Management of acute coronary

syndromes (ACS)

This presentation reflects the recommendations in the National Heart Foundation of Australia/Cardiac
Society of Australia and New Zealand’s Guidelines for the Management of Acute Coronary Syndromes
(ACS) (2006), updated in the 2007 and 2011 addenda. The presentation is designed for use in health
professional development and training on acute ACS care.
 Outline
• Cardiovascular disease (CVD) – the facts and risk factors
• Acute coronary syndromes (ACS)
• Presentation of ACS
 ACS management: summary of updates in the 2011 addendum1
1. Systems of care
2. Investigations
3. Management of patients with ST-segment elevation myocardial
infarction (STEMI)
4. Management of patients with non-ST-segment elevation ACS (NSTEACS)
5. Long-term management

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand
guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
 CVD – the facts
• Heart disease is the single leading
cause of death.

• In 2009, 28 Australians died from a

heart attack each day. That’s one life
claimed every 51 minutes.1

• CVD is expected to affect 1 in 4

Australians by 2051.2

References
1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.
2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.
Risk factors for CVD
Modifiable risk factors(Those Non-modifiable risk
which can be altered to reduce factors(those which cannot be
CV risk): altered)
• smoking • gender
• poor diet • age
• high cholesterol • family history of CVD
• physical inactivity • diabetes
• high blood pressure • human immunodeficiency virus
• being overweight (HIV).
• depression, social isolation and
lack of social support.
 Acute coronary syndromes (ACS)

• ACS is a broad spectrum of clinical presentations, spanning

STEMI/NSTEMI(heart attack) as well as angina, which is just chest
pain without evidence of myonecrosis1/infarction (muscle death).
• Myocardial infarction (MI) occurs when the blood supply to the
heart muscle is interrupted due to partial or complete occlusion
(thrombus) of the coronary artery. As a result, some of the heart
muscle becomes infarcted (dies).
• A heart attack can be confirmed by an electrocardiogram (ECG) test.

Reference
1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1–S14.
Thrombus formation in the arterial lumen
Acute presentation of ACS
• Critical factors to timely Heart attack
treatment:
 recognition

 time

• People experiencing ACS

symptoms should seek
help promptly and activate
emergency services.
Signs and symptoms of
ACS presentation
Symptoms may include:
• chest discomfort (tightness, pressure, heaviness) at rest or for a
prolonged period (> 10 minutes, not relieved by sublingual nitrates)
• repeated chest discomfort
• discomfort associated with syncope/acute heart failure.

The pain may spread to other parts of the upper body, including:
• back, neck, jaw, arm(s), shoulder(s) or epigastric pain.

The person may also experience:

• dyspnoea (shortness of breath), diaphoresis (profuse perspiration),
dizziness, nausea or vomiting
• recent research shows that women, the elderly and people with
diabetes are less likely to experience chest pain as a symptom.
 2011 addendum to 2006 Guidelines

The 2011 addendum to the 2006 Guidelines provides

updates to:
1. Systems of care to support delivery of ACS services
2. Early response
3. Management of patients with STEMI
4. Management of patients with NSTEACS
5. Long-term management (after control of myocardial
ischaemia).1

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the
management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
1. Systems of care to support delivery of
ACS services
Formal systems of care:
• defined continuum of care – from presentation to long-term management
• system-based approaches to deliver timely reperfusion at a local level (Grade B)
• routine audit integrated into all clinical ACS services (Grade B)
• training GPs/health workers to initiate fibrinolysis (if primary percutaneous coronary
intervention [PCI] services are not readily accessible)
• practitioners are supported by ready access to expert cardiology consultation (Consensus)
• cardiac clinical networks established with appropriate protocols (Grade B).

For example: iCCnet CHSA network links > 70 hospitals, health centres and general
practitioner [GP] surgeries across SA, aligned to the Health Reform Agenda principles.
2. Early response: Timely treatment is critical
Time from symptom onset and likely outcome

< 1 hour
Aborted heart attack or only little heart muscle damage

1–2 hours
Minor heart muscle damage only

2–4 hours
Some heart muscle damage with moderate heart muscle salvage

4–6 hours
Significant heart muscle damage with only minor heart muscle salvage

6–12 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit

> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable

In cases of major delay to hospitalisation (> 30 minutes) ambulance

crews should consider pre-hospital fibrinolysis.
STEMI – what is it?

