Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Current Management of ACS

Download as pptx, pdf, or txt
Download as pptx, pdf, or txt
You are on page 1of 35

Current Management of Acute Coronary Syndrome :

from Diagnosis to Intervention

Dr. Safir, SpJP(K),FIHA,FAPSC

Departement Cardiology and Vascular


Medicine Diponegoro University/Dr.Kariadi
Hospital Semarang
2024
INTRODUCTION

• Cardiovascular Disease remains the No. 1 cause of death in the US and


Worldwide
• In 2020, approximately 19.1 million (37%) deaths were attributed to
CVD globally.
• Approximately every 40 seconds, someone in the US will have a
myocardial infarction
• Deaths from ACS occur, on average, at younger ages in LMICs (low &
middle income countries) than in high-income countries, often at
economically productive ages, and likewise frequently affect the poor
within LMICs
• In Indonesia, CAD account for 1.5% (3.7 million)
Heart Disease and Stroke statistics-2022 Update : A report from the AHA. Circulation. 2022;145:e153–e639
World Health Organization; IHME, Global Burden of Disease 2022
Vedanthan, et al. Circ Res.2014;114(12):1959-1975
Kementerian Kesehatan Badan Penelitian dan Pengembangan Kesehatan,2018.
Acute Coronary Syndrome
(ACS)
Acute thrombosis induced by a ruptured or eroded atherosclerotic coronary
plaque, with or without concomitant vasoconstriction, causing a sudden
and critical reduction in blood flow

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.

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


ACS EPIDEMIOLOGY: RISK FACTORS

Several risk factors contribute to the development of acs/atherosclerosis

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

Libby P: Inflammation in Atherosclerosis. Nature 2020;420:868


Definition of Myocardial Infarction

Thygesen K,et al. European Heart Journal (2018) 00, 1–33


Universal Classification of MI

Thygesen K,et al. European Heart Journal (2018) 00, 1–33


ACS DIAGNOSIS

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

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


Differential diagnosis of ACS in the
Table 4 Differential diagnoses of acute coronary syndromes in the
setting of acute chest pain
setting of acute chest pain

Bold = common and/or important differential diagnoses.


aDilated, hypertrophic and restrictive cardiomyopathies may cause angina or chest discomfort.

©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

Tiwari RP, et al. Mol Diagn Ther (2012) 16:371–381


Cardiac Troponin Kinetics in Patients After Acute Myocardial
Injury and Acute Myocardial Infarction

Thygesen K,et al. European Heart Journal (2018) 00, 1–33


Management of Acute Coronary Syndrome
An overview of the initial
triage, management and
investigation of patients
who present with signs and
symptoms potentially
consistent with ACS

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


MANAGEMENT OF ACS
RAPID ASSESSMENT IN ED INITIAL TREATMENT
(10 min)
Morphine

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

Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018


STEMI
Modes of presentation and
pathways to invasive
management and myocardial
revascularization in STEMI

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


2021 ACC/AHA/SCAI Guideline for Coronary Artery
Revascularization
Revascularization in STEMI

Indications for Revascularization in STEMI (Patients Without


Fibrinolytics)

Lawton et al. Circulation. 2022;145:e18–e114.


Importance of Revascularization--Time is Muscle
Tujuan reperfusi adalah untuk menyelamatkan otot jantung sebanyak dan secepat mungkin.

Semakin lama reperfusi, kerusakan otot jantung semakin luas dan


100 keluaran pasien semakin buruk
Penurunan Mortalitas %

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

One ACS Multicenter Registry

Juzar D.A,et al. Indonesian J Cardiol 2022:43:45-55


strategy (1)
Recommendations Class Level
Recommendations for reperfusion therapy for patients with STEMI
Reperfusion therapy is recommended in all patients with a working diagnosis of
STEMI (persistent ST-segment elevation or equivalents) and symptoms of ischaemia I A
of ≤12 h duration.
A PPCI strategy is recommended over fibrinolysis if the anticipated time from
I A
diagnosis to PCI is <120 min.
If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of
STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients I A
without contraindications.
Rescue PCI is recommended
Recommendations for for failed fibrinolysis
reperfusion (i.e. ST-segment
therapy and timing resolution
of invasive <50%
within 60–90 min of fibrinolytic administration) or in the presence of haemodynamic I A
strategy (2)
or electrical instability, worsening ischaemia, or persistent chest pain.
Recommendations Class Level

©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)

In patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an


IIa B
s.c. dose 24 h later should be considered.
Contraindications for fibrinolytic therapy
NSTE-ACS
Selection of invasive
strategy and
reperfusion therapy
in NSTE-ACS

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization

Recommendations for the Timing of Invasive Strategy in Patients With NSTE-


ACS

Lawton et al. Circulation. 2022;145:e18–e114.


Timing and logistical factors influence choice of
reperfusion strategy

Time to reperfusion Healthcare resource

• Patient ability to recognize • PCI vs non-PCI capable hospitals1–3


symptoms1,2 • Dependence on operator
• Mode of transportation to the expertise/volume3
hospital • Availability of a 24/7 service1,3*
(self-presentation vs EMS)1,2 • Availability of a pre-hospital
• Inter-hospital transfer challenges system for diagnosis and
(distance, traffic patterns, treatment3,4,5
*Patients treated during non-working hours (6 PM to 8 AM) have
climatic conditions etc)2,3 a greater delay to therapy, twice the failure rate of PPCI, and a
>2-fold increased 30-day mortality rate3,6

• 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

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


Recommendations for antiplatelet and anticoagulant therapy in
acute coronary syndrome

Byrne R.A,et al. European Heart Journal (2023) 00, 1–107


Byrne R.A,et al. European Heart Journal (2023) 00, 1–107
Acute coronary syndrome patient expectations
TAKE HOME MESSAGE

• Acute Coronary Syndrome: major cause of mortality and morbidity


• Early diagnosis and prompt treatment plays an important role in improving
outcomes of ACS patients
• Revascularization (primary PCI or fibrinolytic) is cornerstone therapy in STEMI
patients
• Risk stratification is useful to guide appropriate management in NSTE-ACS patients
• Antithrombotic therapy has recommended in all patients with ACS, either treated
with invasive strategy or medically managed
• Secondary prevention after ACS should be offered to every patient and should start
as early as possible after the index event. This includes cardiac rehabilitation, lifestyle
management, and pharmacological treatment, and has been shown to both increase
quality of life and decrease morbidity and mortality
THANK YOU

You might also like