Acute coronary syndrome, NSTEMI, STEMI, UA, unstable angina, Cardiology, rounds, IM, Internal Medicine, Cebu, CDUH, Evardone

1. ACUTE CORONARY
SYNDROME
Jose Socrates ‘Dee’ Matuod Evardone
Cardiology RIC
Level II CDUH-IM
JULY 2015

2. CASE
Profile:
78F, Filipino
Hypertensive,
Non-DM,
Non-smoker,
Non-alcoholic beverage drinker
CC: CHEST PAIN

3. CASE
HPI:
2 hours PTA- sudden onset of squeezing,
retrosternal chest pain, radiating towards the neck,
associated with headache. (+) Vomiting x1, pain
score of 8/10, not relieved by rest, about >10
minutes. Admitted at primary hospital and managed
as essential hypertension with NSSTWCs on ECG.
Subsequently transferred to a Tertiary level for
further workup and management

4. CASEPhysical Exam
Awake, coherent, in
mild distress
Warm, good turgor
and mobility, CRT <2
seconds,
Anicteric sclerae, pink
palpebral
conjunctivae,
Equal chest
expansion, dec BS on
both lower lung fields,
with crackles
Distinct heart sounds, ,
tachycardic, regular,
no murmur
Flat, Normoactive
bowel sounds, soft, no
organomegaly
Strong peripheral
pulses, no edema
Neurologic: WNL
BP: 130/60mmHg,
HR: 118 bpm,
RR: 26 cpm,
99% O2 mp: 36.5°
Neck: No JVD, no
murmur

5. CASE
IMPRESSION:
1) NSTE-ACS (UA vs NSTEMI)
2) HCVD

6. CASE
DIAGNOSTICS:
ECG – Sinus Rhythm with NSSTWCs
CXR – Beginning congestion,
inflammatory process bilaterally
Troponin I – 3.13 (elevated)

7. CASE
MANAGEMENT: (ER)
Aspirin 80 mg 4 tabs chewed, swallowed
Clopidogrel 75mg , 4 tabs
Clexane 0.4cc
Attached to cardiac monitor
Advised ICU/CCU admission

8. ACUTE CORONARY SYNDROME
SOURCES:

9. ACUTE CORONARY SYNDROME
I: Diagnosis and Management of Patients with Stable
Ischemic Heart Disease
II: Diagnosis and Management of Patients with
Non-ST Elevation Acute Coronary Syndrome
III: Diagnosis and Management of Patients with
ST Segment Elevation Myocardial Infarction

10. ACUTE CORONARY SYNDROME
What is ACS?
- refers to a spectrum of clinical presentations
ranging from those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in non–ST-
segment elevation myocardial infarction (NSTEMI) or in
unstable angina
- in general reserved for ischemia precipitated by
acute coronary atherothrombosis

11. Ischemic
Heart
Disease

12. ACUTE CORONARY SYNDROME
Ischemic Heart
Disease
Chronic coronary artery
disease (CAD) with
STABLE ANGINA
Acute Coronary
Syndrome
STEMI
1) NSTEMI-ACS
2) Unstable Angina

13. ACUTE CORONARY SYNDROME
Classic manifestation of ischemia is angina pectoris:
Pressure,
Tightness,
Squeezing,
Heaviness,
Burning
ACS most commonly occurs without obvious precipitating
factors

15. Coronary Circulation

16. Coronary Circulation

17. Coronary Circulation

18. LOCALIZATION OF CORONARY CIRCULATION IN
M.I.
ANATOMIC ECG LEADS CORONARY ARTERY
Septal V1-v2 Proximal LAD
Anterior V3-V4 LAD
Apical V5-V6 Distal LAD, LCx, or RCA
Lateral I, aVL LCx
Inferior II, III, aVF RCA(85%), LCx (15%)
RV V1-V2 & V4R (most Se) Proximal RCA
Posterior ST depression V1-V3 RCA or LCx

20. ACUTE CORONARY SYNDROME

21. ACUTE CORONARY SYNDROME

22. ACUTE CORONARY SYNDROME
The American
College of Cardiology (ACC) and American Heart Association (AHA)
guidelines list the following as pain descriptions uncharacteristic of
myocardial ischemia:
• Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory
movements or coughing)
• Primary or sole location of the discomfort in the middle or lower
abdominal region
• Pain that may be localized by the tip of one finger, particularly over
the left ventricular apex
• Pain reproduced with movement or palpation of the chest wall or
arms
• Constant pain that persists for many hours
• Very brief episodes of pain that last a few seconds or less
• Pain that radiates into the lower extremities

