Acute Coronary Syndrome

A C U TE C O R O N A R Y
S Y N D R O M ES
(ACS)
A 54-year-old man presents with 6 hours of acute

substernal chest pain. He has an ECG within the firs
t 10 minutes of arrival. He has 4 mm acute ST-seg
ment elevation in leadsV2V5. What is the America
n College of Cardiology (ACC) and American Heart
Association (AHA) recommended reperfusion strate
gy?
(A) Pain control then percutaneous coronary
intervention (PCI) once patient is pain free
(B) Primary PCI in<90 minutes
(C) Primary PCI in<120 minutes
(D) Thrombolysis in<90 minutes
(E) Thrombolysis in<120 minutes
Specialty board review Tintinalli Emergency medi
A 65-year-old male presents with 2 hours of chest

pain. He has ST elevations across his precordial lea
ds and is diagnosed with an AMI. He is given thromb
olytics in the ED. One hour after administration, he i
s still having chest pain and his BP is 80/60. The ne
xt best course of action would be
(A) Dopamine infusion
(B) Nitroglycerin drip
(C) Placement of an aortic balloonpump
(D) Repeat thrombolytic administration
(E) Rescue PCI
Specialty board review Tintinalli Emergency medi
PEER-8
PEER-8
PEER-8
PEER-8
PEER-8
O verview of A C S
Definition of terms
Pathogenesis
Initial evaluation and
management
D ef n
i ition O f Term s
Acute Coronary Syndrome
A spectrum of conditions compatible

with acute myocardial ischemia and/or
infarction that are usually due to an abr
upt reduction in coronary blood flow.
P athogenesis
Sudden imbalance between myocardial
oxygen consumption (MVO2) and deman
d
Coronary artery obstruction
Initial evaluation and m anagem ent

Class I
1. Patients with suspected ACS should be risk
stratified.(LOE: B)
2. Patients with suspected ACS and high-risk
features (chest pain, severe dyspnea, syncop
e/presyncope, or palpitations) should be refe
rred immediately to the ED and transported
by EMS. (LOE: C)
Class IIb
3. Patients with less severe symptoms may be
considered for. (LOE: C)
risk (0-5 points), medium risk (6-7) andhigh risk(>7 p
high risk(>3 points)
Risk Category
(tertiles)
GRACE
Risk Score
Probability of
Death
In-hospital
(%)
Low
1-108
109-140
141-372
<1
1-3
>3
Intermediate
High
(STEMI)
S T-ELEVATIO N
M Y O C A R D IA L IN FA R C TIO N
STEMI
1. Definition and Diagnosis
2. Onset of MI
3. Reperfusion at a PCI-Capable
Hospital
4. Reperfusion at a NonPCICapable Hospital
5. Delayed Invasive Management
6. Coronary Artery Bypass Graft
Surgery
7. Routine Medical Therapies
8. Complications After STEMI
9. Risk Assessment After STEMI
10. Posthospitalization Plan of Care
1. D ef n
i ition and D iagnosis
STEMI - characteristic symptoms
of myocardial ischemia in associatio
n with persistent electrocardiograph
ic ST elevation and subsequent rele
ase of biomarkers of myocardial nec
rosis.
1. D ef n
Diagnosis
New ST elevation at the J point in
at least 2 contiguous leads
2 mm (0.2 mV) in men or 1.5 mm

(0.15 mV) in women in leads V2V3
1 mm (0.1 mV) in other contiguous
chest leads or the limb leads
New LBBB
1. D ef n
The patients will evolve ECG evidence of Q-
wave infarction.
ST depression in 2 precordial leads (V1V4)
Transmural posterior injury
Multi-lead ST depression with coexistent ST
elevation in lead aVR LM or proximal Lt LA

D artery occlusion
Hyperacute T-wave changes may be
observed in the very early phase of STEMI, b

efore the development of ST elevation.
2. O nset of M I
Regional Systems of STEMI Care, Reperfusion
Therapy, and Time-to-Treatment Goals

Class I
1. All communities should create and maintain a regional

system of STEMI care that includes assessment and continuou
s quality improvement of EMS and hospital-based activities. (L
OE: B)
2. Performance of a 12-lead ECG by EMS personnel at the site
of first medical contact (FMC) is recommended. (LOE: B)
3. Reperfusion therapy should be administered to all eligible
patients with STEMI with symptom onset within the prior 12
hours. (LOE: A)
2. O nset of M I
Regional Systems of STEMI Care, Reperfusion
Therapy, and Time-to-Treatment Goals

Class I
4. Primary PCI is the recommended method of reperfusion.

