ACUTE CORONARY

SYNDROME
Jose Socrates Dee Matuod Evardone
Cardiology RIC
Level II CDUH-IM
JULY 2015
 CASE
Profile:

78F, Filipino
Hypertensive,
Non-DM,
Non-smoker,
Non-alcoholic beverage drinker

CC: CHEST PAIN

 CASE
HPI:
2 hours PTA- sudden onset of squeezing,
retrosternal chest pain, radiating towards the neck,
associated with headache. (+) Vomiting x1, pain
score of 8/10, not relieved by rest, about >10
minutes. Admitted at primary hospital and managed
as essential hypertension with NSSTWCs on ECG.

Subsequently transferred to a Tertiary level for

further workup and management
 Physical Exam CASE
BP: 130/60mmHg,
HR: 118 bpm,
RR: 26 cpm,
Awake, coherent, in 99% O2 mp: 36.5 Warm, good turgor
mild distress and mobility, CRT <2
seconds,
Anicteric sclerae, pink
palpebral Neck: No JVD, no
conjunctivae, murmur

Distinct heart sounds, , Flat, Normoactive

tachycardic, regular, bowel sounds, soft, no
no murmur organomegaly
Strong peripheral
Equal chest pulses, no edema
expansion, dec BS on
both lower lung fields, Neurologic: WNL
with crackles
 CASE
IMPRESSION:

1) NSTE-ACS (UA vs NSTEMI)

2) HCVD
 CASE
DIAGNOSTICS:
ECG Sinus Rhythm with NSSTWCs
CXR Beginning congestion,
inflammatory process bilaterally
Troponin I 3.13 (elevated)
 CASE
MANAGEMENT: (ER)
Aspirin 80 mg 4 tabs chewed, swallowed
Clopidogrel 75mg , 4 tabs
Clexane 0.4cc
Attached to cardiac monitor
Advised ICU/CCU admission
ACUTE CORONARY SYNDROME
SOURCES:
ACUTE CORONARY SYNDROME

I: Diagnosis and Management of Patients with Stable

Ischemic Heart Disease

II: Diagnosis and Management of Patients with

Non-ST Elevation Acute Coronary Syndrome

III: Diagnosis and Management of Patients with

ST Segment Elevation Myocardial Infarction
 ACUTE CORONARY SYNDROME
What is ACS?

- refers to a spectrum of clinical presentations

ranging from those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in nonST-
segment elevation myocardial infarction (NSTEMI) or in
unstable angina
- in general reserved for ischemia precipitated by
acute coronary atherothrombosis
Ischemic
Heart
Disease
ACUTE CORONARY SYNDROME
Ischemic Heart
Disease

Chronic coronary artery

disease (CAD) with Acute Coronary
Syndrome
STABLE ANGINA

STEMI

1) NSTEMI-ACS
2) Unstable Angina
 ACUTE CORONARY SYNDROME
Classic manifestation of ischemia is angina pectoris:
Pressure,
Tightness,
Squeezing,
Heaviness,
Burning

ACS most commonly occurs without obvious precipitating

factors
Coronary Circulation
Coronary Circulation
Coronary Circulation
LOCALIZATION OF CORONARY CIRCULATION IN
M.I.
ANATOMIC ECG LEADS CORONARY ARTERY

Septal V1-v2 Proximal LAD

Anterior V3-V4 LAD
Apical V5-V6 Distal LAD, LCx, or RCA
Lateral I, aVL LCx
Inferior II, III, aVF RCA(85%), LCx (15%)
RV V1-V2 & V4R (most Se) Proximal RCA
Posterior ST depression V1-V3 RCA or LCx
ACUTE CORONARY SYNDROME
ACUTE CORONARY SYNDROME
 ACUTE CORONARY SYNDROME
The American
College of Cardiology (ACC) and American Heart Association (AHA)
guidelines list the following as pain descriptions uncharacteristic of
myocardial ischemia:
Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory
movements or coughing)
Primary or sole location of the discomfort in the middle or lower
abdominal region
Pain that may be localized by the tip of one finger, particularly over
the left ventricular apex
Pain reproduced with movement or palpation of the chest wall or
arms
Constant pain that persists for many hours
Very brief episodes of pain that last a few seconds or less
Pain that radiates into the lower extremities
ISCHEMIC HEART DISEASE
 Ischemic Heart Disease
The major determinants of myocardial oxygen
demand (MVO2) are:
1) heart rate,
2) myocardial contractility, and
3) myocardial wall tension (stress)