23. ISCHEMIC HEART DISEASE

24. Ischemic Heart Disease
The major determinants of myocardial oxygen
demand (MVO2) are:
1) heart rate,
2) myocardial contractility, and
3) myocardial wall tension (stress)
About 75% of the total coronary resistance to flow occurs
across three sets of arteries:
(1) large epicardial arteries (Resistance 1 = R1),
(2) prearteriolar vessels (R2), and
(3) arteriolar and intramyocardial capillary vessels (R3)

25. 50% Stenosis:
there is a limitation of the ability to increase flow to
meet increased myocardial demand.
80% Stenosis:
myocardial ischemia at rest or with minimal stress
Ischemic Heart Disease
Coronary Blood Flow Limitation:
• spasm,
• arterial thrombi, and,
• rarely, coronary emboli
• as well as by ostial narrowing due to aortitis
• Congenital Anomalies

26. ACUTE CORONARY SYNDROME

27. The severity and duration of the imbalance between
myocardial oxygen supply and demand determine
whether the damage is :
 reversible (≤20 min for total occlusion in the absence
of collaterals) or
 permanent, with subsequent myocardial necrosis
(>20 min).
Ischemic Heart Disease

28. ACUTE CORONARY SYNDROME
Evaluation
of the
patient
with known
or
suspected
ischemic
heart
disease

29. Requirements :
• Two sets of cardiac enzymes at 4-hr intervals should be normal
• ECG at the time of arrival and preexercise 12-lead ECG show no
significant abnormality
• Absence of rest electrocardiographic abnormalities that would preclude
accurate assessment of the exercise ECG
• From admission to the time that results are available from the second set
of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms,
or persistent atypical symptoms
• Absence of ischemic chest pain at the time of exercise testing
Indications and Contraindications for Exercise
Electrocardiographic Testing in the Emergency Department
Contraindications
• New or evolving electrocardiographic abnormalities on the rest tracing
• Abnormal cardiac enzyme levels
• Inability to perform exercise
• Worsening or persistent ischemic chest pain symptoms from admission to the
time of exercise testing
• Clinical risk profiling indicating that imminent coronary angiography is likely

30. A
C
U
T
E
C
O
R
O
N
A
R
Y
S
Y
N
D
R
O
M
E

31. ISCHEMIC HEART DISEASE

32. STABLE ISCHEMIC HEART DISEASE
Laboratory Tests:
1. Fasting lipid profile
2. Fasting glucose and/or glycated hemoglobin (HbA1c) level if
available; additional oral glucose tolerance test (OGTT) if
both are inconclusive;
3. Complete blood count (CBC);
4. Creatinine level with estimation of glomerular filtration rate
(GFR);
5. Biochemical markers of myocardial injury (Troponin T or I) if
clinical evaluation suggests an Acute Coronary Syndrome
(ACS);
6. Thyroid hormone levels
7. Liver function tests early after beginning statin therapy.

33. ISCHEMIC HEART DISEASE
Pre-Test Probability (PTP) Assessment
Diamond and Forrester pre-test probability of cad by age, sex and symptoms

34. ISCHEMIC HEART DISEASE

35. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Non-invasive stress testing
Stress Imaging

36. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS

37. ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Exercise ECG (Treadmill Exercise Test or TET)
its simplicity, lower cost and widespread availability, the
TET is the initial test of choice to identify inducible
ischemia in the majority of patients with intermediate PTP
who are able to exercise
The low sensitivity of the TET (45% to 50%) despite a high
specificity (85% to 90%) is the reason why it is not
recommended in patients with a PTP greater than 65%
In the latter case,a stress imaging study is more
appropriate.