(LOE: A)
5.EMS transport directly to a PCI-capable hospital for primary

PCI is the recommended triage strategy for patients with
STEMI. (LOE: B)
6. Immediate transfer to a PCI-capable hospital for primary PCI
is the recommended triage strategy for patients with STEMI
who initially arrive at or are transported to a nonPCI-capable
hospital, with an FMC-to-device time system goal of 120 minut
es or less. (LOE: B)
2. O nset of M I
Regional Systems of STEMI Care,
Reperfusion Therapy, and Time-to-Treatm

ent Goals
Class I
7. In the absence of contraindications, fibrinolytic therapy

should be administered to patients with STEMI at nonPCIcapable hospitals when the anticipated FMC-to-device tim
e at a PCI-capable hospital exceeds 120 minutes because
of unavoidable delays. (LOE: B)
8. When fibrinolytic therapy is indicated or chosen as the
primary reperfusion strategy, it should be administered wi
thin 30 minutes of hospital arrival. (LOE: B)
2. O nset of M I
Regional Systems of STEMI Care,
Reperfusion Therapy, and Time-to-Tr

eatment Goals
Class IIa
1. Reperfusion therapy is reasonable for patients

with STEMI and symptom onset within the prior 12 t
o 24 hours who have clinical and/or ECG evidence o
f ongoing ischemia. Primary PCI is the preferred. (L
OE: B)
R EPER FU SIO N TH ER A PY FO R STEM I
2. O nset of M I
Evaluation and Management of
Patients With STEMI and Out-ofHospital Cardiac Arrest

Class I
1. Therapeutic hypothermia should be started as

soon as possible in comatose patients with STEMI an
d OHCA caused by VF or VT, including patients who
undergo primary PCI. (LOE: B)
2. Immediate angiography and PCI when indicated
should be performed in resuscitated OHCA patients
whose initial ECG shows STEMI. (LOE: B)
3. R eperfusion at a P C I-C apable

Hospi
tal
Primary PCI In STEMI
3. R eperfusion at a PC I-C apable

H ospital
Aspiration Thrombectomy
Class IIa
1. Manual aspiration thrombectomy is reasonable

for patients undergoing primary PCI. (LOE: B)

H ospital
Use of Stents in Patients With STEMI
Class I
1. Placement of a stent (bare-metal stent [BMS] or drugeluting stent [DES]) is useful in primary PCI for patients with
STEMI. (LOE: A)
2. BMS should be used in patients with high bleeding risk,
inability to comply with 1 year of dual antiplatelet therapy
(DAPT), or anticipated invasive or surgical procedures in the
next 1 year. (LOE: C)
Class III: Harm
1. DES should not be used in primary PCI for patients with

STEMI who are unable to tolerate or comply with a prolonged
course of DAPT because of the increased risk of stent thromb
osis with premature discontinuation of one or both agents. (L
OE: B)

H ospital
Adjunctive Antithrombotic Therapy
for Primary PCI
4. R eperfusion at a N onP C I-C apable

H ospital
Fibrinolytic Therapy When There Is
an Anticipated Delay to Performing P

rimary PCI Within 120 Minutes of FMC

H ospital
Timing of Fibrinolytic Therapy
The benefits of fibrinolytic therapy in patients

with ST elevation or bundle-branch block MI are
well established, with a time-dependent reductio
n in both mortality and morbidity rates during th
e initial 12 hours after symptom onset.
Administering a fibrinolytic agent in
symptomatic patients presenting >12 hours after
symptom onset with STEMI and a large area of m
yocardium at risk or hemodynamic instability if P
CI is unavailable.

H ospital
Choice of Fibrinolytic Agent

H ospital
Contraindications and Complications
With Fibrinolytic Therapy

H ospital
Adjunctive Antithrombotic Therapy
With Fibrinolysis

H ospital
Assessment of Reperfusion After
Fibrinolysis
Relief of chest pain

Resolution of ST elevation at 60-90
minutes after fibrinolytic therapy
Presence of reperfusion arrhythmias (eg.
Idioventricular rhythm)

H ospital
Transfer of Patients With STEMI to a
PCI-Capable Hospital for Coronary An

giography After Fibrinolytic Therapy
5. D elayed Invasive M anagem ent

Coronary Angiography in Patients
Who Initially Were Managed With Fibr

inolytic Therapy or Who Did Not Recei
ve Reperfusion

PCI of an Infarct Artery in Patients
Who Initially Were Managed With Fibr

inolysis or Who Did Not Receive Repe
rfusion Therapy

PCI of a Noninfarct Artery Before
Hospital Discharge
Class I
1. PCI is indicated in a noninfarct artery at a time

separate from primary PCI in patients who have spont
aneous symptoms of myocardial ischemia. (LOE: C)
Class IIa
1. PCI is reasonable in a noninfarct artery at a time

separate from primary PCI in patients with intermediat
e-or high-risk findings on noninvasive testing. (LOE: B)

Adjunctive Antithrombotic Therapy to
Support Delayed PCI After

Fibrinolytic Therapy
6. C oronary A rtery B ypass G raft

Surgery
CABG in Patients With STEMI
Class I
1. Urgent CABG is indicated in patients with

STEMI and coronary anatomy not amenable t
o PCI who have ongoing or recurrent ischemia
, cardiogenic shock, severe HF, or other highrisk features. (LOE: B)
2. CABG is recommended in patients with
STEMI at time of operative repair of mechanic
al defects. (LOE: B)

Surgery
CABG in Patients With STEMI
Class IIa
1. The use of mechanical circulatory support is

reasonable in patients with STEMI who are hemodyn
amically unstable and require urgent CABG. (LOE: C)
Class IIb
1. Emergency CABG within 6 hours of symptom

onset may be considered in patients with STEMI who
do not have cardiogenic shock and are not candidat
es for PCI or fibrinolytic therapy. (LOE: C)

Surgery
Timing of Urgent CABG in Patients With
STEMI in Relation to Use of Antiplatelet Ag

ents
Class I
1. Aspirin should not be withheld before urgent CABG.