About 75% of the total coronary resistance to flow occurs

across three sets of arteries:
(1) large epicardial arteries (Resistance 1 = R1),
(2) prearteriolar vessels (R2), and
(3) arteriolar and intramyocardial capillary vessels (R3)
 Ischemic Heart Disease
Coronary Blood Flow Limitation:
spasm,
arterial thrombi, and,
rarely, coronary emboli
as well as by ostial narrowing due to aortitis
Congenital Anomalies

50% Stenosis:
there is a limitation of the ability to increase flow to
meet increased myocardial demand.
80% Stenosis:
myocardial ischemia at rest or with minimal stress
ACUTE CORONARY SYNDROME
 Ischemic Heart Disease

The severity and duration of the imbalance between

myocardial oxygen supply and demand determine
whether the damage is :

reversible (20 min for total occlusion in the absence

of collaterals) or
permanent, with subsequent myocardial necrosis
(>20 min).
ACUTE CORONARY SYNDROME

Evaluation
of the
patient
with known
or
suspected
ischemic
heart
disease
 Indications and Contraindications for Exercise
Electrocardiographic Testing in the Emergency Department
Requirements :
Two sets of cardiac enzymes at 4-hr intervals should be normal
ECG at the time of arrival and preexercise 12-lead ECG show no
significant abnormality
Absence of rest electrocardiographic abnormalities that would preclude
accurate assessment of the exercise ECG
From admission to the time that results are available from the second set
of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms,
or persistent atypical symptoms
Absence of ischemic chest pain at the time of exercise testing
Contraindications
New or evolving electrocardiographic abnormalities on the rest tracing
Abnormal cardiac enzyme levels
Inability to perform exercise
Worsening or persistent ischemic chest pain symptoms from admission to the
time of exercise testing
Clinical risk profiling indicating that imminent coronary angiography is likely
 C S
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ISCHEMIC HEART DISEASE
 STABLE ISCHEMIC HEART DISEASE
Laboratory Tests:
1. Fasting lipid profile

2. Fasting glucose and/or glycated hemoglobin (HbA1c) level if

available; additional oral glucose tolerance test (OGTT) if
both are inconclusive;
3. Complete blood count (CBC);

4. Creatinine level with estimation of glomerular filtration rate

(GFR);
5. Biochemical markers of myocardial injury (Troponin T or I) if
clinical evaluation suggests an Acute Coronary Syndrome
(ACS);
6. Thyroid hormone levels

7. Liver function tests early after beginning statin therapy.

 ISCHEMIC HEART DISEASE
Pre-Test Probability (PTP) Assessment
Diamond and Forrester pre-test probability of cad by age, sex and symptoms
ISCHEMIC HEART DISEASE
 ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Non-invasive stress testing
Stress Imaging
ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
 ISCHEMIC HEART DISEASE
ESTABLISHING DIAGNOSIS
Exercise ECG (Treadmill Exercise Test or TET)

its simplicity, lower cost and widespread availability, the

TET is the initial test of choice to identify inducible
ischemia in the majority of patients with intermediate PTP
who are able to exercise

The low sensitivity of the TET (45% to 50%) despite a high

specificity (85% to 90%) is the reason why it is not
recommended in patients with a PTP greater than 65%

In the latter case,a stress imaging study is more

appropriate.
 ISCHEMIC HEART DISEASE
CORONARY ARTERIOGRAPHY
Coronary arteriography is indicated in:
(1) patients with chronic stable angina pectoris who are severely
symptomatic despite medical therapy and are being considered
for revascularization, i.e., a percutaneous coronary intervention
(PCI) or coronary artery bypass grafting (CABG);
(2) patients with troublesome symptoms that present diagnostic
difficulties in whom there is a need to confirm or rule out the
diagnosis of IHD;
(3) patients with known or possible angina pectoris who have
survived cardiac arrest;
(4) patients with angina or evidence of ischemia on noninvasive
testing with clinical or laboratory evidence of ventricular
dysfunction; and
(5) patients judged to be at high risk of sustaining coronary
events based on signs of severe ischemia on noninvasive testing,
regardless of the presence or severity of symptoms
 ISCHEMIC HEART DISEASE

