Download Unstable Angina and Non–ST Elevation Myocardial Infarction

UNSTABLE ANGINA AND
NON–ST ELEVATION
MYOCARDIAL INFARCTION
YEDITEPE UNIVERSITY FACULTY OF MEDICINE
PHASE 4 CARDIOLOGY COURSE 2014-2015
PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
MUSTAFA AYTEK SIMSEK, M.D., Attending Physician
PATHOPHYSIOLOGY OF ACS
EVOLUTION OF CORONARY
THROMBOSIS
CAUSES OF UA/NSTEMI

Thrombus or thromboembolism, usually arising on
disrupted or eroded plaque – Most Common Cause.
Dynamic obstruction – coronary spasm or
vasoconstriction
 Progressive mechanical obstruction to coronary flow – ie
restenosis after PCI
 Coronary arterial inflammation
 Coronary artery dissection


Secondary UA – Increasing oxygen demands in the
setting of a fixed lesion.
CLINICAL INDICATORS OF INCREASED
RISK IN UA/NSTEMI
TIMI RISK SCORE
T: Troponin elevation (or CK-MB elevation)
H: History or CAD (>50% Stenosis)
R: Risk Factors: > 3 (HTN, Hyperlipidemia, Family Hx, DM II, Active Smoker)
E: EKG changes: ST elevation or depression 0.5 mm concordant leads
A2:Aspirin use within the past 7 days; Age over 65
T: Two or more episodes of CP within 2 hours
GRACE PREDICTION SCORE CARD

Medical History
1.
2.

3.
Findings at initial hospital presentation
4.
5.

Age in years (0-100 points)
History of congestive heart failure (24 points)
History of myocardial infarction (12 points)
6.
Resting heart rate (0-43 points)
Systolic blood pressure (0-24 points)
ST depression (11 points)
Findings during hospitalization
7.
8.
9.
Initial serum creatinine (1 to 20 points)
Elevated cardiac enzymes (15 points)
No in-hospital percutaneous coronary intervention (14
points)
JAMA 2004:291;2727-33
DECIDING BETWEEN EARLY INVASIVE VS A CONSERVATIVE
STRATEGIES
Definitive/Possible ACS
Initiate ASA, BB, Nitrates,
Anticoagulants, Telemetry
Early Invasive Strategy
• TIMI Risk Score >3
• New ST segment
deviation
• Positive biomarkers
Coronary angiography
(24-48 hours)
Conservative Strategy
•TIMI Risk Score <3 (Esp.
Women)
•No ST segment deviation
•Negative Biomarkers
Recurrent Signs/Symptoms
Heart failure
Arrhythmias
Remains Stable
↓
Assess EF and/or Stress Testing
↓
EF<40% OR Positive stress
Go to Angiography
GENERAL TREATMENT MEASURES

Antiplatelet Therapy

Anticoagulant Therapy

Control of Cardiac Pain


Analgesics

Nitrates

Beta Blockers

Oxygen
Limitation of Infarct Size

Early reperfusion

Reduction of myocardial energy demand
ANTIPLATELET THERAPY

Aspirin

162-325 mg, nonenteric-coated ASA to be chew

maintenance of 75-162 mg daily
ANTIPLATELET THERAPY



Clopidogrel 300 mg loading
75 mg/day
Prasugrel oral loading dose
of 60 mg and 10 mg orally
daily
Ticagrelor a loading dose of
180 mg and 90 mg twice
daily
ANTICOAGULANT THERAPY



Heparin activated partial
thromboplastin time (aPTT)
target of 1.5 to 2 times that
of control
Low-Molecular-Weight
Heparins
Fondaparinux
CONTROL OF CARDIAC PAIN

Analgesics



meperidine, pentazocine, and morphine
Morphine 2 to 8 mg/ 5 to 15 minutes --until the pain is relieved or
there is evident toxicity
Nitrates

sublingual nitrates, intravenous nitroglycerin

systolic pressure <90 mm Hg

right ventricular infarction
CONTROL OF CARDIAC PAIN

Beta Blockers

Killip class II or higher (precipitating cardiogenic shock)

Patients with heart failure (rales > 10 cm up from diaphragm),

hypotension (blood pressure < 90 mm Hg),

bradycardia (heart rate < 60 beats/min),
CONTROL OF CARDIAC PAIN

Oxygen

pulse oximetry

Sao2 < 90%

2 to 4 liters/min of 100% oxygen

6 to 12 hours
LIMITATION OF INFARCT SIZE

Early reperfusion

Routine Measures for Infarct Size Limitation

Beta blocker (HR 50-70)

Inhibitors of the renin-angiotensin-aldosterone
system (RAAS)

Arterial oxygenation
LIMITATION OF INFARCT SIZE


Angiotensin-converting enzyme (ACE) inhibitor

Start ACE inhibitor orally in patients with pulmonary
congestion or LVEF <40%

if the following are absent: hypotension (SBP <100 mm Hg or
<30 mm Hg below baseline) or known contraindications to
this class of medications.
Angiotensin receptor blocker (ARB)

Start ARB orally in patients who are intolerant of ACE
inhibitors and with either clinical or radiologic signs of heart
failure or LVEF <40%