(LOE: C)
2. Clopidogrel or ticagrelor should be discontinued at least
24 hours before urgent on-pump CABG, if possible. (LOE: B)
3. Short-acting intravenous GP IIb/IIIa receptor antagonists
(eptifibatide, tirofiban) should be discontinued at least 2 to
4 hours before urgent CABG (LOE: B)
4. Abciximab should be discontinued at least 12 hours
before urgent CABG. (LOE: B)

Surgery
Timing of Urgent CABG in Patients
With STEMI in Relation to Use of Antipl

atelet Agents
Class IIb
1. Urgent off-pump CABG within 24 hours of

clopidogrel or ticagrelor administration might be cons
idered, especially if the benefits of prompt revascular
ization outweigh the risks of bleeding. (LOE: B)
2. Urgent CABG within 5 days of clopidogrel or
ticagrelor administration or within 7 days of prasugrel
administration might be considered, especially if the
benefits of prompt revascularization outweigh the ris
ks of bleeding. (LOE: C)
7. R outine M edical Therapies
8. C om plications A fter STEM I

8.1 Cardiogenic shock
Class I
1. Emergency revascularization with either PCI or

CABG is recommended in suitable patients with cardi
ogenic shock due to pump failure after STEMI irrespec
tive of the time delay from MI onset. (LOE: B)
2. In the absence of contraindications, fibrinolytic
therapy should be administered to patients with STE
MI and cardiogenic shock who are unsuitable candida
tes for either PCI or CABG. (LOE: B)

8.1 Cardiogenic shock
Class IIa
1. The use of intra-aortic balloon pump (IABP) counterpulsation can be useful for patients with cardiogenic s
hock after STEMI who do not quickly stabilize with phar
macological therapy. (LOE: B)
Class IIb
1. Alternative LV assist devices for circulatory support

may be considered in patients with refractory cardioge
nic shock. (LOE: C)

8.2 Severe HF
Indication for angiography

Medical treatment diuretics, vasodilators, and
inotropic agents then add Inhibitors of the reninangiotensin aldosterone system and beta-blocke
r
8.3 RV infarction
Complicates in patients with inferior STEMI

most often due to proximal occlusion of the RCA
higher mortality risk

8.4 mechanical complication
Most occur in the first 24 hours, and the
remainder present within the first week

Mitral Regurgitation
Ventricular Septal Rupture
LV Free-wall Rupture
LV Aneurysm

8.5 Electrical Complications During
the Hospital Phase of STEMI

Ventricular Arrhythmias
Class I
1. Implantable cardioverter-defibrillator (ICD)

therapy is indicated before discharge in patie
nts who develop sustained VT/VF more than 4
8 hours after STEMI, provided the arrhythmia i
s not due to transient or reversible ischemia, r
einfarction, or metabolic abnormalities. (LOE:
B)

8.5 Electrical Complications During
the Hospital Phase of STEMI
AF and Other Supraventricular
Tachyarrhythmias
Bradycardia, AV Block, and
Intraventricular Conduction Defects
Class I
1. Temporary pacing is indicated for symptomatic

bradyarrhythmias unresponsive to medical treatm
ent. (LOE: C)

8.6 Pericarditis
Class I
1. Aspirin is recommended for treatment of pericarditis after

STEMI. (LOE: B)
Class IIb
1. Administration of acetaminophen, colchicine, or narcotic

analgesics may be reasonable if aspirin, even in higher
doses, is not effective. (LOE: C)
Class III: Harm
1. Glucocorticoids and nonsteroidal anti-inflammatory drugs

are potentially harmful for treatment of pericarditis after
STEMI. (LOE: B)

8.7 Thromboembolic and Bleeding
Complications
Anticoagulation
Class I
1. Anticoagulant therapy with a vitamin K antagonist

should be provided to patients with STEMI and AF with C
HADS2 score 2, mechanical heart valves, venous thro
mboembolism, or hypercoagulable disorder. (LOE: C)
2. The duration of triple antithrombotic therapy with a
vitamin K antagonist, aspirin, and a P2Y12 receptor inhi
bitor should be minimized to the extent possible to limit
the risk of bleeding. (LOE: C)

Complications
Anticoagulation
Class IIa
1. Anticoagulant therapy with a vitamin K antagonist is reasonable

for patients with STEMI and asymptomatic LV mural thrombi. (LOE:
C)
Class IIb
1. Anticoagulant therapy may be considered for patients with

STEMI and anterior apical akinesis or dyskinesis. (LOE: C)
2. Targeting vitamin K antagonist therapy to a lower INR (2.0 - 2.5)
might be considered in patients with STEMI who are receiving DAPT
. (LOE: C)

Complications
Heparin-Induced Thrombocytopenia
Bleeding complication
ICH
Older age
female sex
low body weight (<70 kg [female] and <80 kg
[male])
prior stroke
hypertension on presentation (SBP>160 - 170 mm
Hg)
Vascular Access Site Bleeding

Complications

8.8 Acute Kidney Injury
8.9 Hyperglycemia
Maintain BS <180
9. R isk A ssessm ent A fter STEM I

Use of Noninvasive Testing for
Ischemia Before Discharge

Class I
1. Noninvasive testing for ischemia should be

performed before discharge to assess the presen
ce and extent of inducible ischemia in patients w
ith STEMI who have not had coronary angiograph
y and do not have high risk clinical features for w
hich coronary angiography would be warranted. (
LOE: B)

Use of Noninvasive Testing for
Ischemia Before Discharge

Class IIb
1. Noninvasive testing for ischemia might be

considered before discharge to evaluate the func
tional significance of a noninfarct artery stenosis
previously identified at angiography. (LOE: C)
2. Noninvasive testing for ischemia might be
considered before discharge to guide the postdis
charge exercise prescription. (LOE: C)

Assessment of LV Function
Class I
1. LVEF should be measured in all patients with STEMI.