MANAGEMENT
Lifestyle Modification and Treatment of Risk Factors
1) Healthy Diet
2) Physical Activity
3) Hypertension
4) Smoking
5) DM
6) Weight Management
7) Lipid Management
 ISCHEMIC HEART DISEASE
MANAGEMENT
Pharmacologic Therapy to Improve Prognosis
Whether or not revascularization is being considered,
receive the following medications to improve prognosis,
thereby reducing the risk for MI and death:
1. Aspirin low-dose (80 to 160 mg/day)
2. Clopidogrel in case of aspirin intolerance (75 mg/day)
3. Statins irrespective of LDL-cholesterol levels
4. Beta blockers post-MI
5. ACEIs or ARBs (especially in patients with concomitant HF,
hypertension or diabetes)
Pharmacologic Therapy to Improve Prognosis
Pharmacologic Therapy to Improve Prognosis
Pharmacologic Therapy to Improve Prognosis
R
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Non-ST-Segment Elevation
Acute Coronary Syndrome

(Non-ST-Segment Elevation
Myocardial Infarction and
Unstable Angina)
 NSTE-ACS
Pathophysiology:
1. imbalance between oxygen supply and oxygen
demand resulting from a partially occluding
thrombus forming on a disrupted
atherothrombotic coronary plaque or on
eroded coronary artery endothelium
2. dynamic obstruction
3. severe mechanical obstruction
4. increased myocardial oxygen demand
NSTE-ACS
NSTE-ACS
 NSTE-ACS
DIAGNOSIS:
Clinical :
(1) it occurs at rest (or with minimal exertion),
lasting >10 minutes;
(2) it is of relatively recent onset (i.e., within the
prior 2 weeks); and/or
(3) it occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than
previous episodes)

NSTEMI - elevated levels of biomarkers of cardiac necrosis

 NSTE-ACS
DIAGNOSIS:
3 major noninvasive tools are used in the
evaluation of NSTEMI-ACS:
1. the electrocardiogram (ECG),
2. cardiac biomarkers, and
3. stress testing
GOALS :
(1) recognize or exclude myocardial infarction (MI) using
cardiac biomarkers, preferably cTn;
(2) detect rest ischemia (using serial or continuous ECGs);
and
(3) detect significant coronary obstruction at rest with CCTA
and myocardial ischemia using stress testing
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 MEDICAL TREATMENT
Bed rest
Continuous ECG monitoring
Ambulation only if
No recurrence of ischemia (symptoms or ECG changes)
Does not develop an elevation of a biomarker of necrosis for
1224 h

ANTI-ISCHEMIC ANTITHROMBOTIC
 NSTE-ACS
Drugs Commonly Used in Intensive Medical Management of
Patients with UA and NSTEMI
 NSTE-ACS
MEDICAL
TREATMENT

ANTI-ISCHEMIC ANTITHROMBOTIC
THERAPY THERAPY

antiplatelet drugs

anticoagulants.
 NSTE-ACS
ORAL ANTIPLATELETS

Aspirin Initial dose of 325 mg nonenteric formulation followed by 75100

mg/d of an enteric or a nonenteric formulation

Clopidogrel Loading dose of 300600 mg followed by 75 mg/d

Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d

Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily

Intravenous Antiplatelet Therapy

Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 g/ kg per min

(maximum 10 g/min) for 1224 h
Eptifibatide 180 g/kg bolus followed 10 min later by second bolus of 180 g
with infusion of 2.0 g/kg per min for 7296 h following first bolus

Tirofiban 5 g/kg per min followed by infusion of 0.15 g/kg per min for 48
96 h
 NSTE-ACS
HEPARINS
Unfractionated Bolus 70100 U/kg (maximum 5000 U) IV followed
heparin by infusion of 1215 U/kg per h (initial maximum
(UFH) 1000 U/h) titrated to ACT 250300 s
Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded
by a 30-mg IV bolus; renal adjustment to
1 mg/kg once daily if creatine clearance <30 cc/min
Fondaparinux 2.5 mg SC qd

Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of

1.75 mg/kg per h.
 NSTE-ACS
Class I Recommendations for Use of an Early Invasive
Strategy in Patients with Non-ST-Segment Elevation
Acute Coronary Syndrome:
Class I (Level of Evidence: A) Indications
1. Recurrent angina at rest/low-level activity despite treatment
2. Elevated TnT or TnI
3. New ST-segment depression
4. CHF symptoms, rales, MR
5. EF <0.40
6. Sustained VT
7. PCI <6 months, prior CABG
8. High-risk findings from noninvasive testing
9. Hemodynamic instability
10. Mild-to-moderate renal dysfunction
11. Diabetes mellitus
12. High TIMI Risk Score (>3)b
 NSTE-ACS
PRINZMETALS VARIANT ANGINA
- syndrome of severe ischemic pain that usually occurs at rest and
is associated with transient ST segment elevation
- focal spasm of an epicardial coronary artery, leading to severe
transient myocardial ischemia and occasionally infarction
- may be related to hypercontractility of vascular smooth muscle
due to adrenergic vasoconstrictors, leukotrienes, or serotonin
- has decreased substantially during the past few decades

- PVA are generally younger and have fewer coronary risk factors

- The clinical diagnosis of PVA is made by the detection of

transient ST-segment elevation with rest pain
- Focal spasm is most common in the right coronary artery
 NSTE-ACS
PRINZMETALS VARIANT ANGINA
Diagnosis:
Hyperventilation or intracoronary acetylcholine has been
used to provoke focal coronary stenosis on angiography or to
provoke rest angina with ST-segment elevation to establish the
diagnosis
TREATMENT
Nitrates and Calcium Channel Blockers
Aspirin- may actually increase the severity of ischemic
episodes

PROGNOSIS
1. Survival at 5 years is excellent (9095%)
2. Nonfatal MI occurs in up to 20% of patients by 5 years
3. There is a tendency for symptoms
4. and cardiac events to diminish over time
 NSTE-ACS

CORONARY ANGIOGRAPHY

IS NOT RECOMMENDED in patients with

extensive co-morbidities (e.g., liver or pulmonary
failure; cancer);
in whom the risks of revascularization are not likely to
outweigh the benefits;
in patients with acute chest pain and a low likelihood
of ACS;
or in patients who will not consent to
revascularization regardless of the findings.
 NSTE-ACS

Revascularization by PCI

PCI IS RECOMMENDED for NSTE-ACS patients with

1- to 2-vessel CAD, with or without significant proximal
left anterior descending CAD, but with a large area of
viable myocardium and high-risk criteria on
noninvasive testing.
 NSTE-ACS

Revascularization by CABG Surgery

CABG IS RECOMMENDED for patients with

1. significant left main disease, and is the
preferred revascularization strategy for
patients with
2. multi-vessel coronary disease;
3. vessels with lesions not favorable for PCI;
4. depressed systolic function (LVEF lower than
50%); and diabetes.
 NSTE-ACS

Drug/Medication Management

Strongly RECOMMENDED for patients with

1. aspirin indefinitely, and ticagrelor 90 mg twice daily
or clopidogrel 75 mg daily, for 12 months
2. underwent stenting, with aspirin indefinitely, plus
ticagrelor 90 mg twice daily or prasugrel 10 mg
daily or clopidogrel 75 mg daily, for 12 months in
patients with drug-eluting stents, and 6 months in
patients with bare metal stents
3. beta blockers be continued indefinitely for all NSTE-
ACS patients unless contraindicated
ST-Segment Elevation
Myocardial Infarction
(STEMI)
ACUTE CORONARY SYNDROME
ACUTE CORONARY SYNDROME
 STEMI
Criteria for Acute Myocardial Infarction
Detection of a rise and/or fall of cardiac biomarker values
(preferably cardiac troponin [cTn]) with at least one value
above the 99th percentile upper reference limit (URL) and
with at least one of the following:
Symptoms of ischemia
New or presumed new significant ST-segment T-wave (ST-T) changes or
new left bundle branch block (LBBB)
Development of pathologic Q waves in the electrocardiogram (ECG)
Imaging evidence of new loss of viable myocardium or new regional wall
motion abnormality
Identification of an intracoronary thrombus by angiography or autopsy

Cardiac death with symptoms suggestive of myocardial ischemia and

presumed new ischemic ECG changes of new LBBB, but death occurred
before cardiac biomarkers were obtained or before cardiac biomarker values
would be increased.
 STEMI
Criteria for Acute Myocardial Infarction
Percutaneous coronary intervention (PCI)related MI is arbitrarily defined by
elevation of cTn values (>5 99th percentile URL) in patients with normal baseline
values (99th percentile URL) or a rise of cTn values >20% if the baseline values are
elevated and are stable or falling. In addition, either
(i) symptoms suggestive of myocardial ischemia, or
(ii) new ischemic ECG changes, or
(iii) angiographic findings consistent with a procedural complication, or
(iv) imaging demonstration of new loss of viable myocardium or new regional wall motion
abnormality are required.

