Acute coronary syndrome

Patsadee Nachom MD
Jonathan Abrams. N Engl J Med 2005;352:2524-33
 ACS vs stable IHD
Both have “angina” = retrosternal pressure w
hich may radiate to arm or jaw

ACS (STEMI & NSTE-ACS)

• Onset & duration
– Prolonged (>20 min) angin
al pain at rest : 80% of cas
e
– New onset angina CCS II o
r III (1 month)
– Increasing angina CCS III
– Post-MI angina
Stable IHD
• “Typical angina”
• Associated symptoms (su 1)Substernal chest discomfort
2) Provoked by exertion or emoti
ggest MI) : Diaphoresis, n onal stress and
ausea, abdominal pain, d 3) Relieved by rest or NTG (withi
yspnea n 5-10 min).
 Approach to chest pain
• R/O Life threatening condition
– Acute coronary syndrome
– Pulmonary embolism
– Aortic dissection
– Other : tension pneumothorax, esophageal rupture
• Using sensitive tools (symptoms , signs , lab) to
R/O
 Angina equivalent / atypical presentation

• Absence of angina BUT

– Shortness of breath
– Arm /Jaw/ epigastric pain (dyspepsia)
– Diaphoresis, nausea/vomiting
• Chest pain with stabbing /pleuritc feature

• In older patient (>75 years), women, DM,

CRF, dementia.
 Definition of myocardial infarction
= evidence of myocardial necrosis in clinical
setting consistent with acute MI

Detection of a rise and/or fall of cardiac biomarker values [

preferably cTn)] with at least one value above the 99th
percentile URL + at least one of :
• Symptoms of ischaemia.
• New or presumed new significant ST–T changes or new LBBB
• Development of pathological Q waves in the ECG.
• Imaging evidence of new loss of viable myocardium or new RWMA.
• Identification of an intracoronary thrombus by CAG or autopsy.

3rd universal definition of myocardial infarction ESC/ACCF/AHA/WHF 2012

 Universal classification of MI
• Type 1: Spontaneous MI
• Type 2: MI secondary to an ischaemi
c imbalance
• Type 3: MI resulting in death when bi
omarker values are unavailable
• Type 4a: MI related to percutaneous
coronary intervention (PCI)
• Type 4b: MI related to stent thrombo
sis
• Type 5: MI related to coronary artery
bypass grafting (CABG)
Laboratory
 High sensitivity-cardiac Troponin (hs-cTn)

Definition : Assay for cTn measurement

• in the single digit range of ng/L (=picogram/mL)
• with CV (coefficient of variation) <10% at 99th percentile (URL) of re
ference subject

European Heart Journal doi:10.1093/eurheartj/ehs154

 Rapid early rule-in AMI with hs-TnT
(not for STEMI !)

= Increase hs-TnT> 7 ng/L (50% of 14)

(eg. From 10 => 17) Need 20% change
(eg. From 20 =>24ng/L)

European Heart Journal doi:10.1093/eurheartj/ehs154

Differential diagnosis
If low pretest probability for A
CS but TnT +ve  w/u oth
er cause

European Heart Journal doi:10.1093/eurheartj/ehs154

 STEMI

EKG in STEMI
Fibrinolytic Rx & Pharmacoinvasive strategy
AMI complication
LV aneurysm
 LBBB (not known to be old): Sgarb
ossa’s criteria
LBBB alone  acute MI (need clinical setting)

Repolarization pattern Acute MI

ST elevation (in absence of LVH and LBBB)

• New ST elevation at J point i

n 2 contiguous leads
– Cut-points:  0.1 mV in all lea
ds other than V2-V3
– In V2-V3 :

 0.2 mV in men ( 0.25mv if a

ge< 40 years),
 0.15 mV in women
• STE > 20 min + clinical = ST
EMI
 Hyperacute T-wave
• DDx from hyperkalemia (which show no QT prolong)
• Should F/U EKG 5-10 minute apart if not sure
 STE in other condition

Normal (male pattern)

Early repolarization

STE of normal variant

N Engl J Med 2003;349:2128-35.

 Pericarditis AMI

DDx S
TE

LVH LBBB HyperK Brugada

N Engl J Med 2003;349:2128-35.
Time is myocardium
fibrinolysis

Harm!

PCI
Fibrinolytic Rx
•  Death 10%  8% (I
SIS-2)
• In-hospital death 5-6
%
• NNT 20-100 ,RRR 15-
20%
• ICH ~ 0.6 -1% (usuall
y occur in first 24 hr)
but half will death if oc
cur
Adjunctive anti-platelet & anti-
coagulation for fibrinolytic Rx

2013 ACCF/AHA STEMI guideline

Adjunctive anti-platelet & anti-coagulati
on for fibrinolytic Rx
• Start within 30 minute after initiate fibrinolytic Rx
 Assessment of reperfusion after fibrinolysis
Reliability : STE resolution > relief of chest pain