(LOE: C)
Assessment of Risk for Sudden Cardiac
Death
Class I
1. Patients with an initially reduced LVEF who are

possible candidates for ICD therapy should undergo
reevaluation of LVEF 40+ days after discharge. (LOE: B)
10. P osthospitalization Plan of C are
(NSTE-ACS)
N O N -S T-ELEVATIO N A C U TE
C O R O N A R Y S Y N D R O M ES
NSTE-ACS
1. Diagnosis
2. Initial Evaluation and
Management
3. Early Hospital care
4. Myocardial Revascularization
5. Late Hospital care, Hospital
Discharge, and Posthospital
Discharge Care
6. Special Patient Groups
7. Quality of Care and Outcomes for
ACS
1. D iagnosis
History
A pressure-type chest pain that typically occurs
at rest or with minimal exertion lasting 10 min

utes.
The pain most frequently starts in the
retrosternal area and can radiate to either or bot
h arms, the neck, or the jaw.
NSTE-ACS may also present with diaphoresis,
dyspnea, nausea, abdominal pain, or syncope.
Atypical chest pain in DM, impair renal function,
and dementia
epigastric pain, indigestion, stabbing or pleuritic pain,
and increasing dyspnea in the absence of chest pain
1. D iagnosis
Physical examination
PE : normal
Signs of HF should expedite the diagnosis
and treatment.
MI may cause a S4, a paradoxical splitting
of S2, or a new murmur of mitral regurgita
tion due to papillary muscle dysfunction.
1. D iagnosis
Electrocardiogram
A 12-lead ECG within 10 minutes

Changes on ECG in NSTE-ACS include ST
depression, transient ST-elevation, or new

T-wave inversion.
Persistent ST-elevation or anterior ST
depression indicative of true posterior MI s
hould be treated according to the STEMI
CPG.
If ECG can be relatively normal or
nondiagnostic, repeat in 15-30 minutes
1. D iagnosis
Biomarkers of Myocardial Necrosis
Cardiac troponins are the most sensitive
and specific biomarkers for NSTE-ACS.
Rise within a few hours but remain elevated
for up to 2 weeks with a large infarction
negative cardiac troponin

NPV > 95% and NPV>99% in high sense
cardiac troponin
1. D iagnosis
Differential diagnosis of NSTE-ACS
includes :
Nonischemic cardiovascular causes of chest pain (eg,
aortic dissection, expanding aortic aneurysm, pericarditis,

pulmonary embolism)
Noncardiovascular causes of chest, back, or upper
abdominal discomfort include:
- Pulmonary causes (eg, pneumonia, pleuritis,
pneumothorax)
- Gastrointestinal causes (eg, gastroesophageal reflux,
esophageal spasm, peptic ulcer, pancreatitis, biliary disease)
- Musculoskeletal causes (eg, costochondritis, cervical
radiculopathy)
- Psychiatric disorders
- Other etiologies (eg, sickle cell crisis, herpes zoster)

M anagem ent
PrognosisEarly Risk Stratification
2. Initial Evaluation and M anagem ent

Cardiac Biomarkers and the Universal
Definition of MI

M anagem ent
Discharge From the ED or Chest Pain
Unit
Class IIa
1. It is reasonable to observe patients with symptoms

consistent with ACS without objective evidence of myo
cardial ischemia with serial ECGs and cardiac troponin
at 3 - 6 hour intervals. (LOE: B)
2. It is reasonable for patients with possible ACS who
have normal serial ECGs and cardiac troponins to hav
e a treadmill ECG (LOE: A), stress myocardial perfusio
n imaging or stress echocardiography before discharg
e or within 72 hours after discharge. (LOE: B)

Managem ent
Discharge From the ED or Chest Pain Unit

Class IIa
3. In patients with possible ACS and a normal ECG,

normal cardiac troponins, and no history of CAD, it is rea
sonable to initially perform (without serial ECGs and trop
onins) coronary CT angiography to assess coronary arter
y anatomy (LOE: A) or rest myocardial perfusion imagin
g with a technetium-99m radiopharmaceutical to exclud
e myocardial ischemia. (LOE: B)
4. It is reasonable to give low-risk patients who are
referred for outpatient testing daily aspirin, short-acting
nitroglycerin, and other medication if appropriate (eg, b
eta blockers), with instructions about activity level and c
linician follow-up. (LOE: C)
3. Early H ospital care
Standard Medical Therapies

