INTRODUCTION

PATHOPHYSIOLOGY


APPROACH TO SUSPECTED
ACUTE CORONARY SYNDROME


MANAGEMENT UPDATE
Coronary Artery Disease leading cause of morbidity & mortality.
Although decrease in cardiovascular mortality still major cause of
morbidity & burden of disease.


CAD is a continuum of disease.

Angina -> unstable angina -> AMI -> sudden cardiac death

Acute coronary syndrome : unstable angina, NSTEMI, STEMI

Stable angina transient episodic chest pain to myocardial
ischaemia, reproducible, frequency constant over time.usually
relieved with rest/ NTG.


CLASS 1
NO PAIN WITH ORDINARY PHYSICAL ACTIVITY
CLASS 2
SLIGHT LIMITATION OF PHYSICAL ACTIVITY
PAIN OCCURS WITH WALKING, CLIMBING
STAIRS,STRESS
CLASS 3
SEVERE LIMITATION OF DAILY ACTIVITY PAIN
OCCURS ON MINIMAL EXERTION
CLASS 4
UNABLE TO CONDUCT ANY ACTIVITY WITHOUT
PAIN, PAIN AT REST

Pain occurring at rest duration > 20 min, within one week of first visit
New onset angina ~ Class 2 severity, onset with last 2 months
Worsening of chest pain increase by at least 1 class, increases in
frequency, duration
Angina becoming resistance to drugs that previously gave good control.

NB! ECG normal, ST depression(>0.5mm), T wave changes

ECC/ACC DEFN rise and fall in cardiac enzymes with one or more of
the following:
Ischaemic type chest pain/symptoms
ECG changes ST changes, pathological Q waves
Coronary artery intervention data
Pathological findings of an acute MI

NSTEMI =
UNSTABLE ANGINA SYMPTOMS + POSITIVE CARDIAC ENZYMES

STEMI = ST ELEVATION ON ECG + SYMPTOMS
WHY IS IT IMPORTANT TO RECOGNISE
PATIENTS WITH UNSTABLE ANGINA??

5 -17% suffer an MI within a week after admission.
3 -15% die within a year.
Identifying those with chest pain suggestive of IHD/ACS.
Thorough history required:
Character of pain
Onset and duration
Location and radiation
Aggravating and relieving factors
Autonomic symptoms

TYPICAL VS ATYPICAL HISTORY
Failure to recognise symptoms other than chest pain -> approx 2 hr delay
in seeking medical attention
CHARACTERISTIC SUGGESTIVE OF ANGINA LESS SUGGESTIVE OF
ANGINA
TYPE OF PAIN DULL
PRESSURE/CRUSHING
PAIN
SHARP/STABBING
DURATION 2-5 MIN, <20 MIN SECONDSTO
HOURS/CONTINUOUS
ONSET GRADUAL RAPID
LOCATION/CHEST WALL
TENDERNESS
SUBSTERNAL, NOT
TENDER TO PALP.
LATERAL CHEST
WALL/TENDER TO PALP.
REPRODUCIBALITY WITH
EXERTION/ACTIVITY
WITH
BREATHING/MOVING
AUTONOMIC SYMPTOMS PRESENT USUALLY ABSENT
RISK FACTORS FOR DEVELOPING ATYPICAL PAIN:

Diabetes, females, non white patients, elderly, dementia, no prior history of MI

ATYPICAL SYMPTOMS:
GIT symptoms
Syncope
SOB
Pleuritic/positional pain
Chest wall tenderness
No chest pain/symptoms

NRMI 2 STUDY MI without chest pain -> increased risk of death (23% vs 9%)
More complications hypotension,heart failure, stroke
Delayed ED presentation, delayed intervention

First point of entry into ACS algorithm

Abnormal or normal

Neither 100% sensitive or 100% specific for AMI

Single ECG for AMI sensitivity of 60%, specificity 90%

Represents single point in time needs to be read in context

Normal ECG does not exclude ACS 1-6% proven to have AMI, 4%
unstable angina
GUIDELINES:
Initial 12 lead ECG goal door to ECG time 10min, read by experienced
doctor (Class 1 B)
If ECG not diagnostic/high suspicion of ACS serial ECGs initially 15 -30
min intervals (Class 1 B)

ECG adjuncts leads V7 V9, RV 4 (Class 2a B)

Continuous 12 lead ECG monitoring reasonable alternative to serial ECGs
(Class 2a B)
Mortality at 42 days in troponin positive patients
Rapid release within 2 hours

Not cardiac specific

Rule out for NSTEMI rather than rule in.


