ACS update 2013

T Benjanuwattra
Chiang Mai Heart Center

Acute Coronary Syndrome

Plaque Rupture and

Distal Embolization

thrombus formation

Mechanical Plugging
Vasoconstriction
and occlusion

Acute coronary syndrome

No ST elevation
Partial
flow

UA/NSTEMI

ST elevation
Complete
obstruction

STEMI
Antithrombin Rx
Antiplatelet Rx

Risk of death and severity of acute coronary syndrome

In the first 15 days, ACS

patients presenting with STsegment elevation (STEMI)
had the greatest risk of
death[Fox 2008:B]

After 15 days there was a

higher risk of death in patients
with ST-segment depression
(NSTEMI) at initial
presentation[Fox 2008:B]

Regardless of the type of ACS,

mortality tends to increase over
time[Fox 2008:A]

Fox KA, et al. Nat Clin Pract Cardiovasc Med. 2008;5:580-589.

Post-discharge mortality among ACS

patients who initially presented with ST
elevation, ST depression or no STsegment deviation (GRACE registry)*
[Fox 2008:A]

*New ST-segment elevation plus one elevated cardiac

biomarker was considered STEMI. One elevated cardiac
biomarker without a new ST-segment elevation was
considered NSTEMI

Acute coronary syndrome

No ST elevation
Partial
flow

UA/NSTEMI

ST elevation
Complete
obstruction

STEMI
Antithrombin Rx
Antiplatelet Rx

Myocardial Infarction

Time-Terminate STEMI

Time is the most potent Therapy for STEMI

Time=muscle
Muscle=survive

Universal Defination of Myocardial

Infarction
Criteria of Myoocardial Infarction
Myocardial necrosis
Detection of rise and/or fall of cardiac biomarker
(preferably troponins) with at least one value
Above the 99th percentile of the upper reference limit
With evidence of myocardial ischemia with at least one of the
following :
Symptoms of ischemia
New ST-T changes or LBBB
Development of new Q-waves
Imaging evidence of new loss of viable myocardium
Or new regional wall motion abnormality
The Joint ESC-ACCF-AHA-WHF Task Force. EHJ 2012

Dx
Cardiac Marker +ve
At least one
CP > 20 min
Ab ECG ( STE )
Image..abnormal wall motion
Doc intracoronary clot

KINETICS OF CARDIAC MARKERS AFTER

AMI
MARKER

DETECTION

PEAK

DISAPPEARANCE

Myoglobin

14h

67h

24 h

CK-MB mass

3 12 h

12 18 h

2 3 days

Total CK

48h

12 30 h

3 4 days

cTnT

46h

12 48 h

5 15 days

cTnI

46h

12 24 h

5 7 days

These values represent averages.

Coronary Artery

Acute Q wave MI

Inferior Wall

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

(RCA)

Inferior Wall

Reciprocal Changes

II, III, aVF

I, aVL

Antero-septal Wall

V1, V2, V3 (V4)

Along sternal borders

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

(LAD)

Anterior Wall

V3, V4
Left anterior chest

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

(LAD)

Lateral

I, aVL, V5, V6

Lateral Wall

(Circumflex)

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

Antero-lateral Wall

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

(prox - LAD)

Extensive anterior wall MI

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

(LM or prox - LAD)

55-year-old man with acute chest pain 30 mins. prior to ER

3 hr after the onset

Prior to SK

Acute extensive anterior wall MI : Tombstones appearance

Acute extensive anterior wall MI : Tombstone appearance

This patient had acute anterior wall MI which

deteriorate to VF.

Hyper : Rhabdomyolysis
from simva 80 mg daily
+ Lopid 1200mg daily

Hyper K

K 10.1 mEq/lit

Acute pericarditis

68-yr-old woman with acute chest pain

Acute pericarditis

68-yr-old woman with acute chest pain

3 Days later

Pulmonary Embolus:
Diagnosis
Answer:
S1Q3T3 is seen in only 6% of pts. with PE

Early repolarization

Hyperacute inf MI

Evolution of acute ant-lat MI

Cabera

55-year-old man
with acute anterior
chest tightness:

LBBB & AMI

q wave still be seen at V5,V6

Reverse R progression in right precordial lead
Discordant ST deviation > 7mm
Concordant ST>2mm
Notching ascending limb S wave in lead V3, V4
(Caberra)
Notching ascending limb of R wave in lead
I,AVL,and V6(Chapman)

15

Circle sizes = sample size of the

individual study.
= weighted meta-regression.