Stent thrombosis associated with MI when detected by coronary angiography or

autopsy in the setting of myocardial ischemia and with a rise and/ or fall of cardiac
biomarker values with at least one value above the 99th percentile URL.

Coronary artery bypass grafting (CABG)related MI is arbitrarily defined by

elevation of cardiac biomarker values (>10 99th percentile URL) in patients with
normal baseline cTn values (99th percentile URL). In addition, either
(i) new pathologic Q waves or new LBBB, or
(ii) angiographic documented new graft or new native coronary artery occlusion, or
(iii) imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality.
 STEMI

Classification of Myocardial Infarction

Type I: Spontaneous Myocardial Infarction

Type 2: Myocardial Infarction Secondary to an Ischemic
Imbalance
Type 3: Myocardial Infarction Resulting in Death When
Biomarker Values Are Unavailable
Type 4a: Myocardial Infarction Related to Percutaneous
Coronary Intervention (PCI)
Type 4b: Myocardial Infarction Related to Stent Thrombosis
Type 5: Myocardial Infarction Related to Coronary Artery
Bypass Grafting (CABG
 STEMI
MEDICAL
TREATMENT

ANTI-ISCHEMIC ANTITHROMBOTIC
FIBRINOLYSIS
THERAPY THERAPY

Antiplatelet drugs

Anticoagulants
 STEMI
MANAGEMENT IN THE EMERGENCY DEPARTMENT
the goals for the management of patients with suspected
STEMI include:
1. control of cardiac discomfort,

2. rapid identification of patients who are candidates for

urgent reperfusion therapy,
3. triage of lower-risk patients to the appropriate location
in the hospital, and
4. avoidance of inappropriate discharge of patients with
STEMI
Aspirin
is essential in the management of patients with suspected STEMI and is effective across
the entire spectrum of acute coronary syndromes

OXYGEN
O2 should be administered by nasal prongs or face mask (24 L/min) for
the first 612 h after infarction
 STEMI
CONTROL OF DISCOMFORT
1) Sublingual nitroglycerin
Up to three doses of 0.4 mg should be administered at about 5-min intervals
2) Morphine
3) Intravenous beta blockers/ Oral Beta blockers
in the first 24 h for patients who do not
have any of the following:
(1) signs of heart failure,
(2) evidence of a low-output state,
(3) increased risk for cardiogenic shock, or
(4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds,
second- or third-degree heart block, active asthma, or reactive airway disease).
Fifteen minutes after the last intravenous dose, an oral
regimen is initiated of 50 mg every 6 h for 48 h, followed by 100
mg every 12 h
STEMI
 STEMI

Initial ER Management

Aspirin 160 to 320 mg tablet (non-enteric coated, chewed);

Clopidogrel 300 to 600 mg whether or not fibrinolysis will be
given;
Clopidgrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when
a patient will undergo PCI;
Nitrates, either via sublingual or intravenous(IV) routes. Nitrates
are contraindicated in patients with hypotension or those who
took a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs
for tadalafil);
Morphine 2 to 4 mg IV for relief of chest pain, and;
Supplemental oxygen MAY BE RECOMMENDED during the first 6
hours to patients with arterial oxygen saturation of less than 90%.
 STEMI

In-hospital Treatment

Reperfusion therapy IS RECOMMENDED to all eligible

patients with STEMI with symptom onset within the
prior 12 hours.
Early revascularization, the goal being 12 hours, is a
primary treatment goal in patients with STEMI
STEMI
 STEMI
Fibrinolysis

TPA 15-mg bolus followed by

50 mg intravenously over the first 30 min,
followed by 35 mg over the next 60 min