Inhibitors of the Renin-Angiotensin-
Aldosterone System
Class I
1. ACE inhibitors should be started and continued indefinitely

in all patients with LVEF less than 0.40 and in those with hyp
ertension, diabetes mellitus, or stable CKD, unless contraindi
cated. (LOE: A)
2. ARBs are recommended in patients with HF or MI with
LVEF less than 0.40 who are ACE inhibitor intolerant. (LOE: A)
3. Aldosterone blockade is recommended in patients postMI
without significant renal dysfunction (Cr >2.5 mg/dL in men
or >2.0 mg/dL in women) or hyperkalemia (K+ >5.0 mEq/L)
who are receiving therapeutic doses of ACE inhibitor and bet
a blocker and have a LVEF 0.40 or less, diabetes mellitus, or
HF. (LOE: A)

Inhibitors of the Renin-Angiotensin-
Aldosterone System
Class IIa
1. ARBs are reasonable in other patients with cardiac or

other vascular disease who are ACE inhibitor intolerant.
(LOE: B)
Class IIb
1. ACE inhibitors may be reasonable in all other

patients with cardiac or other vascular disease. (LOE: B)
Initial Antiplatelet/Anticoagulant
Therapy in Patients With Definite or

Likely NSTE-ACS
Ischemia-Guided Strategy Versus
Early Invasive Strategies
4. M yocardial R evascularization
PCIGeneral Considerations
Class IIb
1. A strategy of multivessel PCI, in contrast to

culprit lesiononly PCI, may be reasonable in
patients undergoing coronary revascularization a
s part of treatment for NSTE-ACS. (LOE: B)
PCIAntiplatelet and Anticoagulant
Therapy
Class I
1. Patients already taking daily aspirin before PCI

should take 81 mg to 325 mg nonenteric-coated
aspirin before PCI. (LOE: B)
2. Patients not on aspirin therapy should be given
non-enteric- coated aspirin 325 mg as soon as poss
ible before PCI. (LOE: B)
3. After PCI, aspirin should be continued indefinitely
at a dose of 81 mg to 325 mg daily. (LOE: B)
PCIAntiplatelet and Anticoagulant Therapy
Class I
4. A loading dose of a P2Y12 receptor inhibitor should be

given before the procedure in patients undergoing PCI with
stenting. (LOE: A)
Options include:
a. Clopidogrel: 600 mg (LOE: B) or
b. Prasugrel: 60 mg (LOE: B) or
c. Ticagrelor: 180 mg (LOE: B)
5. In patients with NSTE-ACS and high-risk features (eg,
elevated troponin) not adequately pretreated with clopidogre
l or ticagrelor, it is useful to administer a GP IIb/IIIa inhibitor (
abciximab, double-bolus eptifibatide, or high-dose bolus tirofi
ban) at the time of PCI. (LOE: A)
Therapy
Class I
6. In patients receiving a stent (bare-metal stent or

drug-eluting stent [DES]) during PCI for NSTEACS, P2Y12
inhibitor therapy should be given for at least 12 months.
Options include:
a. Clopidogrel: 75 mg daily (LOE: B) or
b. Prasugrel: 10 mg daily (LOE: B) or
c. Ticagrelor: 90 mg twice daily (LOE: B)
PCIAntiplatelet and Anticoagulant Therapy
Class IIa
1. It is reasonable to choose ticagrelor over clopidogrel for

P2Y12 inhibition treatment in patients with NSTE-ACS treated
with an early invasive strategy and/or coronary stenting. (LOE:
B)
2. It is reasonable to choose prasugrel over clopidogrel for
P2Y12 treatment in patients with NSTE-ACS who undergo PCI
who are not at high risk of bleeding complications. (LOE: B)
elevated troponin) treated with UFH and adequately pretreate
d with clopidogrel, it is reasonable to administer a GP IIb/IIIa in
hibitor (abciximab, double-bolus eptifibatide, or high-bolus dos
e tirofiban) at the time of PCI. (LOE: B)
Therapy
Class IIa
4. After PCI, it is reasonable to use 81 mg per day

of aspirin in preference to higher maintenance
doses. (LOB: B)
5. If the risk of morbidity from bleeding outweighs
the anticipated benefit of a recommended
duration of P2Y12 inhibitor therapy after stent imp
lantation, earlier discontinuation (eg, <12 months)
of P2Y12 inhibitor therapy is reasonable. (LOE: C)
Therapy
Class IIb
1. Continuation of DAPT beyond 12 months may be

considered in patients undergoing stent implantation.
(LOE: C)
Class III: Harm
1. Prasugrel should not be administered to patients

with a prior history of stroke or transient ischemic
attack. (Level of Evidence: B)
PCIGP IIb/IIIa Inhibitors
Class I

elevated troponin) who are not adequately pretreated with
clopidogrel or ticagrelor, it is useful to administer a GP IIb/III
a inhibitor (abciximab, double-bolus eptifibatide, or high-dos
e bolus tirofiban). (LOE: A)
Class IIa

elevated troponin) treated with UFH and adequately pretrea
ted with clopidogrel, it is reasonable to administer a GP IIb/II
Ia inhibitor (abciximab, double-bolus eptifibatide, or high-do
se bolus tirofiban) at the time of PCI. (LOE: B)
PCIAnticoagulant Therapy in Patients
Undergoing PCI
Class I
1. An anticoagulant should be administered to