38. ISCHEMIC HEART DISEASE
CORONARY ARTERIOGRAPHY
Coronary arteriography is indicated in:
(1) patients with chronic stable angina pectoris who are severely
symptomatic despite medical therapy and are being considered
for revascularization, i.e., a percutaneous coronary intervention
(PCI) or coronary artery bypass grafting (CABG);
(2) patients with troublesome symptoms that present diagnostic
difficulties in whom there is a need to confirm or rule out the
diagnosis of IHD;
(3) patients with known or possible angina pectoris who have
survived cardiac arrest;
(4) patients with angina or evidence of ischemia on noninvasive
testing with clinical or laboratory evidence of ventricular
dysfunction; and
(5) patients judged to be at high risk of sustaining coronary
events based on signs of severe ischemia on noninvasive testing,
regardless of the presence or severity of symptoms

39. ISCHEMIC HEART DISEASE
MANAGEMENT
Lifestyle Modification and Treatment of Risk Factors
1) Healthy Diet
2) Physical Activity
3) Hypertension
4) Smoking
5) DM
6) Weight Management
7) Lipid Management

40. ISCHEMIC HEART DISEASE
MANAGEMENT
Pharmacologic Therapy to Improve Prognosis
Whether or not revascularization is being considered,
receive the following medications to improve prognosis,
thereby reducing the risk for MI and death:
1. Aspirin low-dose (80 to 160 mg/day)
2. Clopidogrel in case of aspirin intolerance (75 mg/day)
3. Statins irrespective of LDL-cholesterol levels
4. Beta blockers post-MI
5. ACEIs or ARBs (especially in patients with concomitant HF,
hypertension or diabetes)

41. Pharmacologic Therapy to Improve Prognosis

42. Pharmacologic Therapy to Improve Prognosis

43. Pharmacologic Therapy to Improve Prognosis

44. R
E
V
A
S
C
U
L
A
R
I
Z
A
T
I
O
N

45. Non-ST-Segment Elevation
Acute Coronary Syndrome
(Non-ST-Segment Elevation
Myocardial Infarction and
Unstable Angina)

46. NSTE-ACS
Pathophysiology:
1. imbalance between oxygen supply and oxygen
demand resulting from a partially occluding
thrombus forming on a disrupted
atherothrombotic coronary plaque or on
eroded coronary artery endothelium
2. dynamic obstruction
3. severe mechanical obstruction
4. increased myocardial oxygen demand

47. NSTE-ACS

48. NSTE-ACS

49. NSTE-ACS
DIAGNOSIS:
Clinical :
(1) it occurs at rest (or with minimal exertion),
lasting >10 minutes;
(2) it is of relatively recent onset (i.e., within the
prior 2 weeks); and/or
(3) it occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than
previous episodes)
NSTEMI - elevated levels of biomarkers of cardiac necrosis

50. NSTE-ACS
DIAGNOSIS:
3 major noninvasive tools are used in the
evaluation of NSTEMI-ACS:
1. the electrocardiogram (ECG),
2. cardiac biomarkers, and
3. stress testing
GOALS :
(1) recognize or exclude myocardial infarction (MI) using
cardiac biomarkers, preferably cTn;
(2) detect rest ischemia (using serial or continuous ECGs);
and
(3) detect significant coronary obstruction at rest with CCTA
and myocardial ischemia using stress testing

52. C
a
u
s
e
s
o
f
e
l
e
v
a
t
e
d
t
r
o
p
o
n
i
n

53. C
a
u
s
e
s
o
f
e
l
e
v
a
t
e
d
t
r
o
p
o
n
i
n

55. MEDICAL TREATMENT
• Bed rest
• Continuous ECG monitoring
• Ambulation only if
No recurrence of ischemia (symptoms or ECG changes)
Does not develop an elevation of a biomarker of necrosis for
12–24 h
ANTI-ISCHEMIC ANTITHROMBOTIC

56. NSTE-ACS
Drugs Commonly Used in Intensive Medical Management of
Patients with UA and NSTEMI

57. NSTE-ACS
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
antiplatelet drugs
anticoagulants.

60. NSTE-ACS
ORAL ANTIPLATELETS
Aspirin Initial dose of 325 mg nonenteric formulation followed by 75–100
mg/d of an enteric or a nonenteric formulation
Clopidogrel Loading dose of 300–600 mg followed by 75 mg/d
Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d
Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily
Intravenous Antiplatelet Therapy
Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 μg/ kg per min
(maximum 10 μg/min) for 12–24 h
Eptifibatide 180 μg/kg bolus followed 10 min later by second bolus of 180 μg
with infusion of 2.0 μg/kg per min for 72–96 h following first bolus
Tirofiban 5 μg/kg per min followed by infusion of 0.15 μg/kg per min for 48–
96 h

61. NSTE-ACS
HEPARINS
Unfractionated
heparin
(UFH)
Bolus 70–100 U/kg (maximum 5000 U) IV followed
by infusion of 12–15 U/kg per h (initial maximum
1000 U/h) titrated to ACT 250–300 s
Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded
by a 30-mg IV bolus; renal adjustment to
1 mg/kg once daily if creatine clearance <30 cc/min
Fondaparinux 2.5 mg SC qd
Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of
1.75 mg/kg per h.

