other
symptom.denies toxic habits.
• He is able to carry out his regular household activities without any
difficulty.
• His physical examination is normal.
• How to manage this patient?

EVALUATION OF PATIENTS WITH STABLE CHEST PAIN

Recommended Antithrombotic Therapies for Acute Coronary Syndromes

• rapid reperfusion with primary PCI within 120minutes reduces
mortality
• If PCI is not performed within approximately 120minutes of the initial
presentation of STEMI (either at the presenting hospital or on
transfer), fibrinolytic therapy with alteplase, reteplase, or
tenecteplase should be administered.

• the optimal timing of revascularization of the nonculprit coronary
arteries remains uncertain and should be determined based on
patient characteristics such as the exact coronary anatomy and kidney
function.
• when cardiogenic shock is present during the initial event, only the
occluded artery responsible for the STEMI should be treated because
clinical trial evidence demonstrates no advantages and potential
harms from treating multiple coronary arteries in patients with STEMI
and cardiogenic shock

• Oral antiplatelet therapies (aspirin and a P2Y12 inhibitor) and
parenteral anticoagulants (unfractionated heparin, low-
molecularweight heparin, direct thrombin inhibitors, or Factor Xa
inhibitors) are recommended therapies in the initial management of
ACS, regardless of whether treatment is invasive or noninvasive
• In patients with planned coronary angiography, administration of
P2Y12 inhibitors should be withheld until after the coronary anatomy
is defined to avoid exposing patients who might need cardiac surgery
to the bleeding risks from these medications

• Among patients with NSTEMI undergoing cardiac catheterization,
current guidelines recommend access to the coronary arteries via the
radial artery instead of the femoral artery.
• Because the radial artery is more easily compressed to prevent
bleeding, compared with the femoral artery, bleeding and vascular
complications, such as retroperitoneal hemorrhage and arteriovenous
fistulae, are less frequent

• Overall, 5% to 10% of people with ACS have concomitant atrial
fibrillation.
• In these patients, therapeutic goals consist of reducing ischemic event
rates and reducing thromboembolic complications of atrial
fibrillation, such as stroke.
• Previously, standard therapy consisted of dual antiplatelet therapy
(DAPT) combined with oral anticoagulation.
• However, more recent observational studies reported that this triple
antithrombotic therapy was associated with a 5.5% rate of major
bleeding compared with 2.5% for patients treated with DAPT

• Results of randomized clinical trials and meta analyses of randomized
trials have demonstrated that a non– vitamin K antagonist oral
anticoagulant, such as apixaban or rivaroxaban, combined with a
P2Y12 inhibitor, such as clopidogrel or ticagrelor, is associated with
lower rates of bleeding after discharge over the following year.
• In the presence of left ventricular thrombus or aneurysm, full-dose
anticoagulation with warfarin is typically recommended for at least
3months.
• However,more recent single-center studies suggested that non–
vitamin K antagonist oral anticoagulants such as apixaban and
rivaroxaban may provide similar efficacy without need for monitoring.

• High-intensity statins should be initiated at the time of presentation
in all patients with ACS
• Atorvastatin reduced the rate of recurrent coronary ischemia
requiring emergency hospitalization from 8.4% to 6.2%.

• Patients with ACS and left ventricular dysfunction or diabetes should
be prescribed either an angiotensin-converting enzyme inhibitor or an
angiotensin II receptor blocker prior to discharge .
• There is no evidence that one class is superior to the other among
patients with ACS.
• The angiotensin receptor and neprilysin inhibitor sacubitril-valsartan
may be preferred to angiotensin converting enzyme inhibition in
patients with an ejection fraction less than or equal to 40% when the
blood pressure and creatinine are stable after discharge.

• In patients with left ventricular dysfunction, β-blockers should be
prescribed, but randomized trials have not demonstrated benefit of
β-blockers in patients with normal left ventricular function and
revascularization of all significant coronary lesions

• Mineralocorticoid receptor antagonists, such as spironolactone and
eplerenone, are associated with reduced morbidity and mortality in
patients with ACS and left ventricular dysfunction

• A metaanalysis of 2 randomized trials in patients with heart failure
with reduced ejection fraction without ACS showed that sodium
glucose cotransporter-2 inhibitors were associated with lower rates of
cardiovascular mortality compared with placebo

• Recurrent ischemic events are common among patients with previous
ACS.
• Intensive lifestyle modification, such as a plant based diet and daily
exercise, is important and should include referral to cardiac
rehabilitation programs.
• Smoking cessation can reduce the relative risk of all-cause and
cardiovascular mortality by 70% to 80%

• DAPT with aspirin and a P2Y12 receptor antagonist is indicated for at
least 1 year if no bleeding complications occur.2 A longer duration of
DAPT further decreased the risk of recurrent MI and ischemic stroke,
but was associated with an increased rate in major bleeding.
• Patients at increased risk of bleeding, such as those with a history of
bleeding, anemia, or thrombocytopenia, are not good candidates for
long-term therapywithDAPT.

• The PRECISE-DAPT score, a risk score identified patients treated with
DAPT who were at increased risk of bleeding and consists of 5 items:
1)age, 2)creatinine clearance,3) hemoglobin, 4)white blood cell count,
and 5)history of spontaneous bleeding.
• In addition to risk scores, considering patient values and preferences
is important when deciding what patients are appropriate candidates
for shorter or longer durations of DAPT

• Another option for long-term antithrombotic therapy is low-dose
aspirin combined with 2.5 mg of rivaroxaban twice daily.(COMPASS
trial)
• Patients with ACS benefit from intensive low-density lipoprotein
cholesterol (LDL-C) lowering to less than approximately 50 mg/dL.
• The combination of ezetimibe plus statins reduced the rate of the
primary end point of cardiovascular death, non fatal MI, unstable
angina requiring rehospitalization, coronary revascularization, or
nonfatal stroke from 34.7% to 32.7% (P = .016) at 7 years.

• High-intensity statins, such as rosuvastatin and atorvastatin, and
ezetimibe are first-line therapy for patients with ACS.
• Proprotein convertase subtilisin-kexin type 9 inhibitors can be added
to high-intensity statins and ezetimibe when needed to reduce LDL-C
by 50% to 60% to at least less than 70 mg/dL
• Patients with ACS should receive annual influenza vaccines.

• An assessment of left ventricular function should be performed at the
time of admission for ACS.
• If the ejection fraction is not normal, repeated echocardiography
should be performed by approximately 3 months after optimal
medical therapy is prescribed.
• If the left ventricular ejection fraction is less than or equal to 35% at
that time, referral to a cardiac electrophysiologist should be
considered for possible implantable cardioverter defibrillator
placement to reduce the risk of sudden cardiac death from fatal
ventricular arrhythmias.(MADIT II trial ).

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