patients with NSTE-ACS undergoing PCI to reduce the
risk of intracoronary and catheter thrombus formation
. (LOE: C)
2. Intravenous UFH is useful in patients with NSTEACS
undergoing PCI. (LOE: C)
3. Bivalirudin is useful as an anticoagulant with or
without prior treatment with UFH in patients with NST
E-ACS undergoing PCI. (LOE: B)
Undergoing PCI
Class I
4. 0.3 mg/kg IV enoxaparin should be administered at

the time of PCI to patients with NSTE-ACS who have re
ceived fewer than 2 therapeutic subcutaneous doses (
eg, 1 mg/kg SC) or received the last subcutaneous eno
xaparin dose 8 to 12 hours before PCI. (LOE: B)
5. If PCI is performed while the patient is on
fondaparinux, an additional 85 IU/kg of UFH should be
given intravenously immediately before PCI . (LOE: B)
Undergoing PCI
Class I
6. In patients with NSTE-ACS, anticoagulant therapy

should be discontinued after PCI unless there is a
compelling reason to continue such therapy. (LOE: C)
Class IIa
1. In patients with NSTE-ACS undergoing PCI who are at

high risk of bleeding, it is reasonable to use bivalirudin
monotherapy in preference to the combination of UFH a
nd a GP IIb/IIIa receptor antagonist. (LOE: B)
Undergoing PCI
Class IIb
1. Performance of PCI with enoxaparin may be

reasonable in patients treated with upstream subcutan
eous enoxaparin for NSTE-ACS. (LOE: B)
Class III: Harm
1. Fondaparinux should not be used as the sole

anticoagulant to support PCI in patients with NSTEACS
due to an increased risk of catheter thrombosis. (LOE:
B)
Timing of Urgent CABG in Patients With NSTE-
ACS in Relation to Use of Antiplatelet Agents

Class I
1. Nonenteric-coated aspirin (81 mg to 325 mg daily) should

be administered preoperatively to patients undergoing CABG.
(LOE: B)
2. In patients referred for elective CABG, clopidogrel and
ticagrelor should be discontinued for at least 5 days before
surgery (Level of Evidence: B) and prasugrel for at least 7 days
before surgery. (LOE: C)
3. In patients referred for urgent CABG, clopidogrel and
ticagrelor should be discontinued for at least 24 hours to
reduce major bleeding. (LOE: B)
Timing of Urgent CABG in Patients With
NSTE-ACS in Relation to Use of Antiplatelet A

gents
Class I
4. In patients referred for CABG, short-acting intravenous GP

IIb/IIIa inhibitors (eptifibatide or tirofiban) should be
discontinued for at least 2 to 4 hours before surgery and abcix
imab for at least 12 hours before to limit blood loss and transf
usion. (LOE: B)
Class IIb
1. In patients referred for urgent CABG, it may be reasonable
to perform surgery less than 5 days after clopidogrel or
ticagrelor has been discontinued and less than 7 days after pr
asugrel has been discontinued. (LOE: C)
5. Late H ospitalcare, H ospitalD ischarge,

and Post-hospitalD ischarge Care
5.1 General Principles
(Cardioprotective Therapy and

Symptom Management)

5.2 Medical Regimen and Use of
Medications at Discharge
Class I
1. Medications required in the hospital to control ischemia

should be continued after hospital discharge in patients
with NSTE-ACS who do not undergo coronary revasculariza
tion, patients with incomplete or unsuccessful revasculariz
ation, and patients with recurrent symptoms after revascu
larization. Titration of the doses may be required. (LOE: C)
2. All patients who are postNSTE-ACS should be given
sublingual or spray nitroglycerin with verbal and written in
structions for its use. (LOE: C)

5.2 Medical Regimen and Use of
Medications at Discharge
Class I
3. Before hospital discharge, patients with NSTE-ACS

should be informed about symptoms of worsening myocar
dial ischemia and MI and should be given verbal and writte
n instructions about how and when to seek emergency car
e for such symptoms. (LOE: C)
4. Before hospital discharge, patients who are postNSTEACS and/or designated responsible caregivers should be pr
ovided with easily understood and culturally sensitive verb
al and written instructions about medication type, purpose,
dose, frequency, side effects, and duration of use. (LOE: C)

5.2 Medical Regimen and Use of Medications
at Discharge
Class I
5. For patients who are postNSTE-ACS and have initial

angina lasting more than 1 minute, nitroglycerin (1 dose subl
ingual or spray) is recommended if angina does not subside
within 3 to 5 minutes; call 9-1-1 immediately to access emer
gency medical services. (LOE: C)
6. If the pattern or severity of angina changes, suggesting
worsening myocardial ischemia (eg, pain is more frequent or
severe or is precipitated by less effort or occurs at rest), pati
ents should contact their clinician without delay to assess the
need for additional treatment or testing. (LOE: C)
7. Before discharge, patients should be educated about
modification of cardiovascular risk factors. (LOE: C)

5.2.1 Late Hospital and Posthospital Oral
Antiplatelet Therapy
Class I
1. Aspirin should be continued indefinitely. The maintenance

dose should be 81 mg daily in patients treated with
ticagrelor and 81 mg to 325 mg daily in all other patients. (L
OE: A)
2. In addition to aspirin, a P2Y12 inhibitor should be
continued for up to 12 months in all patients with NSTE-ACS
without contraindications who are treated with an ischemia-g
uided strategy.
Options include:
Clopidogrel: 75 mg daily (LOE:B) or
Ticagrelor: 90 mg twice daily (LOE: B)