10

Solid line

P = 0.006

62 min
0

Benefit
Favors PCI
Harm
Favors Lysis

-5

Absolute Risk Difference in Death (%)

Mortality rates with primary PCI as a function

of PCI-related time delay

20

40

60

80

100

PCI-Related Time Delay (door-to-balloon - door-to-needle)

Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-6

Transfer to 1o PCI vs Local medical

thrombolysis

Components of delay in STEMI and ideal time

intervals for intervention

< 10 min

Patient delay

System delay

Time to reperfusion therapy

Wire passage in culprit artery
if primary PCI

Bolus or infusion
Start if thrombolysis

All delays are related to FMC (first medical contact)

Eur Heart J 2012;33:2569-2619.

Prehospital and in-hospital management, and

reperfusion strategies within 24 h of FMC
STEMI diagnosis*
Primary-PCI capable
center

EMS or non primary-PCI

capable center

Preferably
< 60 min

PCI possible < 120 min ?

Immediate transfer
to PCI center

Yes
Preferably
< 90 min
(< 60 min in early presenters)

No
Preferably
< 30 min

Immediately

No
Yes
Preferably 3-24 h

Immediate transfer
to PCI center
Successful

fibrinolysis ?
*The time point the diagnosis is confirmed with patients
history and ECG ideally with in 10 min from the first
medical contact (FMC)
All delays are related to FMC (first medical contrct)
Eur Heart J 2012;33:2569-2619.

2013 ACCF/AHA Guideline Acute STEMI

STEMI patient who is a candidate
for reperfusion
Initially seen at a
Non-PCI-capable
Hospital*

Initially seen at a
PCI-capable
hospital
DIDO time < 30 min
Send to cath lab for
primary PCI

Transfer for
primary PCI

FMC-device time < 90

min

FMC-device time
as soon as
possible and
< 120 min

(Class I, LOE : A)

Administer fibrinolytic agent

within 30 min of arrival when
anticipated FMC-device > 120
min
(Class I, LOE: B)

(Class I, LOE : B)
Urgent transfer for PCI
for patients with
evidence of failed
reperfusion or
reocclusion

Diagnostic angiogram

Medical therapy
only

PCI

CABG

Transfer for
angiography and
revascularization
within 3-24 h for other
patients as part of an
invasive strategy*

(Class IIa, LOE : B)

(Class IIa, LOE : B)

Circulation. 2013;127:529-555;

Adjunctive Antithrombotic Therapy to Support

Reperfusion With Fibrinolytic Therapy
Antiplatelet therapy
COR

LOE

162- to 325-mg loading

81- to 325-mg daily maintenance dose (indefinite)

IIa

Aspirin

81 mg daily is the preferred maintenance dose

P2Y12 receptor inhibitors
Clopidogrel :
Age < 75 y : 300-mg loading dose

Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleeding

Age >75 y: no loading dose, give 75 mg

Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleed

I
I
I

A (14 d)
C (up to 1y)
A
A (14 d)
C (up to 1y)

COR, Class of Recommendation; LOE, Level of Evidence.

Circulation. 2013;127:529-555;

Adjunctive Antithrombotic Therapy to Support

Reperfusion With Fibrinolytic Therapy
Anticoagulant therapy
COR

LOE

UFH
Weight-based IV bolus and infusion adjusted to obtain aPTT of 1.5 to 2.0 times
control for 48 h or until revascularization. IV bolus of 60 U/kg (maximum 4000 U)
followed by an infusion of 12 U/kg/h (maximum 1000 U) initially, adjusted to
maintain aPTT at 1.5 to 2.0 times control (approximately 50 to 70 s) for 48 h or until
revascularization
Enoxaparin :
If age <75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg subcutaneously every
12 h (maximum 100 mg for the first 2 doses)
If age 75 y: no bolus, 0.75 mg/kg subcutaneously every 12 h (maximum 75 mg for
the first 2 doses)
Regardless of age, if CrCl <30 mL/min: 1 mg/kg subcutaneously every 24 h
Duration: For the index hospitalization, up to 8 d or until revascularization
Fondaparinux :
Initial dose 2.5 mg IV, then 2.5 mg subcutaneously daily starting the following day,
for the index hospitalization up to 8 d or until revascularization
Contraindicated if CrCl <30 mL/min

aPTT indicates activated partial thromboplastin time; COR, Class of Recommendation; CrCl, creatinine clearance; IV,
intravenous; LOE, Level of Evidence; N/A, not available; and UFH, unfractionated heparin
Circulation. 2013;127:529-555;

Antithrombin
PPCI or
fibrinolytic

UFH, LMWH, fondaparinox

Revas

Open
Stabilized
artery

Severe stenosis
Subtotal occlusion

Antiplatelets

ASA, clopidogrel or ticagrelor,

( +/- G2b3a inhibitors )

