Download ACS Treatments

TREATMENT OF ACUTE
CORONARY SYNDROMES
At the end of this self study the participant will:
• Describe ACS risk stratification
• List goals of medication therapies
• Describe complications of ACS.
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Treatment depends on the patient’s
identified risk
• Low risk
• Intermediate risk
• High risk
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ACS Risk Stratification
Findings indicating HIGH
likelihood of ACS
Findings indicating
INTERMEDIATE likelihood
of ACS in absence of highlikelihood findings
Findings indicating LOW
likelihood of ACS in absence of
high- or intermediatelikelihood findings
History
Chest or left arm pain or
discomfort as chief
symptom
Reproduction of previous
documented angina
Known history of coronary
artery disease, including
myocardial infarction
Chest or left arm pain or
discomfort as chief
symptom
Age > 50 years
Probable ischemic symptoms
Recent cocaine use
ECG
New or presumably new
transient ST-segment
deviation (> 0.05 mV) or
T-wave inversion (> 0.2
mV) with symptoms
Fixed Q waves
Abnormal ST segments or T
waves not documented to be
new
T-wave flattening or inversion
of T waves in leads with
dominant R waves
Normal ECG
Serum
cardiac
markers
Elevated cardiac troponin
T or I, or elevated CK-MB
Normal
Normal
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Taken from http://www.aafp.org/afp/20050701/119.html
Low Risk Medical Management
• ASA
• NTG (PO/NTP)
• Consider
– BetaBlocker
– Stress Test
– Risk factor modification
• Statin
• Discharge/Admit to Chest Pain Center
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Intermediate Risk Medical Management
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Oxygen (if O2 sat < 90%)
ASA, Clopidogrel if ASA intolerant/ sensitive
NTG (PO/NTP/Spray)
LMWH/ Unfractionated Heparin
-Blocker
ACE inhibitor: EF < 40%
Statin
Consider Echocardiagram, stress test
Admit to Telemetry
Braunwald, et al, http://www.acc.org/clinical/guidelines/unstable/unstable.pdf accessed
April 2, 2002.
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Medical Management
High Risk UA/Non-STEMI
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Oxygen (if O2 sat < 90%)
ASA, Clopidogrel if ASA intolerant/ sensitive
Clopidogrel if medical management/ PCI
Enoxaparin
NTG (IV/PO/NTP)
-Blocker
ACE inhibitor: ejection fraction <40%
Statins
Consider Echocardiogram
Admit to CCU/Telemetry
Braunwald, et al, http://www.acc.org/clinical/guidelines/unstable/unstable.pdf
accessed April 2, 2002.
Aggressive Management High Risk
UA/Non-STEMI (Cath, PCI, CABG)
• Oxygen (O2 sat < 90%)
• Clopidogrel if ASA intolerant/
sensitive
• Clopidogrel in addition to ASA
• LMWH or Unfractionated Heparin
• NTG (IV/PO/NTP)
• -Blocker
• GP IIb-IIIa Inhibitor for PCI
• Cardiac Catheterization
Braunwald, et al, http://www.acc.org/clinical/guidelines/unstable/unstable.pdf
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accessed April 2, 2002.
Medical Management
Acute STEMI
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Oxygen (O2 sat < 90%)
NTG SL
ASA
Unfractionated Heparin
IV Nitroglycerin
IV Morphine Sulfate
Fibrinolytic Therapy (if candidate) or Primary PCI
Consider Beta Blocker; Consider ACE-I
Admit to CCU or Arrange for PCI
*Ryan et al, JACC 1999;34(3):890-911.