Streptokinase 1.5 million units (MU) intravenously over 1 h

Tenecteplase given as a single weight-based intravenous bolus
(TNK) of 0.53 mg/kg over 10 s
double-bolus regimen consisting of a 10-MU
Reteplase (rPA) bolus given over 23 min, followed by
second 10-MU bolus 30 min later
STEMI
STEMI
 STEMI
TIMI
TIMI FLOW GRADE The degree of perfusion in the
infarct-related artery (IRA) is typically described by the TIMI
flow grade:

TIMI 0 refers to the absence of antegrade flow beyond a

coronary occlusion.
TIMI 1 flow is faint antegrade coronary flow beyond the
occlusion, although filling of the distal coronary bed is
incomplete.
TIMI 2 flow is delayed or sluggish antegrade flow with
complete filling of the distal territory.
TIMI 3 flow is normal flow which fills the distal coronary
bed completely.
 STEMI
Primary Percutaneous Coronary
Intervention (PCI)

1. RECOMMENDED in patients with STEMI and ischemic

symptoms of less than 12 hours duration
2. RECOMMENDED in patients with STEMI and ischemic
symptoms of less than 12 hours duration who have
contraindications to fibrinolytic therapy, irrespective of
the time delay from first medical contact.
3. RECOMMENDED in patients with STEMI and cardiogenic
shock or acute severe heart failure (HF), irrespective of
time delay from MI onset
4. MAY BE RECOMMENDED in patients with STEMI if there is
clinical and/or ECG evidence of ongoing ischemia between
12 and 24 hours after symptom onset
 STEMI
Coronary Artery Bypass Grafting (CABG)

1. IS RECOMMENDED in failed PCI with persistent pain or

hemodynamic instability in patients with coronary anatomy
suitable for surgery
2. IS RECOMMENDED in persistent or recurrent ischemia
refractory to medical therapy in patients who have coronary
anatomy suitable for surgery, and are not candidates for PCI
or fibronolytic therapy
3. RECOMMENDED in patients with STEMI at the time of
operative repair of mechanical defects.
 STEMI
Antiplatelets and Antithrombotics

1. It IS RECOMMENDED that aspirin should be used

indefinitely in all patients with STEMI with a dosage of 80 to
100 mg/day.
2. It IS RECOMMENDED that clopidogrel 75 mg per day orally
should be added to aspirin in patients with STEMI and
maintained for at least 14 days
3. It IS RECOMMENDED that patients who are truly intolerant
to aspirin can instead receive clopidogrel 75 mg per day as
long-term secondary prevention
 STEMI
Duration of Dual Antiplatelet Therapy and Antithrombotic
Combination Therapies after STEMI

1. Combination Therapies after STEMI DAPT by combining

aspirin and an ADP-receptor blocker (clopidogrel, prasugrel
or ticagrelor) IS RECOMMENDED in patients with STEMI
who are undergoing primary PCI (for up to 12 months) or
(clopidogrel) fibrinolysis (for up to 12 months, although the
data available pertain only to one month of DAPT), and in
those who have not undergone reperfusion therapy (for at
least 1 month and up to 12 months).
 STEMI
Lipid Lowering Agents

1. High-dose statins are RECOMMENDED in all patients during

the first 24 hours of admission for STEMI, irrespective of the
patients cholesterol concentration, in the absence of
contraindications (allergy, active liver disease).
2. Atorvastatin or Rosuvastatin are recommended during the
early phase of therapy up to at least four weeks.
3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to
40 mg) or atorvastatin (40 to 80 mg) therapy before
emergency percutaneous coronary intervention to
1. reduce periprocedural inflammatory response,
2. to reduce myocardial dysfunction, and
3. to prevent contrast-induced nephropathy
THANK YOU
ACUTE CORONARY SYNDROME
STABLE ISCHEMIC HEART DISEASE
Recommended:
Echocardiography
Ambulatory ECG Monitoring
Ischemic Heart Disease
Ischemic Heart Disease
STABLE ISCHEMIC HEART DISEASE
STABLE ISCHEMIC HEART DISEASE
STABLE ISCHEMIC HEART DISEASE
ACUTE CORONARY SYNDROME
ACUTE CORONARY SYNDROME
RISK FACTORS
STEMI
STEMI
ACUTE CORONARY SYNDROME
Definition of Myocardial Infarction
ACUTE CORONARY SYNDROME
Classification of Myocardial Infarction