EKG : resolution at least 50% in the worst lead at 60 – 90 minutes aft

er initiate fibrinolysis
 Medication
• Oral beta blocker :should be initiated in first 24 hr if DO NOT have any of:
– HF
– Evidence of low output state
– Increase risk for cardiogenic shock : age > 70 years, SBP < 120 mmHg, presenti
ng HR > 110 bpm
– C/I : PR > 0.24 sec, 2-3 heart block, reactive airway disease
 Reevaluate for initiate beta-blocker after stable

• Statin : High intensity statin Rx (Atorvastatin 80/40 mg daily)  keep LDL <
70 mg/dL in long term

• ACEI (ARB if ACEI intolerant) : (class IIa)

– if LVEF  40%, anterior MI, HF (class I)

• Aldosterone antagonist if LVEF  40% + either symptomatic HF or DM

Complication after STEMI
Cardiogenic shock
RV infarction
Mechanical complication :
Electrical complication
Pericarditis
 Cardiogenic shock
• Loss > 40% LV myocardial Killip classification
• Frank pulmonary edema wit
h hypoperfusion , SBP < 90
mmHg
• CI <2.2 L/min/sq.m., PCWP
> 18 mmHg,

Rx
• Revascularization
• Inotrope
• IABP
Intra-aortic balloon counterpulsatio
n
 Inferior MI with RV infarct
• BP drop after NGT with lung clear, high JVP
• STE  1mm in V1, V3r & V4r ( most sensitive)
• Rx : Reperfusion :NSS load  inotropic drug  cardiov
ersion if AF  IABP
All need
surgical
repair
 Inferior wall MI with HF
• DDx :
– Mechanical complication : Papillary muscle ru
pture, VSR
– On top pre-existing LV systolic dysfunction
– Severe multi-vessel CAD
– Bradycardia / VT
Electrical complication :ventricul
ar arrhythmia
• Sustained VT/VF (5-10% of AMI case)
– 90% occur in first 48 hr
– Rx : cardioversion / defibrillation
– Prevention : correction of electrolyte & acid/base, HF ,
shock, decrease inotrope
• early beta-blocker (within 24 hr) if no C/I

• NSVT / PVC :
– no need to Rx (prophylaxis lidocaine is harmful !)
– Correction of electrolyte (K 4.5, Mg 2),
Stress induce cardiomyopathy (Takotsu
bo, broken heart syndrome
• Catecholamine exce
ss state
• Post-menopausal wo
men
• Ischemic like chest p
ain / HF
• ECG : anterior preco
rdial STE
• Low peak TnT level (
but high BNP)
• Dx by R/O (CAG)
 NSTE-ACS
(unstable angina & NSTEMI)
 Likelihood of ACS
Clinical presentation

Lab
Known CAD EKG :
•dynamic ST change
/ CAD risks •Marked (3 mm) inverted-T
in multiple precordial lead
TnT : rising /falling
 Likelihood of ACS
High likelihood
• Known coronary disease (
particularly recent PCI)  Intermediate likelihood 
• Typical angina reproducin Absence of high-likelihood Low likelihood   
g prior documented angin features + any of : Absence of high- & i
a   • Typical angina in a patient ntermediate-likel
• Hemodynamic or ECG ch ihood features b
anges during pain   without prior documented ut may have:  
• Dynamic ST-segment ele angina     • Chest discomfort
vation or depression of ≥1 • Atypical anginal symptoms in reproduced by p
mm   alpation  
diabetics or in nondiabetics • T waves flat or i
• Marked symmetric T-wav with  2 other risk factors    
e inversion in multiple pre nverted <1 mm  
cordial leads   • Male gender  /  Age > 70 y     • Normal ECG
• Elevated cardiac enzyme • Extracardiac vascular Dz    
s in a rising and falling pat • ST depression 0.5-1.0 mm or
tern
inverted-T of ≥1 mm    
• Low-level Tn elevation that is
"flat" and does not rise or fall

Hurst’s the heart 13th edition

TIMI risk score
• All cause mortality, new o
r recurrent MI, urgent rev
ascularization at 14 days
GRACE risk sco
re
Recommendation for invasive evaluatio
n (CAG) and revascularization

Urgent • Refractory angina with associated heart failure,

life-threatening ventricular arrhythmia or
(<2h) hemodynamic instability

Early • Grace score > 140 (in-hospital death >3%)

• Relevant rise or fall in troponin

(<24h) • Dynamic ST or T wave change (symptomatic or

silent

Invasive • Recurrent symptom

• Other high risk : DM, eGFR < 60, LVEF <40%,

strategy early post MI angina, recent PCI, prior CABG,

GRACE score 109-140
 NSTE-ACS management
Antiplatelet • ASA 300 mg  75-100 mg daily
(both of) • Clopidogrel : 300 mg loading 75 mg daily dose

Anticoagula • Fondaparinux 2.5 mg sc OD (least bleeding) C/I if cr

nt <20mL/min
• Enoxaparin 1mg/kg twice daily ( OD if CrCl <30)
3-8 days • UFH : bolus 60 IU/kg (max 5000 IU)  12 IU/kg/hr titrate to
(Any of) keep aPTT 50-70ms (1.5-2.5 ratio) max 1000 IU/h

• NTG, MO, O2
• Beta-blocker
Other • ACE-I / ARB
• Statin