Acute Coronary SyndromeAcute Coronary Syndrome

First Department of CardiologyMedical University of Gdańsk

Krzysztof Chlebus M.D., Ph. D., FESC

Worldwide StatisticsWorldwide Statistics

Each year:Each year:

•• > 4 million patients are admitted with > 4 million patients are admitted with

unstable angina and acute MI unstable angina and acute MI

•• > 900,000 patients undergo PTCA with or > 900,000 patients undergo PTCA with or

without stentwithout stent

EpidemiologyEpidemiology

NN CountriesCountries STESTE--ACSACS nonnon--STESTE--ACSACS

Euro Euro HeartHeart SurveySurvey 10 48410 484 25 25 EuropeEurope 42,3%42,3% 51,2%51,2%

GRACEGRACE 11 54311 543 14 14 WorldWorld 30%30% 63%63%

Cumulative 6Cumulative 6--month mortality month mortality

from ischemic heart diseasefrom ischemic heart disease

0 1 2 3 4 5 6

5

10

0

15

20

25

Months after hospital admission

Dea

ths

/ 100

pts

/ m

onth

Acute MIUnstable anginaStable angina

Duke Cardiovascular Database

N = 21,761; 1985-1992Diagnosis on adm to hosp

Ischemic Heart DiseaseIschemic Heart Disease

evaluationevaluation

•• Based on the patientBased on the patient’’ss

–– history / physical examhistory / physical exam

–– electrocardiogramelectrocardiogram

•• Patients are categorized into 3 groupsPatients are categorized into 3 groups

–– nonnon--cardiac chest paincardiac chest pain

–– unstable anginaunstable angina

–– myocardial infarctionmyocardial infarction

Classification of ACS

Traditional way:

unstabile angina

subendocardial MI

transmural MI

sudden cardiac death

Klasyfikacja ostrych zespołów wieńcowych

Podejście obecne:

Rozpoznanie wstępne

Bez przetrwałego uniesienia ST

Z przetrwałym uniesieniem ST

Końcowa diagnoza:

Niestabilna choroba wieńcowa

Zawał serca z uniesieniami ST

Zawał serca bez uniesienia ST

Nagły zgon sercowy

Acute Coronary SyndromeAcute Coronary Syndrome

The spectrum of clinical conditions The spectrum of clinical conditions

ranging from:ranging from:

unstable anginaunstable angina

nonnon--Q wave MIQ wave MI

QQ--wave MIwave MI

characterized by the common characterized by the common

pathophysiology of a disrupted pathophysiology of a disrupted

atherosleroticatheroslerotic plaqueplaque

Acute Coronary SyndromeAcute Coronary Syndrome((atat admissionadmission))

no ST-segment elevation ST-segment elevation

TNT+TNT+ TNT+TNT+ CKMB+CKMB+

unstabileunstabile anginaangina nonnon--QQ AMIAMI Q Q wavewave AMIAMI

Acute Coronary SyndromeAcute Coronary Syndrome((atat admissionadmission))

no ST-segment elevation ST-segment elevation

TNT+TNT+ TNT+TNT+ CKMB+CKMB+

unstabileunstabile anginaangina non STEMInon STEMI STEMISTEMI

Chronology of the interface between the patient and the clinician through the progression of plaque formation and the onset of complications of STEMI.

Management Before STEMI

41 2 3 4 5 6

Onset of STEMI- Prehospital issues- Initial recognition and management

in the Emergency Department (ED)- Reperfusion

Hospital Management- Medications- Arrhythmias- Complications- Preparation for discharge

Secondary Prevention/Long-Term Management

Presentation

Working Dx

ECG

Cardiac Biomarker

Final Dx

UA

NQMI QwMI

No ST Elevation

NSTEMI

Ischemic DiscomfortAcute Coronary Syndrome

UnstableAngina

Myocardial Infarction

ST Elevation

Modified from Libby. Circulation 2001;104:365, Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.

Patomechanizm ostrych zepołówwieńcowych

Odczyn zapalny jako przyczyna wystąpienia OZW

Teoria niestabilnej blaszki miażdżycowej

Klasyczne czynniki ryzyka OZW

• wysiłek fizyczny

• silny stres emocjonalny

Circulation 14 X 2003, 1664Circulation 14 X 2003, 1664

The same lumendifferent plaques

TheThe same lumensame lumen

differentdifferent plaquesplaques

Acute Coronary SyndromeAcute Coronary Syndrome

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