62. NSTE-ACS
Class I Recommendations for Use of an Early Invasive
Strategy in Patients with Non-ST-Segment Elevation
Acute Coronary Syndrome:
Class I (Level of Evidence: A) Indications
1. Recurrent angina at rest/low-level activity despite treatment
2. Elevated TnT or TnI
3. New ST-segment depression
4. CHF symptoms, rales, MR
5. EF <0.40
6. Sustained VT
7. PCI <6 months, prior CABG
8. High-risk findings from noninvasive testing
9. Hemodynamic instability
10. Mild-to-moderate renal dysfunction
11. Diabetes mellitus
12. High TIMI Risk Score (>3)b

63. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
- syndrome of severe ischemic pain that usually occurs at rest and
is associated with transient ST segment elevation
- focal spasm of an epicardial coronary artery, leading to severe
transient myocardial ischemia and occasionally infarction
- may be related to hypercontractility of vascular smooth muscle
due to adrenergic vasoconstrictors, leukotrienes, or serotonin
- has decreased substantially during the past few decades
- PVA are generally younger and have fewer coronary risk factors
- The clinical diagnosis of PVA is made by the detection of
transient ST-segment elevation with rest pain
- Focal spasm is most common in the right coronary artery

64. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
Diagnosis:
Hyperventilation or intracoronary acetylcholine has been
used to provoke focal coronary stenosis on angiography or to
provoke rest angina with ST-segment elevation to establish the
diagnosis
TREATMENT
Nitrates and Calcium Channel Blockers
Aspirin- may actually increase the severity of ischemic
episodes
PROGNOSIS
1. Survival at 5 years is excellent (∼90–95%)
2. Nonfatal MI occurs in up to 20% of patients by 5 years
3. There is a tendency for symptoms
4. and cardiac events to diminish over time

65. NSTE-ACS
CORONARY ANGIOGRAPHY
IS NOT RECOMMENDED in patients with
• extensive co-morbidities (e.g., liver or pulmonary
failure; cancer);
• in whom the risks of revascularization are not likely to
outweigh the benefits;
• in patients with acute chest pain and a low likelihood
of ACS;
• or in patients who will not consent to
revascularization regardless of the findings.

66. NSTE-ACS
Revascularization by PCI
PCI IS RECOMMENDED for NSTE-ACS patients with
1- to 2-vessel CAD, with or without significant proximal
left anterior descending CAD, but with a large area of
viable myocardium and high-risk criteria on
noninvasive testing.

67. NSTE-ACS
Revascularization by CABG Surgery
CABG IS RECOMMENDED for patients with
1. significant left main disease, and is the
preferred revascularization strategy for
patients with
2. multi-vessel coronary disease;
3. vessels with lesions not favorable for PCI;
4. depressed systolic function (LVEF lower than
50%); and diabetes.

68. NSTE-ACS
Drug/Medication Management
Strongly RECOMMENDED for patients with
1. aspirin indefinitely, and ticagrelor 90 mg twice daily
or clopidogrel 75 mg daily, for 12 months
2. underwent stenting, with aspirin indefinitely, plus
ticagrelor 90 mg twice daily or prasugrel 10 mg
daily or clopidogrel 75 mg daily, for 12 months in
patients with drug-eluting stents, and 6 months in
patients with bare metal stents
3. beta blockers be continued indefinitely for all NSTE-
ACS patients unless contraindicated

69. ST-Segment Elevation
Myocardial Infarction
(STEMI)

70. ACUTE CORONARY SYNDROME

71. ACUTE CORONARY SYNDROME

72. STEMI
Criteria for Acute Myocardial Infarction
• Detection of a rise and/or fall of cardiac biomarker values
(preferably cardiac troponin [cTn]) with at least one value
above the 99th percentile upper reference limit (URL) and
with at least one of the following:
• Symptoms of ischemia
• New or presumed new significant ST-segment T-wave (ST-T) changes or
new left bundle branch block (LBBB)
• Development of pathologic Q waves in the electrocardiogram (ECG)
• Imaging evidence of new loss of viable myocardium or new regional wall
motion abnormality
• Identification of an intracoronary thrombus by angiography or autopsy
• Cardiac death with symptoms suggestive of myocardial ischemia and
presumed new ischemic ECG changes of new LBBB, but death occurred
before cardiac biomarkers were obtained or before cardiac biomarker values
would be increased.

