Current Management of ACS
Current Management of ACS
Current Management of ACS
Bentzon JF et al. Circ Res. 2014;114:1852-1866; Roffi M et al. Eur Heart J 2016;37(3):267-315; Ibanez B, et al. Eur Heart J. 2018;39:119-177
The spectrum of clinical
presentations,
electrocardiographic
findings, and high-
sensitivity cardiac
troponin levels in patients
with acute coronary
syndrome.
Smoking
Family
history of High blood
heart pressure
disease or (BP)
stroke
ACS risk
High
Overweight factors blood
/obese cholesterol
Physical
Diabetes
inactivity
Stable vs Vulnerable Plaque
Diagnosis of ACS is based on a quick but thorough assessment of the patient based on:
Patient’s history
Findings on physical examination
Electrocardiography
Radiologic studies
Cardiac biomarker tests
Results of these investigations aid:
Accurate diagnosis
Early risk stratification to guide treatment
Symptoms at presentation
in acute coronary syndrome
©ESC
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without
www.escardio.org/guidelines
persistent ST-segment elevation (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa575)
ACS DIAGNOSIS: STEMI AND UA/NSTEMI
ELECTROCARDIOGRAPHIC DIAGNOSIS
Cardiac Biomarkers
M
• Can be repeated per 10 – 30 min,
sulfate iv for patient who not responsive
Vital signs, O2 saturation 1-5 mg
Bedside monitor
IV access
Rapid anamnesis,
physical exam
O O2 • when SaO2 < 90% or PaO < 60
ECG
Blood sample (cardiac
enzymes, electrolytes,
N Nitrate • If ongoing chest pain by the time admitted at ER
BGA, etc) •
A
ASPIRIN Ticagrelor 180 mg loading dose + 90 mg
BID
Loading or • 300 mg loading dose + 75 mg OD
160 – 320mg clopidogrel* if ticagrelor is not available or
contraindicated
80
60
40
20
Tingkat Keselamatan
Otot Jantung
0
0 4 8 12 16 20 24
Waktu dari Awitan Gejala hingga Terapi Reperfusi, dalam Jam
Periode kritis tergantung waktu Periode tidak tergantung waktu
Tujuan: menyelamatkan otot jantung Tujuan: membuka arteri yang terkait dengan infark
Adapted from Gersh BJ, et al. JAMA. 2005;293:979.
Hospital mortality rate in ST-ACS based on reperfusion strategies
©ESC
Recommendations for reperfusion therapy for patients with STEMI (continued)
In patients with a working diagnosis of STEMI and a time from symptom
www.escardio.org/guidelines onset
2023 ESC Guidelines >12 h,
for the management of acute coronary syndromes
(European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad191)
a PPCI strategy is recommended in the presence of ongoing symptoms suggestive of I C
ischaemia, haemodynamic instability, or life-threatening arrhythmias.
A routine PPCI strategy should be considered in STEMI patients presenting late
IIa B
(12–48 h) after symptom onset.
Routine PCI of an occluded IRA is not recommended in STEMI patients presenting
III A
>48 h after symptom onset and without persistent symptoms.
Byrne R.A,et al. European Heart Journal (2023) 00, 1–107
Recommendations Class Level
Fibrinolytic therapy
When fibrinolysis is the reperfusion strategy, it is recommended to initiate this
treatment as soon as possible after diagnosis in the pre-hospital setting (aim for I A
target of <10 min to lytic bolus).
A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended. I B
A half-dose of tenecteplase should be considered in patients >75 years of age. IIa B
Recommendations for fibrinolytic
Antiplatelet co-therapy with fibrinolysis therapy (2)
Aspirin and clopidogrel are recommended. I A
Recommendations Class Level
Anticoagulation co-therapy with fibrinolysis
Anticoagulation is recommended in patients treated with fibrinolysis until
I A
revascularization (if performed) or for the duration of hospital stay (up to 8 days).
©ESC
Enoxaparin i.v. followed by s.c. is recommended as the preferred anticoagulant. I A
When enoxaparin is not available, UFH is recommended as a weight-adjusted i.v.
www.escardio.org/guidelines I
2023 ESC Guidelines for the management of acute coronary B
syndromes
bolus, followed by infusion. (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad191)
• 1. Ibanez B et al. Eur Heart J 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3. Armstrong PW et al. Circulation
2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation 2004;110:1909–1915; 6.
Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142
Antithrombotic Therapy in
Acute Coronary Syndrome
Recommended default
antithrombotic therapy
regimens in acute coronary
syndrome patients