Thrombolytic or Fibrinolytic Agents
(start within 30 minutes of “door”)
Goal: break down clots allowing perfusion (remember
destroys all clots, not just those in coronary arteries)
Reteplase (rPA)
• treatment of MI; double bolus
Tenecteplase (TNK)
• treatment of MI; single bolus
Alteplase (tPA)
• treatment of ischemic stroke, PE, catheter declotting; bolus
followed by an infusion
Combination Therapy: Fibrinolytic, plus IIb/IIIa inhibitor
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Antiplatelet Agents
• Goal: Prevent further clotting by preventing platelet
aggregation
• Salicylates: All ACS
– ASA (chewed for acute chest pain)
• ADP-receptor inhibitors: UA, stents
– Clopidigrel (Plavix)
• Glycoprotein (GP) IIb-IIIa receptor antagonists: NonSTEMI, UA
– Abciximab (ReoPro)
– Eptifibatide (intergrelin)
– Tirofiban (Aggrastat)
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Antithrombin Agents
• Goal: Prevent further clotting by thrombin inhibition,
either directly or indirectly
• Heparin -unfractionated heparin (UFH)
• Low–molecular-weight heparins (LMWH) with
UA/NSTEMI indications (not indicated for STEMI)
– enoxaparin
– dalteparin
• Direct-acting antithrombins
– Bivalirudin (angiomax)
– argatrobran
– lepirudin
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Incredible Machine. National Geographic Society. 1986. Used by Permission
Vitamin K Antagonists
• Goal: Prevent clotting through oral therapy
• Coumadin (Warfarin)
– Chronic Atrial Fibrillation
– Prosthetic Valves
– Mural Thrombus
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Adjunctive Therapy: Beta Blockers
-lol drugs
 Actions:  myocardial 02 demand, heart rate, 
arrhythmias
 Contraindications: avoid in bronchospastic diseases,
cardiac failure, severe abnormalities in cardiac
conduction, hypotension and insulin dependent
diabetics
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Adjunctive Therapy: ACE Inhibitors
-pril drugs
 Actions: decrease afterload, reduce compensatory
LV hypertrophy, improve ejection fraction, limit size
of infarct
 Contraindications: hypotension, renal artery
stenosis, allergy to ACEs
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Adjunctive Therapy: Intravenous
Nitroglycerin
 Actions: dilates coronary arteries, increases
collateral blood flow, decreases preload &
afterload
 Contraindications: hypotension, marked
bradycardia, hypersensitivity to nitrates
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Lipid Lowering Agents
• Lower LDL and increase HDL when combined
with Statin
• Niacin, Lopid, Questran, etc.
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STATINS

Lowers Low Density Lipoproteins (LDL)
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May help to decrease accumulation of plaque
Stabilizes plaque
Reduces chance of plaque rupture
When combined with Niacin, may increase High
Density Lipoprotein (HDL).
– Lipitor, Pravachol, Zocor, etc.
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Percutaneous Coronary Interventions
Stent
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Coronary Artery Bypass Graft (CABG)
• Goal: Surgically enhance circulation
• Can use internal mammary artery,
radial artery or sapphenous vein
– one end is either sewn to the
aorta or may remain connected to
the larger artery where it
originated.
– The other end is attached
(grafted) beyond the blockage in
the coronary artery.
– As a result, blood can flow
around the blocked area,
increasing the supply of oxygen
and nutrients to the heart muscle.
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Post ACS Complications
Left Ventricular Failure
• Problem with forward flow (low cardiac output,
ejection fraction drops)
• Blood backs up into lungs (respiratory implications)
Cardiogenic Shock
• Severe LV failure
• Need to intervene early
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Post ACS Complications
Ventricular Septal Defect
• Hole develops in septum causing oxygenated blood to
remix with deoxygenated blood in heart
• Problem with forward flow
• New systolic murmur, decreased pO2, LV failure
Myocardial Rupture
• Hole develops in free wall (outside wall)
• Problem with forward flow
• LV failure, cardiac arrest
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Post ACS Complications
Papillary Muscle Rupture
• AV valve (tricuspid or mitral) leaflets float upward
into atria during closure
• Blood leaks back into atria during ventricular
contraction
• Loud new systolic murmur, pulmonary edema,
cardiogenic shock
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Post ACS Complications
Ventricular Aneurysm and Thrombosis
• Tend to develop with anterior MI
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Risk of mural thrombus causing a PE
High risk for stroke if aneurysm in LV
Dx with ECHO
Anticoagulate
Post ACS Complications
Recurrent Ischemia or Infarction
• High risk for first 10 days
• Especially with non-transmural MI or non Q wave MI
• Educate patient about significance of symptoms
Pericarditis
• Inflammatory reaction of pericardium
• Pain with inspiration, splinting, pericardial rub
• Referred to as Dressler’s syndrome if
2 weeks to 3 months post MI
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References
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1Braunwald
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2 The
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E, Antman EM, Beasley JW, Califf RM, Cheitlin MD,
Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ,
Schaeffer JW, Smith EE III, Steward DE, & Theroux P. ACC/AHA
guidelines for the management of patients with unstable angina and non-ST
segment elevation myocardial infarction: a report of the American College
of Cardiology/ American Heart Association Task Force on Practice
Guidelines (Committee on the Management of Patients With Unstable
Angina). J Am Coll Cardiology 2000;36:970-1062.
Joint European Society of Cardiology/ American College of
Cardiology Committee. Myocardial Infarction Redefined--A Consensus
Document of The Joint European Society of Cardiology / American
College of Cardiology Committee for the Redefinition of Myocardial
Infarction. J Am Coll Cardiol 2000;36:959-969.