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Management of acute

coronary syndromes (ACS)

This presentation reflects the recommendations in the National Heart Foundation of


Australia/Cardiac Society of Australia and New Zealands Guidelines for the Management
of Acute Coronary Syndromes (ACS) (2006), updated in the 2007 and 2011 addenda.The
presentation is designed for use in health professional development and training on acute
ACS care.

2012 National Heart Foundation of Australia


Outline
Cardiovascular disease (CVD) the facts and risk factors
Acute coronary syndromes (ACS)
Presentation of ACS
ACS management: summary of updates in the 2011 addendum 1
1. Systems of care
2. Investigations
3. Management of patients with ST-segment elevation myocardial
infarction (STEMI)
4. Management of patients with non-ST-segment elevation ACS
(NSTEACS)
5. Long-term management

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand
guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.

2012 National Heart Foundation of Australia


CVD the facts
Heart disease is the single leading
cause of death.

In 2009, 28 Australians died from


a heart attack each day. Thats
one life claimed every 51
minutes.1

CVD is expected to affect 1 in 4


Australians by 2051.2

References
1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.
2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.

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Risk factors for CVD
Modifiable risk factors: Non-modifiable risk factors:
smoking gender
poor diet age
high cholesterol family history of CVD
physical inactivity diabetes
high blood pressure human immunodeficiency virus (HIV).
being overweight
depression, social isolation and
lack of social support.

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Acute coronary syndromes (ACS)
ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack)
through an accelerated pattern of angina without evidence of
myonecrosis1/infarction (muscle death).
Myocardial infarction (MI) occurs when the blood supply to the heart muscle is
interrupted due to partial or complete occlusion (thrombus) of the coronary
artery. As a result, some of the heart muscle becomes infarcted (dies).
A heart attack can be confirmed by an electrocardiogram (ECG) test.

Reference
1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1S14.

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Thrombus formation in the arterial lumen

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Acute presentation
Critical factors to timely
of ACS
treatment:
recognition Heart attack
time
People experiencing ACS
symptoms should seek help
promptly and activate
emergency services.

2012 National Heart Foundation of Australia


Signs and symptoms of
ACS presentation
Symptoms may include:
chest discomfort (tightness, pressure, heaviness) at rest or for a
prolonged period (> 10 minutes, not relieved by sublingual
nitrates)
recurrent chest discomfort
discomfort associated with syncope/acute heart failure.

The pain may spread to other parts of the upper body, including:
back, neck, jaw, arm(s), shoulder(s) or epigastric pain.

The person may also experience:


dyspnoea (shortness of breath), diaphoresis (profuse perspiration),
dizziness, nausea or vomiting
recent research shows that women, the elderly and people with
diabetes are less likely to experience chest pain as a symptom.
2012 National Heart Foundation of Australia
2011 addendum to 2006
Guidelines
The 2011 addendum to the 2006 Guidelines provides updates
to:
1. Systems of care to support delivery of ACS services
2. Early response
3. Management of patients with STEMI
4. Management of patients with NSTEACS
5. Long-term management (after control of myocardial
ischaemia).1

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the
management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.

2012 National Heart Foundation of Australia


1. Systems of care to support delivery of
ACS services
Formal systems of care:
defined continuum of care from presentation to long-term management
system-based approaches to deliver timely reperfusion at a local level (Grade B)
routine audit integrated into all clinical ACS services (Grade B)
training GPs/health workers to initiate fibrinolysis (if primary percutaneous
coronary intervention [PCI] services are not readily accessible)
practitioners are supported by ready access to expert cardiology consultation
(Consensus)
cardiac clinical networks established with appropriate protocols (Grade B).

For example: iCCnet CHSA network links > 70 hospitals, health centres and general
practitioner [GP] surgeries across SA, aligned to the Health Reform Agenda principles.

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2. Early response: treatment is time critical
Time from symptom onset and likely outcome

< 1 hour
Aborted heart attack or only little heart muscle damage
12 hours
Minor heart muscle damage only
24 hours
Some heart muscle damage with moderate heart muscle salvage
46 hours
Significant heart muscle damage with only minor heart muscle salvage
612 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable

In cases of major delay to hospitalisation (> 30 minutes) ambulance


crews should consider pre-hospital fibrinolysis.

