Unstable Angina and Non–ST Elevation Myocardial
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Transcript Unstable Angina and Non–ST Elevation Myocardial
UNSTABLE ANGINA AND
NON–ST ELEVATION
MYOCARDIAL INFARCTION
YEDITEPE UNIVERSITY FACULTY OF MEDICINE
PHASE 4 CARDIOLOGY COURSE 2014-2015
PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
MUSTAFA AYTEK SIMSEK, M.D., Attending Physician
PATHOPHYSIOLOGY OF ACS
EVOLUTION OF CORONARY
THROMBOSIS
CAUSES OF UA/NSTEMI
Thrombus or thromboembolism, usually arising on
disrupted or eroded plaque – Most Common Cause.
Dynamic obstruction – coronary spasm or
vasoconstriction
Progressive mechanical obstruction to coronary flow – ie
restenosis after PCI
Coronary arterial inflammation
Coronary artery dissection
Secondary UA – Increasing oxygen demands in the
setting of a fixed lesion.
CLINICAL INDICATORS OF INCREASED
RISK IN UA/NSTEMI
TIMI RISK SCORE
T: Troponin elevation (or CK-MB elevation)
H: History or CAD (>50% Stenosis)
R: Risk Factors: > 3 (HTN, Hyperlipidemia, Family Hx, DM II, Active Smoker)
E: EKG changes: ST elevation or depression 0.5 mm concordant leads
A2:Aspirin use within the past 7 days; Age over 65
T: Two or more episodes of CP within 2 hours
GRACE PREDICTION SCORE CARD
Medical History
1.
2.
3.
Findings at initial hospital presentation
4.
5.
Age in years (0-100 points)
History of congestive heart failure (24 points)
History of myocardial infarction (12 points)
6.
Resting heart rate (0-43 points)
Systolic blood pressure (0-24 points)
ST depression (11 points)
Findings during hospitalization
7.
8.
9.
Initial serum creatinine (1 to 20 points)
Elevated cardiac enzymes (15 points)
No in-hospital percutaneous coronary intervention (14
points)
JAMA 2004:291;2727-33
DECIDING BETWEEN EARLY INVASIVE VS A CONSERVATIVE
STRATEGIES
Definitive/Possible ACS
Initiate ASA, BB, Nitrates,
Anticoagulants, Telemetry
Early Invasive Strategy
• TIMI Risk Score >3
• New ST segment
deviation
• Positive biomarkers
Coronary angiography
(24-48 hours)
Conservative Strategy
•TIMI Risk Score <3 (Esp.
Women)
•No ST segment deviation
•Negative Biomarkers
Recurrent Signs/Symptoms
Heart failure
Arrhythmias
Remains Stable
↓
Assess EF and/or Stress Testing
↓
EF<40% OR Positive stress
Go to Angiography
GENERAL TREATMENT MEASURES
Antiplatelet Therapy
Anticoagulant Therapy
Control of Cardiac Pain
Analgesics
Nitrates
Beta Blockers
Oxygen
Limitation of Infarct Size
Early reperfusion
Reduction of myocardial energy demand
ANTIPLATELET THERAPY
Aspirin
162-325 mg, nonenteric-coated ASA to be chew
maintenance of 75-162 mg daily
ANTIPLATELET THERAPY
Clopidogrel 300 mg loading
75 mg/day
Prasugrel oral loading dose
of 60 mg and 10 mg orally
daily
Ticagrelor a loading dose of
180 mg and 90 mg twice
daily
ANTICOAGULANT THERAPY
Heparin activated partial
thromboplastin time (aPTT)
target of 1.5 to 2 times that
of control
Low-Molecular-Weight
Heparins
Fondaparinux
CONTROL OF CARDIAC PAIN
Analgesics
meperidine, pentazocine, and morphine
Morphine 2 to 8 mg/ 5 to 15 minutes --until the pain is relieved or
there is evident toxicity
Nitrates
sublingual nitrates, intravenous nitroglycerin
systolic pressure <90 mm Hg
right ventricular infarction
CONTROL OF CARDIAC PAIN
Beta Blockers
Killip class II or higher (precipitating cardiogenic shock)
Patients with heart failure (rales > 10 cm up from diaphragm),
hypotension (blood pressure < 90 mm Hg),
bradycardia (heart rate < 60 beats/min),
CONTROL OF CARDIAC PAIN
Oxygen
pulse oximetry
Sao2 < 90%
2 to 4 liters/min of 100% oxygen
6 to 12 hours
LIMITATION OF INFARCT SIZE
Early reperfusion
Routine Measures for Infarct Size Limitation
Beta blocker (HR 50-70)
Inhibitors of the renin-angiotensin-aldosterone
system (RAAS)
Arterial oxygenation
LIMITATION OF INFARCT SIZE
Angiotensin-converting enzyme (ACE) inhibitor
Start ACE inhibitor orally in patients with pulmonary
congestion or LVEF <40%
if the following are absent: hypotension (SBP <100 mm Hg or
<30 mm Hg below baseline) or known contraindications to
this class of medications.
Angiotensin receptor blocker (ARB)
Start ARB orally in patients who are intolerant of ACE
inhibitors and with either clinical or radiologic signs of heart
failure or LVEF <40%