2. acute coronary syndrome

7/25/2019 2. Acute Coronary Syndrome

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Syndrome

(Focus on early recognition

and initial management)

Muhammad Yolandi Sumadio

Cardiology and VascularDepartment

University North Sumatera


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&hat 's Acute

Coronary

Syndrome


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Acute coronary syndrome (ACS) !eart Attac*+re,ers to spectrum o, presentations that is consistent to -e

caused -y myocardial ischemia.

ACS De/nition

NS01ACS S01ACS

Unsta-le

AnginaNS0M' S0M'

2y 0C3 di4erentiation


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&hat cause ACS

Sta-le

Angina Acute Coronary Syndrome


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&hat happened in ACS


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&hy

should 5e

care


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ACS is a cardiac emergency

!igh mortality and mor-idity


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3lo-al Ma6or Causes o, Death

Global Atlas on Cardiovascular Disease Prevention And

ACS 5ere

responsi-leto

hal, o, CVD

deaths


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ACS Mor-idity and Mortality

1/3 of S!"# $atients die %it&in 2' &ours of onset ofisc&e(ia

1)* of +A $atients die or e,$erience a reinfarction%it&in 30 da-s of dianosis

u$ to 30* of disc&ared $atients are re&os$italied%it&in (ont&s

1* of (en and 23* of %o(en over ae'0 (a- die %it&in 1 -ear follo%in "# S!"# 4S!"#5

6* 7 16* ACS $atients die in t&e 8rst (ont&s after

dianosed9 %it& about one7&alf of deat&s occurrin%it&in 30 da-s.


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S01ACS vs NS01SCS

'ncidence 7 NS0M' 8 S0M'

!ospital mortality7S!"# : 4S!"# ; * vs ) * 5

%thmonth mortality 7

S!"# < 4S!"# 12 * vs 13 * 5

9ong erm Follo5 Up Mortality4S!"# : S!"#


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Are all -adne5s


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0vidence12ased Medical herapy

Signi/cantly lo5ered mor-idity

: mortality

Started 5ith an ade;uatediagnosis (not an

underdiagnosed one) and an

appropriate treatment


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!o5 to

diagnose

ACS


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$< ACS is A C9'N'CA9D'A3N=S'Snot an 0C3

diagnosis

>ecogni?e the symptom

correctly

Diagnosing ACS


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Symptoms compati-le 5ithischaemic heart disease


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ypical chest

pain@ Anginapectoris

Symtomps compati-le 5ith

ischaemic heart disease

Angina

e;uivalentComplications o, coronary

heart disease

Speci/c

9essspeci

/c


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ypical chest pain

=ualit- S>ueein9 &eaviness9 $ressure9 %ei&t9ver- stron $ain9 burnin9 ti&tness

?ocation Centre of t&e c&est9 left c&est %it&radiation to s&oulder9 nec@9 a%9 innerar(9 e$iastriu( can occur %it&outc&est $ain5

Duration +nstable anina 10720 (in."-ocardial infarction last loner

Settin riered b- e,ercise9 se,ual activit-9e,$osure to cold %eat&er9 e(otional

stress aner9 fri&t9 frustration59 or alare (eal.

Believer ore,aerator

4o eect of $osition or res$iration to>uantit- or >ualit- of c&est $ain.

?essened b- nitrat


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ypical chest pain


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ypical chest pain


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Angina 0;uivalent


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9ate resentation


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Atypical Chest ain

i l h t


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ypical chest

pain orang

MedanAN3'N


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"< 9oo* For >is*Factors

Diagnosing ACS


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Diagnosing !eart Disease

Atypicalsymptom and

sign

ypicalsymptomand sign

>is*Factors

>is*Factors

9ess

li*ely

More

li*ely

Most

li*ely

De/ni

te

0vidence

o, heartdisease


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< 0vidence o, ACS

Diagnosing ACS

>ole o, 0C3 in ACS


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Diagnosing !eart Disease

Atypicalsymptom and

sign

ypicalsymptomand sign

&ith or 5ithout>is* Factors

De/nite heart disease

0vidence o, heart disease(diagnostic 0C3 a-normality)

&ith or 5ithout>is* Factors


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ypical@Speci/c

Symptom

Atypical@ 9essSpeci/c

Symptom

Acute Coronary Syndrome

2ut 5ith a

diagnostic 0C3

>oles o, 0C3 in ACS


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0C3 Changes

Unsta-leAnginaNS0

M'