NSTE ACS

THE ELECTROCARDIOGRAM

WELLENS SYNDROME

Clinical UA with:
Inverted or biphasic T-waves in V2 and V3
T wave changes may also be present in V1, V4-V6
Changes appear when pain free
Little to no ST change
No loss of precordial R waves
No pathologic Q waves
Concern:
Highly specific for LAD lesions
At risk for extensive AMI or sudden death

With CP

Wellens Syndrome

THE ELECTROCARDIOGRAM
WELLENS SYNDROME

GRACE risk score

ESC Guideline NSTE ACS

EHJ 2011;32:2999-3054

NSTE-ACS

Dual anti-plt loading

ASA
ESC : 150-300 mg
ACC : 162-325 mg

Ticagrelor : 180 mg [ESC Prefer]

Clopidogrel : 300 mg

Invasive strategy

Conservative strategy

Medium, high risk

Low risk ***

*** ACS + GRACE score < 108 RX
No CP
No HF
ECG
Markers

2012 ACCF/AHA Focus Update. Circulation 2012;126:875-910.

2011 ACCF/AHA Focus Update. Circulation 2011;123:2022-2060.
ESC guideline. EHJ 2011;32:2999-3054.

= ACC

= ESC

* ACC

Invasive strategy

Medium, high risk

i.v. GP IIb/IIIa blocker

IIb

III

Coronary study
ACC : < 24 hr *
ESC : < 72 hr severity **

refractory angina
Haemodynamic instability
Electrical instability
GRACE Score > 140

**ESC
Invasive : < 72 hr

Rise and fall cTn

Dynamic ST or T wave change
DM
CKD e GFR ,60ml/min/1.73 sqm

ACS > 1 high risk

ACS Rx no CP CP

EF <40%

Cath lab : PCI

I

Clopidogrel : more loading

300 mg
Anticlot : UFH or Enoxa
Provisional GP IIb/IIIa
blocker [eptifibatide or
tirofiban]

Early invasive : < 24 hr

Early post MI angina

Recent PCI
Prior CABG
Intermediate-high GRACE risk score

2012 ACCF/AHA Focus Update. Circulation 2012;126:875-910.

2011 ACCF/AHA Focus Update. Circulation 2011;123:2022-2060.
ESC guideline. EHJ 2011;32:2999-3054.

ACS GRACE score > 140

ACS > primary high risk
Urgent : < 2hr
ACS at least one : Refractor angina
HF
Life-threatening VT/VF
Haemodynami instability

= ACC

= ESC

Invasive strategy

Conservative strategy

Medium, high risk

Low risk ***

i.v. GP IIb/IIIa blocker

IIb

Coronary study

Anti-clot : either

ACC : < 24 hr *
ESC : < 72 hr severity **

UFH
Enoxaparin
Fundaparinux
Recurrent
ischaemic

Cath lab : PCI

I

III

Clopidogrel : more loading

300 mg
Anticlot : UFH or Enoxa
Provisional GP IIb/IIIa
blocker [eptifibatide or
tirofiban]

i.v. GP IIb/
IIIa blocker
IIa

Anti-clot : either
IIa

IIb

2012 ACCF/AHA Focus Update. Circulation 2012;126:875-910.

2011 ACCF/AHA Focus Update. Circulation 2011;123:2022-2060.
ESC guideline. EHJ 2011;32:2999-3054.

Enoxaparin
Fundaparinux
Prefer over UFH

*** ACS + GRACE score < 108 RX

No CP
No HF
ECG
Markers
= ACC

= ESC

ACS w/o PCI .

ACS BMS .
ACS DMS .

ASA

ASA

DAPT up to 12 m
DAPT up to 12 m
DAPT up to 12 m
Ticagrelor
or
Clopidogrel

: 75-100 (ESC)
81 (ACC)
Clopidogrel : 75 mg OD (I)
600 150 x 6 75 IIb ACC 2012
IIa ESC 2012
Ticagrelor : 90 mg bid (I)

AB S AP BCDE

ABSAP

BC D E

A = Aspirin 75-160 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = P2Y12Block:Clopi75mgODorTica90bid
B = Bl pressure [goal < 130/80 ]
C = Cigarette cessation
D = DM Hb A, C < 7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 75-160 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure [goal < 130/80]
C = Cigarette cessation
D = DM Hb A, C < 6.5 7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 75-160 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure [goal<130/80]
C = Cigarette cessation
D = DM Hb A, C < 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 75-160 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70-100)
A = ACEI (ARB : ACEI intolerance); Aldosterone Bl
P = Plavix
B = Bl pressure [goal < 130/80]
C = Cigarette cessation
D = DM Hb A, C < 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 75-160 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = P2Y12block : Clopi75mg OD/Tica 90mg bid
B = Bl pressure [goal < 130/80)
C = Cigarette cessation
D = DM Hb A, C < 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 162-325 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure (goal 130/80)
C = Cigarette cessation
D = DM Hb A, C < 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 162-325 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure [goal <130/80)
C = Cigarette cessation
D = DM Hb A, C < 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 162-325 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure [goal<130/80mm)
C = Cigarette cessation
D = DM Hb A1 C 6.5-7%
E = Exercise 4-5 / wk for > 30 min

