Transcript Slide 1
ACUTE CORONARY
SYNDROME
(ACS)
ACS
Pathophysiology is that of a ruptured or
eroded atheromatous plaque.
Acute Myocardial Infarction (AMI)
– ST-segment elevation MI (STEMI)
– Non-ST-segment elevation MI (NSTEMI)
Unstable Angina (UA)
Goals of Therapy in ACS
Reduce the amount of myocardial necrosis that
occurs in patients with MI, preserving left
ventricular function and preventing heart failure
Prevent major adverse cardiac events: death,
nonfatal MI, and need for urgent
revascularization
Treat acute, life threatening complications of
ACS, such as ventricular fibrillation/pulseless
ventricular tachycardia, symptomatic
bradycardias, and unstable tachycardias
Acute Coronary Syndromes Algorithm
Circulation 2005;112:IV-89-IV-110
Copyright ©2005 American Heart Association
Targeted History
Chest discomfort
– what, where, when & how much?
Associated Signs & symptoms
– dyspnea, diaphoresis, nausea
Prior cardiac history
– similar pain?
Risk Factors
Pertinent PmHx
EKG
ST-segment elevation or presumed new LBBB is
characterized by ST-segement elevation >1mm
in 2 or more contiguous precordial leads or 2 or
more adjacent limb leads and is classsified as
ST-elevation MI
Ischemic ST-segment depression> or = 0.5mm
or dynamic T-wave inversion with pain or
discomfort is classified as high-risk UA or
NSTEMI. Transient ST elevation of < 20 minutes
is also included within this catagory
Normal or nondiagnostic changes in ST
segment or T-waves are inconclusive and
require further risk stratification. This
includes patients with normal EKGs and
those with ST-segment deviation of <0.5
Cardiac Biomarkers
CK & CK-MB
– Rise 4-6 hours after injury
– Peak 12-24 hours after injury
– Return to baseline in 24-48 hours
Troponin – Most sensitive and specific
– Rises 4-6 hours after injury
– Peaks 18-24 hours after injury
– May take a week to return to baseline
Longer if poor renal function
Reperfusion
Ultimate goal in ACS and immediate goal
in STEMI
Shown to reduce mortality by 47%
Major determinants of myocardial salvage
and long term prognosis are
– Short time to perfusion
– Complete and sustained patency of the
infarcted artery with normal flow
– Normal microvascular perfusion
Percutaneous Coronary
Intervention (PCI)
Treatment of choice if can be performed
in <90 minutes from patient presentation
Goal should be <30 minutes from patient
presentation to either PCI, or transfer to
facility that performs PCI
Also preferred in patients with
contraindications to fibrinolysis and is
reasonable in patients with cardiogenic
shock or heart failure.
Fibrinolysis
Indicated for STEMI if <12 hours of symptoms
and PCI unable to be performed in <90 minutes
Goal is “door to needle” time of <30 minutes
Absolute contraindications include: prior
intercranial hemorrhage, AVM or malignant
neoplasm, ischemic stroke>3 hour
and<3months, suspected aortic dissection,
active bleeding or bleeding diathesis, significant
closed head or facial trauma < 3months
Acute Coronary Syndromes Algorithm
Circulation 2005;112:IV-89-IV-110
Copyright ©2005 American Heart Association