73. STEMI
Criteria for Acute Myocardial Infarction
• Percutaneous coronary intervention (PCI)–related MI is arbitrarily defined by
elevation of cTn values (>5 × 99th percentile URL) in patients with normal baseline
values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are
elevated and are stable or falling. In addition, either
• Coronary artery bypass grafting (CABG)–related MI is arbitrarily defined by
elevation of cardiac biomarker values (>10 × 99th percentile URL) in patients with
normal baseline cTn values (≤99th percentile URL). In addition, either
(i) symptoms suggestive of myocardial ischemia, or
(ii) new ischemic ECG changes, or
(iii) angiographic findings consistent with a procedural complication, or
(iv) imaging demonstration of new loss of viable myocardium or new regional wall motion
abnormality are required.
• Stent thrombosis associated with MI when detected by coronary angiography or
autopsy in the setting of myocardial ischemia and with a rise and/ or fall of cardiac
biomarker values with at least one value above the 99th percentile URL.
(i) new pathologic Q waves or new LBBB, or
(ii) angiographic documented new graft or new native coronary artery occlusion, or
(iii) imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality.

74. STEMI
Classification of Myocardial Infarction
Type I: Spontaneous Myocardial Infarction
Type 2: Myocardial Infarction Secondary to an Ischemic
Imbalance
Type 3: Myocardial Infarction Resulting in Death When
Biomarker Values Are Unavailable
Type 4a: Myocardial Infarction Related to Percutaneous
Coronary Intervention (PCI)
Type 4b: Myocardial Infarction Related to Stent Thrombosis
Type 5: Myocardial Infarction Related to Coronary Artery
Bypass Grafting (CABG

75. STEMI
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
Antiplatelet drugs
Anticoagulants
FIBRINOLYSIS

76. STEMI
the goals for the management of patients with suspected
STEMI include:
1. control of cardiac discomfort,
2. rapid identification of patients who are candidates for
urgent reperfusion therapy,
3. triage of lower-risk patients to the appropriate location
in the hospital, and
4. avoidance of inappropriate discharge of patients with
STEMI
MANAGEMENT IN THE EMERGENCY DEPARTMENT
Aspirin
is essential in the management of patients with suspected STEMI and is effective across
the entire spectrum of acute coronary syndromes
OXYGEN
O2 should be administered by nasal prongs or face mask (2–4 L/min) for
the first 6–12 h after infarction

77. STEMI
1) Sublingual nitroglycerin
Up to three doses of 0.4 mg should be administered at about 5-min intervals
2) Morphine
3) Intravenous beta blockers/ Oral Beta blockers
CONTROL OF DISCOMFORT
in the first 24 h for patients who do not
have any of the following:
(1) signs of heart failure,
(2) evidence of a low-output state,
(3) increased risk for cardiogenic shock, or
(4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds,
second- or third-degree heart block, active asthma, or reactive airway disease).
Fifteen minutes after the last intravenous dose, an oral
regimen is initiated of 50 mg every 6 h for 48 h, followed by 100
mg every 12 h

78. STEMI

79. STEMI
Initial ER Management
• Aspirin 160 to 320 mg tablet (non-enteric coated, chewed);
• Clopidogrel 300 to 600 mg whether or not fibrinolysis will be
given;
• Clopidgrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when
a patient will undergo PCI;
• Nitrates, either via sublingual or intravenous(IV) routes. Nitrates
are contraindicated in patients with hypotension or those who
took a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs
for tadalafil);
• Morphine 2 to 4 mg IV for relief of chest pain, and;
• Supplemental oxygen MAY BE RECOMMENDED during the first 6
hours to patients with arterial oxygen saturation of less than 90%.