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STEMI what is it?
An ST-segment elevation myocardial infarction (STEMI) can be confirmed by
an ECG.

STEMI is defined as presentation with clinical symptoms consistent with an


ACS with ECG features including any of:
persistent ST-segment elevation 1 mm in two contiguous limb leads
ST-segment elevation 2 mm in two contiguous chest leads
new left bundle branch block (LBBB) pattern.

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3. Management of patients with STEMI

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Early response
Implement reperfusion strategy for patients presenting within 12 hours of
onset of ischaemic symptoms consistent with ACS (determined by physical
examination):
immediate 12-lead ECG
insert cannulae
pain relief
blood tests.
Give aspirin 150300 mg (unless already given, or contraindicated).
Doctor sees patient within 10 minutes of arrival (Australasian Triage Scale
Category 2).
Oxygen therapy indicated only for patients with hypoxia (oxygen
saturation < 93%) and those with evidence of shock (Consensus).

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Choice of reperfusion therapy
In general, PCI is the treatment of choice, providing it can be performed promptly by
a qualified interventional cardiologist in an appropriate facility. 1
All PCI facilities should be able to perform primary angioplasty within 90 minutes of
patient presentation.
Fibrinolysis should be considered early if PCI is not readily available.
In cases of major delay to hospitalisation (> 30 minutes) consider pre-hospital
fibrinolysis.

Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S929.

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PCI cardiac catheter
The catheter can be inserted via the radial or femoral artery (insertion via the femoral
artery
illustrated below).

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PCI how it works

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Primary PCI technique and antithrombotic
therapy
Among patients with STEMI undergoing primary PCI the use of bivalirudin can be
considered as an alternative to heparin and GP IIb/IIIa inhibitors (Grade B).1
Among patients undergoing primary PCI for reperfusion, consider antiplatelet
therapy with either:
high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75
mg/day for at least 12 months) (Grade B)
prasugrel (60 mg oral bolus + 10 mg daily) (Grade B)
ticagrelor (180 mg oral bolus + 90 mg twice daily) (Grade B). 1
Careful assessment of bleeding risk should be undertaken before using
antithrombotic agents (Grade B).1
Consider use of mechanical thrombectomy techniques to reduce thrombus burden
during primary PCI (Grade A).1

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for
the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487502.
2012 National Heart Foundation of Australia
Bleeding risk
The following risk factors should be considered when assessing bleeding risk and
choosing antithrombotic therapies in patients with ACS (Grade B):
age > 75 years
female
history of bleeding
history of stroke or transient ischaemic attack (TIA)
creatinine clearance rate < 60 mL/min
diabetes
heart failure
tachycardia
blood pressure < 120 mmHg or 180 mmHg
peripheral vascular disease (PVD)
anaemia
concomitant use of GP IIb/IIIa inhibitor
enoxaparin 48 hours prior
switching between unfractionated heparin and enoxaparin
procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart
catheterisation).
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Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots
in the coronary vessels to restore blood flow to the heart muscle. 1
Consider early routine revascularisation of patients receiving fibrinolysis, regardless
of success of pharmacologic reperfusion (Grade A).
Absolute contraindications
Active bleeding or bleeding diathesis (excluding menses).
Significant closed head or facial trauma within 3 months.
Suspected aortic dissection.
Any prior intracranial haemorrhage.
Ischaemic stroke within 3 months.
Known structural cerebral vascular lesion.
Known malignant intracranial neoplasm.

Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm.
Accessed 7 August 2011.

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Fibrinolysis
Relative contraindications
Current use of anticoagulants.

Non-compressible vascular punctures.

Recent major surgery (< 3 weeks).

Traumatic or prolonged (> 10 mins) CPR.

Recent internal bleeding (within 4 weeks).

Active peptic ulcer.

History of chronic, severe, poorly controlled hypertension.

Severe uncontrolled hypertension on presentation (systolic 180 mmHg or


diastolic 110 mmHg).
Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.

Pregnancy.