S0M

'

Normal 0C3


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ACSManagement


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he philosophy o,

treating ACS is tolo5er the patient

mortality (not onlyin1hospital -ut also

long term mortality)he mortality -ene/t o, ACStreatment started ,rom the

earliest treatment given


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Clinical diagnosis o, ACS is li*ely

3ive initial pharmacological treatment(M=NAC=)$< =" nasal lpm"< Aspirin ## mg che5 (E)

< Clopidogrel ## mg i, availa-le (E)< 'SDN mg su-lingual (interval minG

maH dose)< Morphin "1 mg iv (i, pain isnIt

responding to nitrate)

>e,er to !ospital 5ith cardiologist

0C3 Analysis

Atypical presentation -ut 5ith diagnostic 0C3


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0C3 Analysis

S0M'J $" hours o,

onset

S0M'8 $" hours

o, onset

NS0 1ACS

>eper,usion7 Fi-rinolytic

rimary C'

Manage conservatively7 'CU@'CCU (E) Continuos nitrat in,usion Dual antiplatelet regimen (aspirin and

clopidogrel) (E) Anticoagulant

(heparin@,ondaparinuH@enoHaparin) (E) !igh intensity statin (E) AC0 inhi-itor (E) 2eta -loc*er (E)

C' in selected high1ris* ,eature patient(E)(E) gives mortality and

mor-idity -ene/t

' iti l h l i l t t ,


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'nitial harmacological reatment ,orAcute Coronary Syndrome

1. O,-en

a. #ndication All ACS Patientb. Contraindication COPD &i& dose

O25

c. Dosae 1 E ?/(in via nasal cannula ' ?/(in for A"# E 10 ?/(in via non7breat&in face

(as@

M=NAC=Morphin1=Hygen1Nitrate1Aspirin1

Clopidogrel

'nitial harmacological reatment ,or


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2. 4itrate F#sosorbid dinitrate #SD45a. #ndication

#sc&e(ic c&est $ainb. Contraindication

Hi$otension SP I 60 ((H5

I ' &ours use of PD! Jiara5c. Caution

e%are of &-$otension9 ive bolus ofsaline if it &a$$en

Bi&t ventricular infatctiond. Dosae ) ( sublinuall- interval ) (in9 (a, 3

doses5e. aret t&era$-

Believe of isc&ae(ic s-($to($s



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3. As$irina. #ndication All ACS $atient for anti$latelet

areation

b. Contraindication Active bleedin or bleedin

tendenc-c. Dosae

?oadin dose of 12732) (usuall- 300(5 c&e%

Continue )7100 ( once dail-e. &era$- bene8t

#($rove survival and outco(e

AS'>'N


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AS'>'N

AS'>'N


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Co($ared %it& $lacebo in t&e #S#S72

trial9 u$ to 1 (ont& of as$irin 12 (

dail- after sus$ected acute "#

$revented about '0 deat&s9 nonfatal

reinfarctions9 or stro@es $er 1000

$atients treated and t&ese earl-

bene8ts $ersisted for at least 10

-ears5.

AS'>'N



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'. Clo$idorela. #ndication All ACS $atient for anti$latelet

areation

b. Contraindication Active bleedin or bleedin

tendenc-c. Dosae

?oadin dose of 300 ( on ti(e Patient : ;0 -o use (aintenance

dose of ;) (e. &era$- bene8t

#($rove survival and outco(e

Clopidogrel


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Clopidogrel



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). "or$&inea. #ndication C&est $ain not res$ondin to nitrate Pul(onar- oede(a

b. Contraindication Hi$otension Bi&t ventricular infarction

c. Dosae

27'( #J =)730(in9 titrate to eecte. Close (onitor to

lood $ressure C4S/res$irator- de$ression


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>esume

ACS is a ,atal cardiac emergency 5ith a risingincidence and high mortality and mor-idity

ACS diagnosis is a clinical diagnosis0C3 role is not important in diagnosing ACS

>ecent advances in treatment o, ACS has

proven to have a huge mortality -ene/t

he treatment mortality -ene/t startseven ,rom the initial treatment given


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+Saving peoples ,romheart attac* starts ,rom you.

han* You

2. acute coronary syndrome

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