80. STEMI
In-hospital Treatment
Reperfusion therapy IS RECOMMENDED to all eligible
patients with STEMI with symptom onset within the
prior 12 hours.
Early revascularization, the goal being 12 hours, is a
primary treatment goal in patients with STEMI

81. STEMI

82. STEMI
Fibrinolysis
15-mg bolus followed byTPA
• 50 mg intravenously over the first 30 min,
• followed by 35 mg over the next 60 min
1.5 million units (MU) intravenously over 1 hStreptokinase
given as a single weight-based intravenous bolus
of 0.53 mg/kg over 10 s
Tenecteplase
(TNK)
double-bolus regimen consisting of a 10-MU
bolus given over 2–3 min, followed byReteplase (rPA)
• second 10-MU bolus 30 min later

83. STEMI

84. STEMI

85. STEMI
TIMI FLOW GRADE — The degree of perfusion in the
infarct-related artery (IRA) is typically described by the TIMI
flow grade:
●TIMI 0 refers to the absence of antegrade flow beyond a
coronary occlusion.
●TIMI 1 flow is faint antegrade coronary flow beyond the
occlusion, although filling of the distal coronary bed is
incomplete.
●TIMI 2 flow is delayed or sluggish antegrade flow with
complete filling of the distal territory.
●TIMI 3 flow is normal flow which fills the distal coronary
bed completely.
TIMI

86. STEMI
Primary Percutaneous Coronary
Intervention (PCI)
1. RECOMMENDED in patients with STEMI and ischemic
symptoms of less than 12 hours’ duration
2. RECOMMENDED in patients with STEMI and ischemic
symptoms of less than 12 hours’ duration who have
contraindications to fibrinolytic therapy, irrespective of
the time delay from first medical contact.
3. RECOMMENDED in patients with STEMI and cardiogenic
shock or acute severe heart failure (HF), irrespective of
time delay from MI onset
4. MAY BE RECOMMENDED in patients with STEMI if there is
clinical and/or ECG evidence of ongoing ischemia between
12 and 24 hours after symptom onset

87. STEMI
Coronary Artery Bypass Grafting (CABG)
1. IS RECOMMENDED in failed PCI with persistent pain or
hemodynamic instability in patients with coronary anatomy
suitable for surgery
2. IS RECOMMENDED in persistent or recurrent ischemia
refractory to medical therapy in patients who have coronary
anatomy suitable for surgery, and are not candidates for PCI
or fibronolytic therapy
3. RECOMMENDED in patients with STEMI at the time of
operative repair of mechanical defects.

88. STEMI
Antiplatelets and Antithrombotics
1. It IS RECOMMENDED that aspirin should be used
indefinitely in all patients with STEMI with a dosage of 80 to
100 mg/day.
2. It IS RECOMMENDED that clopidogrel 75 mg per day orally
should be added to aspirin in patients with STEMI and
maintained for at least 14 days
3. It IS RECOMMENDED that patients who are truly intolerant
to aspirin can instead receive clopidogrel 75 mg per day as
long-term secondary prevention

89. STEMI
Duration of Dual Antiplatelet Therapy and Antithrombotic
Combination Therapies after STEMI
1. Combination Therapies after STEMI DAPT by combining
aspirin and an ADP-receptor blocker (clopidogrel, prasugrel
or ticagrelor) IS RECOMMENDED in patients with STEMI
who are undergoing primary PCI (for up to 12 months) or
(clopidogrel) fibrinolysis (for up to 12 months, although the
data available pertain only to one month of DAPT), and in
those who have not undergone reperfusion therapy (for at
least 1 month and up to 12 months).

90. STEMI
Lipid Lowering Agents
1. High-dose statins are RECOMMENDED in all patients during
the first 24 hours of admission for STEMI, irrespective of the
patient’s cholesterol concentration, in the absence of
contraindications (allergy, active liver disease).
2. Atorvastatin or Rosuvastatin are recommended during the
early phase of therapy up to at least four weeks.
3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to
40 mg) or atorvastatin (40 to 80 mg) therapy before
emergency percutaneous coronary intervention to
1. reduce periprocedural inflammatory response,
2. to reduce myocardial dysfunction, and
3. to prevent contrast-induced nephropathy

91. THANK YOU

92. ACUTE CORONARY SYNDROME

94. STABLE ISCHEMIC HEART DISEASE
Recommended:
Echocardiography
Ambulatory ECG Monitoring

95. Ischemic Heart Disease

96. Ischemic Heart Disease

97. STABLE ISCHEMIC HEART DISEASE

98. STABLE ISCHEMIC HEART DISEASE

99. STABLE ISCHEMIC HEART DISEASE

100. ACUTE CORONARY SYNDROME

101. ACUTE CORONARY SYNDROME
RISK FACTORS

102. STEMI

103. STEMI

104. ACUTE CORONARY SYNDROME
Definition of Myocardial Infarction

105. ACUTE CORONARY SYNDROME
Classification of Myocardial Infarction