CKMB
Used in conjunction with troponins
Useful in diagnosing re-infarction
2 hour delta CKMB mass

Aim to exclude MI within 6hrs of symptom onset

Determine changes in serum marker levels over certain time intervals
delta values

Increasing values while still within normal range suggestive of ischaemia
more rapid anti- ischaemic mxn.
2007ACS/AHA GUIDELINES:
Rapid catergorisation of patient (Class 1 C)

Possible ACS, non diagnostic ECG/biomarkers observed in facility with
cardiac monitoring (Class 1 C)

Alternative to in patient treatment: for those with 12hr ECG/markers
negative stress ECG in 72hrs (Class 1 C)

Giving precautionary treatment for those for OPD stress (Class 1 B)

CLASS 1 RECOMMENDATIONS:
Early invasive strategy for refractory angina, hemodynamic instability
(LOE B)
Early invasive strategy for stabilised patients with elevated risk for
clinical events.
High risk factors include:
Recurrent angina, ischaemia at rest or minimal activity
Elevated troponins
New ST depression
Signs of heart failure/worsening mitral regurg.
Ventricular tachycardia
Prior CABG
PCI in last 6 months
High TIMI/GRACE scores
LVEF < 40%
GENERAL:

IV B Blockers downgraded from Class 1 to 2a recommendation. (COMMIT
Trial)

Oral B Blockers in first 24hrs still Class 1 but not used in signs of heart
failure, cardiogenic shock and reactive airway disease.(LOE B)

MORPHINE downgraded from Class 1 to 2a findings from CRUSADE
Registry
ANTIPLATELET THERAPY:
CLASS 1 RECOMMENDATION
Aspirin to all patients as soon as possible and continued (if no C/I) (LOE A)
Initial dose 162 -325mg
Maintenance 75 -162mg
No added benefit from higher doses except post stenting

Clopidogrel for those allergic to aspirin or major GI bleeding (LOE A)

For initial invasive strategy aspirin + clopidogrel or IV glycoprotein 2b/3a
therapy (LOE A)
Abciximab if no delay in angiography/PCI, eptifibatide/tirofiban if delayed
angiography(LOE B)


CLASS 2a
In patients managed conservatively who develop recurrent ischaemia
on clopidogrel/ASA/Anticoagulant can add glycoprotein inhibitor. (LOE
C)

Invasive strategy can use clopidogrel + glycoprotein inhibitors(LOE C)

CLASS 2b
In patients managed conservatively can add glycoprotein inhibitor
therapy, in addition to aspirin & anticoagulant (LOE B)


For initial conservative strategy:
Aspirin + Clopidogrel + anticoagulant administered for 1 month(LOE
A), continued ideally up to 1 year(LOE B)

If initial conservative strategy selected but patient has recurrent
ischaemic symptoms/heart failure/arrythmias diagnostic angiography
recommended. Clopidogrel or Glycoprotein 2b/3a inhibitors should be
added before angiography.
CLASS 1
Anticoagulant therapy should be added as soon as possible
For patients undergoing angiography/PCI enoxaparin/UFH (LOE A) of
Bivalirudin/ fondaparinux (LOE B)

For conservative strategy: enaxaparin, UFH (LOE A), fondaparinux

For patients with increased risk of bleeding with conservative strategy
fondaparinux

CLASS 2a
Enoxaparin /fondaparinux vs UFH

Enoxaparin/fondaparinux preferred except in those undergoing CABG
within 24hrs (LOE B)
STRESS TEST should be performed for those managed conservatively.
If stress test positive/ high risk needs diagnostic angiography(Class 1
LOE A)

If classed as low risk
need to continue aspirin indefinitely ( LOE A)
Clopidogrel for at least 1 month(LOE A), ideally up to 1 year(LOE B)

PHARMACOLOGICAL UPDATE:
ANALGESIA changes from 2004 guidelines

MORPHINE: still remains Class 1 C for STEMI, titrated doses

NSAIDS/COX 2 INHIBITORS: those on it should have it discontinued (
increased risk of mortality, re infarction, heart failure, myocardial
rupture) Class 1 C