Class I
3. In patients receiving a stent during PCI for NSTE-ACS, P2Y12

inhibitor therapy should be given for at least 12 months.
Options include:
Clopidogrel: 75 mg daily (LOE: B) or
Prasugrel: 10 mg daily (LOE: B) or
Ticagrelor: 90 mg twice daily (LOE: B)
Class IIa
1. It is reasonable to use an aspirin maintenance dose of 81 mg

per day in preference to higher maintenance doses in patients w
ith NSTE-ACS treated either invasively or with coronary stent im
plantation. (LOE: B)

Class IIa
2. It is reasonable to use ticagrelor in preference to

clopidogrel for maintenance P2Y12 treatment in patients
with NSTE-ACS who undergo an early invasive or ischemi
a-guided strategy. (LOE: B)
3. It is reasonable to choose prasugrel over clopidogrel

for maintenance P2Y12 treatment in patients with NSTEACS who undergo PCI who are not at high risk for bleedin
g complications. (LOE: B)

Class IIa
4. If the risk of morbidity from bleeding outweighs the

anticipated benefit of a recommended duration of P2Y12 inhibi
tor therapy after stent implantation, earlier discontinuation (e
g, <12 months) of P2Y12 inhibitor therapy is reasonable. (LOE:
C)
Class IIb
1. Continuation of DAPT beyond 12 months may be considered

in patients undergoing stent implantation. (LOE: C)

5.2.2 Combined Oral Anticoagulant Therapy
and Antiplatelet Therapy in Patients With

NSTE-ACS
Class I
1. The duration of triple antithrombotic therapy with a

vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor
in patients with NSTE-ACS should be minimized to the extent
possible to limit the risk of bleeding. (LOE: C)
2. Proton pump inhibitors should be prescribed in patients

with NSTE-ACS with a history of gastrointestinal bleeding
who require triple antithrombotic therapy with a vitamin K an
tagonist, aspirin, and a P2Y12 receptor inhibitor. (LOE: C)

5.2.2 Combined Oral Anticoagulant Therapy
and Antiplatelet Therapy in Patients With

NSTE-ACS
Class IIa
1. Proton pump inhibitor use is reasonable in patients with

NSTE-ACS without a known history of gastrointestinal bleeding
who require triple antithrombotic therapy with a vitamin K ant
agonist, aspirin, and a P2Y12 receptor inhibitor. (LOE: C)
Class IIb
1. Targeting oral anticoagulant therapy to a lower INR (2.0 2.5) may be reasonable in patients with NSTE-ACS managed
with aspirin and a P2Y12 inhibitor. (LOE: C)

5.3 Risk Reduction Strategies for
Secondary Prevention
5.3.1 Cardiac Rehabilitation and Physical
Activity
Class I
1. All eligible patients with NSTE-ACS should be

referred to a comprehensive cardiovascular rehabilitati
on program either before hospital discharge or during t
he first outpatient visit. (LOE: B)

5.3 Risk Reduction Strategies for Secondary
Prevention
5.3.2 Patient Education
Class I
1. Patients should be educated about appropriate cholesterol

management, BP, smoking cessation, and lifestyle management. (L
OE: C)
2. Patients who have undergone PCI or CABG derive benefit from
risk factor modification and should receive counseling that
revascularization does not obviate the need for lifestyle changes. (
LOE: C)
5.3.3 Pneumococcal Pneumonia

Class I
1. The pneumococcal vaccine is recommended for patients more

than 65 years and in high-risk patients with cardiovascular disease.
(LOE: B)

Prevention
5.3.4 NSAIDs
Class I
1. Before hospital discharge, the patients need for treatment of

chronic musculoskeletal discomfort should be assessed, and a ste
pped-care approach should be used for selection of treatments. P
ain treatment before consideration of NSAIDs should begin with a
cetaminophen, nonacetylated salicylates, tramadol, or small dose
s of narcotics if these medications are not adequate. (LOE: C)
Class IIa
1. It is reasonable to use nonselective NSAIDs, such as naproxen,

if initial therapy with acetaminophen, nonacetylated salicylates, tr
amadol, or small doses of narcotics is insufficient. (LOE: C)

Prevention
5.3.4 NSAIDs
Class IIb
1. NSAIDs with increasing degrees of relative COX- 2 selectivity

may be considered for pain relief only for situations in which intol
erable discomfort persists. In all cases, use of the lowest effectiv
e doses for the shortest possible time is encouraged. (LOE: C)
Class III: Harm
1. NSAIDs with increasing degrees of relative COX- 2 selectivity

should not be administered to patients with NSTE-ACS and chroni
c musculoskeletal discomfort when therapy with acetaminophen,
nonacetylated salicylates, tramadol, small doses of narcotics, or
nonselective NSAIDs provide acceptable pain relief. (LOE: B)