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NSTEACS what is it?
Non-ST-elevation ACS (NSTEACS) applies to patients with suspected ACS
in the absence of other plausible causes of troponin elevation (e.g.
sepsis, pulmonary embolus).
On physical examination, patients with NSTEACS may have a normal
ECG reading, or show minor changes (occurs in up to 50% of patients).
All patients with NSTEACS should have their risk stratified to direct
management decisions.
The management of patients with NSTEACS requires evolving risk
stratification: clinical assessment, assessment of cardiac biomarkers and
time.

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4. Management of patients with NSTEACS

Clinical assessment: careful


clinical history, ECG, chest X-ray
.
and investigations to diagnose
other causes of chest pain and
evaluate the likelihood of
evolving ACS.
Troponin assessment: to assess
the likelihood of MI.
Stratify risk.

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Evolving risk stratification

Admit to coronary care unit or


high dependency unit:
estimate ischaemic risk,
estimate bleeding risk,
choose augmented
antithrombotic therapy
refer for angiography to
determine surgery/PCI, or
medical therapy.

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Evolving risk stratification

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Evolving risk stratification
Intermediate-risk NSTEACS

Recurrent ischaemia or elevated


troponin?
YES NO
admit to CCU or high dependency undertake stress test (e.g. exercise
unit: ECG):
estimate ischaemic risk, estimate positive refer for angiography to
bleeding risk, choose augmented determine surgery/PCI, or medical
antithrombotic therapy therapy
refer for angiography to negative proceed to discharge
determine surgery/PCI, or patient with urgent cardiac follow-
medical therapy. up (on upgraded medical therapy)
according to long-term
management after control of
myocardial ischaemia.

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Evolving risk stratification

Appropriate period of
observation. Consider if
stress test (e.g. exercise
ECG) needed?

YES NO

Stress test (e.g. exercise Proceed to discharge patient with


ECG) using treadmill. urgent cardiac follow-up (on
upgraded medical therapy)
according to long-term
management after control of
myocardial ischaemia.

2012 National Heart Foundation of Australia


Antithrombotic therapy for NSTEACS

For high-risk patients with NSTEACS, assess bleeding risk individually


according to the number and severity of bleeding risk factors (Grade A).
Assign a management strategy according to bleeding risk.
For patients at high risk of bleeding, use a priority low-bleedingstrategy.
Antithrombotic agents with lower bleeding risk include:
clopidogrel in preference to prasugrel (Grade B)
fondaparinux in preference to enoxaparin (Grade B)
bivalirudin in preference to enoxaparin (Grade B).
For patients at low risk of bleeding, use a standard effective antiplatelet
regimen (prasugrel and ticagrelor) (Grade A). (cont.)

2012 National Heart Foundation of Australia


Antithrombotic therapy for NSTEACS
Minimise the number of agents used (Grade B).
When additional agents are needed, substitute rather than add (Grade B).
Consider shorter-acting or reversible agents (Grade B).
Avoid using GP IIb/IIIa inhibitors, where possible (Grade B).

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5. Long-term management
Before discharging a patient:
discharge medication regimen
provide tailored lifestyle advice to reduce risk of further
events, including:
smoking cessation
good nutrition and moderate alcohol intake
physically active lifestyle and weight management as
relevant
managing depression
warning signs of a heart attack.
Refer all patients to comprehensive cardiac rehabilitation
programs.
Provide all patients with a written action plan for chest
pain, which can be downloaded from
www.heartfoundation.org.au

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Medication regimen
Continued antiplatelet therapies for 12 months for all patients with stents (Grade A).
In addition:
aspirin
beta-blockers
ACE inhibitors
statins
warfarin
nitrates
insulin/oral hypoglycaemics
aldosterone antagonists.

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Concluding remarks
This presentation is designed to ensure consistency of information regarding
best practice ACS management, based upon the 2011 addendum to the
National Heart Foundation of Australia/Cardiac Society of Australia and New
Zealand Guidelines for the management of acute coronary syndromes 2006.
Understandings of the pathophysiology of ACS have improved, together with
increasingly accurate diagnostic tools, better risk stratification and improved
medical and invasive treatments. However, these advances have led to an
increase in the complexity of possible treatment strategies. This is evolving.
For more information please visit www.heartfoundation.org.au.
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