NSAIDS should not be administered in hospital for MI (Class 3)


BETA BLOCKERS
Modified recommendation
Oral Beta Blockers should be initiated in first24rs, if no contra-indications
(heart failure, risk of cardiogenic shock) Class 1 B
Patients with early contraindications -> re- evaluated later for possible
use
Role of IV B blockers used in hypertensive patients with STEMI Class 2a
B
Class 3 LOE A IV B blockers should not be administrated to patients
with heart failure, risk of cardiogenic shock
AVAILABLE FIBRINOLYTICS:
STREPTOKINASE 1.5mu infusion over 30min (1hour ACLS)
rtPA accelerated infusion over 1.5hrs
- 15mg IV bolus, 0.75mg/kg over 30 min, 0.5mg/kg over 1hr
ANISTREPLASE 30 U IV over 5 min
TENECTEPLASE 30 TO 50 MG
RETEPLASE 10 U IV bolus, ffd. 10U IV after 30 min

WHICH FIBRINOLYTIC TO USE???
GISSI 2 trial tPA vs Streptokinase , no difference in mortality, marginally higher
stroke rate with tPA (1.3% vs 1%)
GUSTO 1 trial early vessel patency post infract assoc. with better survival.
Accl. tPA/heparin cf comb. Streptokinase/tPA/heprain cf strep with IV vs S/C
heparin
Outcome better flow rates with accl. tPA -> lower mortality rates
ASSENT 2 TRIAL tenecteplase vs aTPA
- tenecteplase was equally or minimally more effective,
especially in those presenting > 4hrs after symptom onset.

Fibrinolysis combined with glycoprotein 2b/3a inhibitors no overall
advantage (ASSENT 3, GUSTO 5 trials)
RESCUE PCI:
CLASS 1 LOE B angiography with +/- PCI in patients (<75 yrs)with
cardiogenic shock, severe heart failure, ventricular dysrythmias

Class 2a persistent ischaemic symptoms post fibrinolysis,
haemodynamic instability, electrical instability (LOE C)

New recommendation PCI for failed fibrinolytic therapy (less than 50%
decrease in ST elevation in worst lead, 90min post fibrinolytic therapy, or
large area of myocardium injured) LOE B

Class 3 angiography performed if invasive strategy contraindicated, or
patient refusal (LOE C)
NEW RECOMMENDATIONS:
CLASS 1
Patients undergoing fibrinolysis should be kept on anticoagulants for
atleast 48 hrs and preferably the duration of hospital stay. LOE A

Anti coagulants with proven efficacy:
Unfractionated Heparin - keeping aPTT 1.5 2 sec above control (LOE C)
Enoxaparin (Clexane) initial dosage of 30mg IV bolus ffd by 1mg/kg
12hrly, caution in renal impairment (LOE A)
Fondaparinux 2.5mg IV, ffd by 2.5mg dly S/C maintenance for duration
of hospitalisation (LOE B)

CLASS 2a recommendation to use anticoagulants in STEMI without
reperfusion :

UFH (LOE B)
LMWH (LOE C)
Fondaparinux (LOE B)
CLASS I
CLOPIDOGREL now recommended in all STEMI patients in addition to
aspirin, whether undergoing reperfusion or not. Dosage 75mg daily(LOE
A)
Duration -14 days (LOE B)

CLASS 2 A
In patients < 75yrs Clopidogrel 300mg loading dose recommended(LOE C)
Long term maintenance therapy should be considered, 75mg dly for 1 year
(LOE C)



INCREASED FOCUS ON SECONDARY PREVENTION:

SMOKING CESSATION

DIET MODIFICATION/WT CONTROL

BP CONTROL

LIPID MANAGEMENT

EXERCISE

DIABETES MANAGEMENT
Despite good reperfusion strategies approx. 1/3 of patients worldwide
miss out.
Attributed to delayed presentation, atypical presentation, complicated
disease presentation, older age

SYMPTOMS OF INFARCT BUT NO ESTABILISHED ECG CHANGES -
keep in mind aortic dissection, GIT disease, other chest pathology

With increase burden of CVD, and lack of health resources risk
stratification becomes important.

Emphasis should also be placed on primary &secondary prevention of
ACS.

Early intervention helps prevent complications, decreases morbidity &
mortality

The way forward fully equipped CHEST PAIN OBSERVATION UNIT