ABSAP

BC D E

A = Aspirin 162-325 mg/day

B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ABR : ACEI intolerance)
P = Plavix
B = Bl pressure [goal < 130/80]
C = Cigarette cessation
D = DM Hb A, C < 7%
E = Exercise 4-5 / wk for > 30 min or 150min/wk

ABSAP

BC D E

A = Aspirin 75-160mg/day
B = Beta - blocker
S = Statin (goal LDL-C 70)
A = ACEI (ARB : ACEI intolerance); Aldosterone Anta
P =P2Y12Block: Clopi 75 OD/ Tica 90 bd
B = Bl pressure [goal 130/80]
C = Cigarette cessation
D = DM Hb A1 C 6.5-7%
E = Exercise 4-5 / wk for > 30 min or 150min/wk

Influenza vaccine once a year ( class I, LOE B )

ACC/AHA 2011 update guideline secondary prevention. JACC 2011;58:2432-2446

TAKE HOME MESSAGE

T.Benjanuwattra

Acute STEMI
Time
2 hr.

PCI < 2 hr. after onset

Primary
PCI

Possible

Not Possible

Fibrinolysis

>6-12 hr.
After onset

12 hr.

Rescue PCI

24 hr.

Angiography *

Failed

Successful

- not earlier than 3 hrs. after

ESC/EACTS 2010 uidelines on myocardial revascularization.EHJ 2010

ACC/AHA 2009 Focused Updates. JACC 2009;54(23):2205-41.
ESC AMI guideline 2012, ACCF/AHA guideline 2013

start fibrinolysis
- reasonable for high risk AMI
.class IIa

Coronary study

NSTE ACS

* ACC

ACC : < 24 hr *
ESC : < 72 hr severity **

refractory angina
Haemodynamic instability
Electrical instability
GRACE Score > 140

**ESC
Conservative strategy
Score 108

Rise and fall cTn

Dynamic ST or T wave change
DM
CKD e GFR ,60ml/min/1.73 sqm

Invasive : < 72 hr
ACS > 1 high risk
ACS Rx no CP CP

EF <40%
Early post MI angina
Recent PCI
Prior CABG
Intermediate-high GRACE risk score

Early invasive : < 24 hr

ACS GRACE score > 140
ACS > primary high risk
Urgent : < 2hr
ACS at least one : Refractor angina
HF
Life-threatening VT/VF
Haemodynami instability

2012 ACCF/AHA Focus Update. Circulation 2012;126:875-910.

2011 ACCF/AHA Focus Update. Circulation 2011;123:2022-2060.
ESC guideline. EHJ 2011;32:2999-3054.

The Alphabet strategy

A advice

Smoking diet exercise

B blood pressure

130/80 mmHg

C cholesterol

LDL <70

Atherogenic triad:
nonHDL goal = LDL
goal +30

FBS 110-130

A1C 6.5-7%

ASA 81- 100, P2Y12

inhibitor, ACEI ( ARB),
Aldosterone antagonist,
BB 3 yrs , statin

D diabetes control

E essential drugs

Thank you for your attention

Criteria for high risk.invasive Rx

Rise and fall cTn
Dynamic ST or T wave change
DM
CKD e GFR ,60ml/min/1.73 sqm
EF <40%
Early post MI angina
Recent PCI
Prior CABG
Intermediate-high GRACE risk score

Invasive Rx
< 72 hr: at least one high risk or recurrent
symtoms
URGENT <2 hr: refractory angina, recurrent
angina despite intense Rx asso with ST
depression (2mm) or deep T inversiobnHF, lifethreatening ventriculararrhythmias, or
haemodynamic instability
Early strategy <24 hr : Grace>140 or either rise
and fall or dynamic ST T change
ESC Guideline NSTE ACS
EHJ 2011;32:2999-3054

 ASA 150-300mgmaintenance 75-100mg

Cloipidogrel 300mg loading for non PCI, 600mg for
invasive strategy maintenance 75 mg od ( 150 mg od
for first 7 day after PCI.option) or Ticagrelor loading
180mg..90mg bid
Fondaparinox ( 2.5 mg sc od ) or Enoxaparin ( 1 mg/kg sc
bid)
Eptifibatide in cath lab..risk of clot burden >>high

ESC Guideline NSTE ACS. EHJ 2011;32:2999-3054

ACCF/AHA Focused Update Guideline UA/NSTEMI. Circulation2012