5.3 Risk Reduction Strategies for
Secondary Prevention
5.3.5 Hormone Therapy
Class III: Harm
1. Hormone therapy with estrogen plus progestin, or

estrogen alone, should not be given as new drugs for
secondary prevention of coronary events to postmenop
ausal women after NSTE-ACS and should not be contin
ued in previous users unless the benefits outweigh the
estimated risks. (LOE: A)

Prevention
5.3.6 Antioxidant Vitamins and Folic Acid
Class III: No Benefit
1. Antioxidant vitamin supplements (eg, vitamins E, C, or

beta carotene) should not be used for secondary preventio
n in patients with NSTE-ACS. (LOE: A)
2. Folic acid, with or without vitamins B6 and B12, should
not be used for secondary prevention in patients with
NSTE-ACS. (LOE: A)

5.4 Plan of Care for Patients With
NSTE-ACS
Class I
1. Posthospital systems of care designed to prevent

hospital readmissions should be used. (LOE: B)
2. An evidence-based plan of care that promotes
medication adherence, timely follow-up with the healt
hcare team, appropriate dietary and physical activities
, and compliance with interventions for secondary pre
vention should be provided to patients with NSTE-ACS.
(LOE: C)

5.4 Plan of Care for Patients With
NSTE-ACS Class I
3. In addition to detailed instructions for daily

exercise, patients should be given specific instructi
on on activities (eg, lifting, climbing stairs, yard wo
rk, and household activities) that are permissible a
nd those to avoid. Specific mention should be mad
e of resumption of driving, return to work, and sexu
al activity. (LOE: B)
4. An annual influenza vaccination is recommended
for patients with cardiovascular disease. (LOE: C)
6. Special P atient G roups
7. Q uality of C are and O utcom es for A C S

Use of Performance Measures and
Registries
Class IIa
1. Participation in a standardized quality-of-care

data registry designed to track and measure
outcomes, complications, and performance meas
ures can be beneficial in improving the quality of
NSTE-ACS care. (LOE: B)
R eferences
2014 AHA/ACC Guideline for the Management
of Patients With NonST-Elevation Acute

Coronary Syndromes . A Report of the
American College of Cardiology/American Hea
rt Association Task Force on Practice Guidelin
es.
2013 ACCF/AHA Guideline for the
Management of ST-Elevation Myocardial Infar
ction. A Report of the American College of
Cardiology Foundation/American Heart Associ
ation Task Force on Practice Guidelines

Acute Coronary Syndrome

Diunggah oleh

Informasi Dokumen

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Acute Coronary Syndrome

Diunggah oleh

Hak Cipta:

Format Tersedia

A C U TE C O R O N A R Y

A 54-year-old man presents with 6 hours of acute

Specialty board review Tintinalli Emergency medi

A 65-year-old male presents with 2 hours of chest

Specialty board review Tintinalli Emergency medi

A spectrum of conditions compatible

Coronary artery obstruction

Initial evaluation and m anagem ent

1. Patients with suspected ACS should be risk

3. Patients with less severe symptoms may be

considered for. (LOE: C)

risk (0-5 points), medium risk (6-7) andhigh risk(>7 p

high risk(>3 points)

New ST elevation at the J point in

at least 2 contiguous leads

2 mm (0.2 mV) in men or 1.5 mm

ST depression in 2 precordial leads (V1V4)

Transmural posterior injury

Multi-lead ST depression with coexistent ST

elevation in lead aVR LM or proximal Lt LA

Hyperacute T-wave changes may be

observed in the very early phase of STEMI, b

Therapy, and Time-to-Treatment Goals

1. All communities should create and maintain a regional

Therapy, and Time-to-Treatment Goals

4. Primary PCI is the recommended method of reperfusion.

5.EMS transport directly to a PCI-capable hospital for primary

Reperfusion Therapy, and Time-to-Treatm

7. In the absence of contraindications, fibrinolytic therapy

Reperfusion Therapy, and Time-to-Tr

1. Reperfusion therapy is reasonable for patients

R EPER FU SIO N TH ER A PY FO R STEM I

Patients With STEMI and Out-ofHospital Cardiac Arrest

1. Therapeutic hypothermia should be started as

3. R eperfusion at a P C I-C apable

3. R eperfusion at a PC I-C apable

1. Manual aspiration thrombectomy is reasonable

3. R eperfusion at a PC I-C apable

Use of Stents in Patients With STEMI

Class III: Harm

1. DES should not be used in primary PCI for patients with

3. R eperfusion at a PC I-C apable

Adjunctive Antithrombotic Therapy

for Primary PCI

4. R eperfusion at a N onP C I-C apable

an Anticipated Delay to Performing P

4. R eperfusion at a N onP C I-C apable

The benefits of fibrinolytic therapy in patients

4. R eperfusion at a N onP C I-C apable

4. R eperfusion at a N onP C I-C apable

Contraindications and Complications

With Fibrinolytic Therapy

4. R eperfusion at a N onP C I-C apable

Adjunctive Antithrombotic Therapy

4. R eperfusion at a N onP C I-C apable

Relief of chest pain

minutes after fibrinolytic therapy

Presence of reperfusion arrhythmias (eg.

4. R eperfusion at a N onP C I-C apable

PCI-Capable Hospital for Coronary An

5. D elayed Invasive M anagem ent

Who Initially Were Managed With Fibr

5. D elayed Invasive M anagem ent

Who Initially Were Managed With Fibr