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Assistant Professor & Head

Department of Cardiology

PUMHSW, Nawabshah (SBA).

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ACS;STEMI/NSTEMI;

Pathophysiology Coronary plaque fissuring & rupture

Platelet aggregation & activation

Activation of coagulation cascade

Generation of Thrombin

Formation of thrombus

Vasospasm

Complete occlusion of coronary vessel

In absence of collaterals lead to STEMI

Partial obstruction--------NSTEMI

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Differential Diagnosis

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ACS; Clinical Diagnosis History

ECG within 5 minutes of presentation

MONA(Previous guidelines)

Establishment of eligibility criteria for reperfusiontherapy

ST-segment elevation of >1mm in at least two contiguousleads

New or presumably new onset LBBB. No contraindication to fibrinolytic therapy.

Window period.

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ACS; Initial Management Admit in CCU.

MONA; Morphine, Oxygen, NG, Aspirin.

I/V line.

History & Examination ( Rapid ).

ECG; Thrombolytic???

Blood chemistry, Cardiac Enzymes.

CXR ( Portable ).

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ACS; Examination Not helpful in diagnosis of AMI but it is helpful in

excluding other D/D

Heamodynamic status of patient with MI Mechanical complication of MI

Evidence of risk factors

Evidence of other co-existing disease

Risk stratification

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STEMI; Exam:Risk stratification KILLIP CLASSIFICATION Class Characteristics Pts; Mortality

I No evid; of HF 85% 5%

II Rales, JVP,or S3 13% 13.6%

III Pulm; edema 1% 32.2%

IV Card; shock 1% 57.8%

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ACS; Antiplatelates

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ACS; Management Anti-coagulant therapy

heparin, low molecular weight heparin (LMWH), warfarin, hirudin, hirulog

Thrombolytics are not indicated

“lytic agents may stimulate the thrombogenic process and result in paradoxical aggravation of

ischemia and myocardial infarction”

TIMI IIIB Investigators

Circulation 1994; 89:1545-1556

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ACS; Management

Beta Blockers

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ACS; Management a

ACEI

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ACS; Management

Nitrates

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ACS; Management

Statins

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ACS; Management General care

Diet Bowel

Sleep

Mobilization

DM management if diabetic

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UA/NSTEMI; Risk Stratification.

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UA/NSTEMI; Cardiac Catheterization

Indications Prior revascularization (PCI or CABG).

CHF.

Depressed LV function (EF<50%). Malignant Ventricular Arrhythmias.

Persistent or Recurrent angina or ischemia

Large perfusion defect on non-invasive functionaltest.

Significant valvular heart disease.

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UA/NSTEMI; CABG/PCI Age

Co morbidities

Severity of CAD Prior revascularization procedures

Technical feasibility

Durability of percutaneous revascularization

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AU/NSTEMI; CABG vs PCI CABG preferred if;

DM

LVD Significant burden of CAD:

LMD

3-VD

2-VD with proximal LAD, LVD or ischemia on stress testing.

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UA/NSTEMIDESPITE OPTIMUM MEDICAL TREATMENT

PATIENTS ARE AT RISK OF;

RECURRENT ANGINA MI

DEATH

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UA/NSTEMI; EARLY DETERMINATION OF CORONARY

ANATOMY MAY IDENTIFY THE PATIENTS THAT WOULD BE MOST APPROPRIATELY TREATED WITH PCI OR SURGICAL REVASCULARIZATION,THEREFORE REDUCING COSTS, HOSPITAL ADMISSIONS AND LENGTH OF STAY

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USA/NSTEMI: TREATMENT THE ULTIMATE GOAL OF TREATMENT IS :

RESTORATION OF MYOCARDIAL

PERFUSION THROUGHRESTORATION OF CORONARYBLOOD FLOW

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USA/NSTEMI: Catheter based

Reperfusion

PERCUTANEOUS CORONARY INTERVENTION(PCI)

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REPERFUSION: STEMI

RESTORATION OF BLOOD FLOW Targets

Fibrinolytic: Door to needle time <30 minutes

Cath based: Door to balloon time <90minutes

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STEMI; Fibrinolytic therapy Streptokinase

Alteplase

Reteplase

Tenekteplase

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STEMI; Cntraindications for Fibrinolytic

therapy Absolute

Any prior intracranial hemmorhage

AVM Malignant intracranial neoplasm

Ischemic stroke <3 months except < 3hrs

Suspected aortic dissection

Active bleeding or bleeding diathesis Significant closed head or facial trauma <3month

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STEMI; contraindications for thrombolytic

therapy Relative

H/O chronic severe poorly controlled HTN

Severe uncontrolled HTN on presentation (SBP>180 &

DBP>110) History of prior ischemic stroke>3months, dementia, or

known intracranial pathology

Traumatic or prolonged CPR(.10 min) or major surgery

<3weeks Recent internal bleeding

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STEMI; Relative contraindications for

thrombolytic therapy; cntd Non compressible vascular punctures

Prior exposure to streptokinase >5 days or allergicreaction

Pregnancy

Active peptic ulcer

Current use of anticoagulants: Higher the INR, higher

the risk of bleeding

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STEMI; Catheter based Reperfusion POBA

Primary angioplasty ( PCI )

Rescue angioplasty

Facilitated angioplasty

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PCI: Percutaneous Coronary

Intervention

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PCI

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THANKYOU

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