• An ST-segment elevation myocardial infarction (STEMI) can be

confirmed by an ECG.

STEMI is defined as presentation with clinical symptoms

consistent with an ACS with ECG features including any of:
• persistent ST-segment elevation ≥ 1 mm in two contiguous limb
leads
• ST-segment elevation ≥ 2 mm in two contiguous chest leads

• new left bundle branch block (LBBB) pattern.

3. Management of patients with STEMI
Early response
• Implement reperfusion strategy for patients presenting within 12 hours of
onset of ischaemic symptoms consistent with ACS (determined by physical
examination):
 immediate 12-lead ECG
 insert cannulae
 pain relief
 blood tests.
• Give aspirin 150–300 mg (unless already given, or contraindicated).

• Doctor sees patient within 10 minutes of arrival (Australasian Triage Scale

Category 2).
• Oxygen therapy indicated only for patients with hypoxia (oxygen saturation
< 93%) and those with evidence of shock (Consensus).
 Choice of reperfusion therapy

• In general, PCI (percutaneous coronary intervention) is the treatment of

choice, providing it can be performed promptly by a qualified
interventional cardiologist in an appropriate facility.1
• All PCI facilities should be able to perform primary angioplasty within 90
minutes of patient arrival.
• Fibrinolysis should be considered early if PCI is not readily available.

• In cases of major delay to hospitalisation (> 30 minutes) consider pre-

hospital fibrinolysis.

Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S9–29.
PCI cardiac catheter
The catheter can be inserted via the radial or femoral artery (insertion via the femoral artery
illustrated below).
PCI – how it works
 Primary PCI – technique and antithrombotic therapy

• Among patients with STEMI undergoing primary PCI the use of bivalirudin can be
considered as an alternative to heparin and GP IIb/IIIa inhibitors (Grade B).1
• Among patients undergoing primary PCI for reperfusion, consider antiplatelet therapy
with either:
 high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75
mg/day for at least 12 months) (Grade B)
 prasugrel (60 mg oral bolus + 10 mg daily) (Grade B)
 ticagrelor (180 mg oral bolus + 90 mg twice daily) (Grade B).1
• Careful assessment of bleeding risk should be undertaken before using
antithrombotic agents (Grade B).1
• Consider use of mechanical thrombectomy techniques to reduce thrombus burden
during primary PCI (Grade A).1

Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for
the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
Bleeding risk
The following risk factors should be considered when assessing bleeding risk and choosing
antithrombotic therapies in patients with ACS (Grade B):
• age > 75 years
• female
• history of bleeding
• history of stroke or transient ischaemic attack (TIA)
• creatinine clearance rate < 60 mL/min
• diabetes
• heart failure
• tachycardia
• blood pressure < 120 mmHg or ≥ 180 mmHg
• peripheral vascular disease (PVD)
• anaemia
• concomitant use of GP IIb/IIIa inhibitor
• enoxaparin 48 hours prior
• switching between unfractionated heparin and enoxaparin
• procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart catheterisation).
 Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the
coronary vessels to restore blood flow to the heart muscle.1
• Consider early routine revascularisation of patients receiving fibrinolysis, regardless of success of
pharmacologic reperfusion (Grade A).
Absolute contraindications
• Active bleeding or bleeding diathesis (excluding menses).
• Significant closed head or facial trauma within 3 months.
• Suspected aortic dissection.
• Any prior intracranial haemorrhage.
• Ischaemic stroke within 3 months.
• Known structural cerebral vascular lesion.
• Known malignant intracranial neoplasm.

Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis – primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm.
Accessed 7 August 2011.
Fibrinolysis
Relative contraindications
• Current use of anticoagulants.
• Non-compressible vascular punctures.
• Recent major surgery (< 3 weeks).
• Traumatic or prolonged (> 10 mins) CPR.
• Recent internal bleeding (within 4 weeks).
• Active peptic ulcer.
• History of chronic, severe, poorly controlled hypertension.
• Severe uncontrolled hypertension on presentation (systolic ≥ 180 mmHg or
diastolic ≥ 110 mmHg).
• Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.
• Pregnancy.
NSTEACS – what is it?

• Non-ST-elevation ACS (NSTEACS) applies to patients with

suspected ACS in the absence of other plausible causes of
troponin elevation (e.g. sepsis, pulmonary embolus).
• On physical examination, patients with NSTEACS may have
a ‘normal’ ECG reading, or show minor changes (occurs in up
to 50% of patients).
• All patients with NSTEACS should have their risk stratified to
direct management decisions.
• The management of patients with NSTEACS requires
evolving risk stratification: clinical assessment, assessment of
cardiac biomarkers and time.
4. Management of patients with NSTEACS

• Clinical assessment: careful

. clinical history, ECG, chest X-ray
and investigations to diagnose
other causes of chest pain and
evaluate the likelihood of
evolving ACS.
• Troponin assessment: to assess
the likelihood of MI.
• Stratify risk.
Evolving risk stratification

Admit to coronary care unit or

high dependency unit:
• estimate ischaemic risk,
estimate bleeding risk,
choose augmented
antithrombotic therapy
→refer for angiography to
determine surgery/PCI, or
medical therapy.
Evolving risk stratification
Evolving risk stratification
Intermediate-risk NSTEACS
Recurrent ischaemia or elevated troponin?
YES
• admit to CCU or high dependency unit:
 estimate ischaemic risk, estimate
bleeding risk, choose augmented
antithrombotic therapy
→refer for angiography to determine
surgery/PCI, or medical therapy.
NO
• undertake stress test (e.g. exercise ECG):
→positive – refer for angiography to
determine surgery/PCI, or medical
therapy
→negative – proceed to discharge patient
with urgent cardiac follow-up (on
upgraded medical therapy) according
to long-term management after control
of myocardial ischaemia.
Evolving risk stratification
YES
Stress test (e.g. exercise ECG)
using treadmill.
Appropriate period of
observation. Consider if
stress test (e.g. exercise
ECG) needed?
NO
Proceed to discharge patient with urgent
cardiac follow-up (on upgraded medical
therapy) according to long-term
management after control of myocardial
ischaemia.
Antithrombotic therapy for NSTEACS

• For high-risk patients with NSTEACS, assess bleeding risk individually

according to the number and severity of bleeding risk factors (Grade A).
• Assign a management strategy according to bleeding risk.

• For patients at high risk of bleeding, use a ‘priority low-bleeding’strategy.

Antithrombotic agents with lower bleeding risk include:
 clopidogrel in preference to prasugrel (Grade B)
 fondaparinux in preference to enoxaparin (Grade B)
 bivalirudin in preference to enoxaparin (Grade B).
• For patients at low risk of bleeding, use a ‘standard’ effective antiplatelet
regimen (prasugrel and ticagrelor) (Grade A). (cont.)
Antithrombotic therapy for NSTEACS

• Minimise the number of agents used (Grade B).

• When additional agents are needed, substitute rather than add (Grade B).

• Consider shorter-acting or reversible agents (Grade B).

• Avoid using GP IIb/IIIa inhibitors, where possible (Grade B).

5. Long-term management

Before discharging a patient:

• discharge medication regimen
• provide tailored lifestyle advice to reduce risk of further events,
including:
 smoking cessation
 good nutrition and moderate alcohol intake
 physically active lifestyle and weight management as relevant
 managing depression
 warning signs of a heart attack.
• Refer all patients to comprehensive cardiac rehabilitation programs.
• Provide all patients with a written action plan for chest pain, which
can be downloaded from www.heartfoundation.org.au
Medication regimen

• Continued antiplatelet therapies for 12 months for all patients with stents (Grade A).

In addition:
• aspirin

• beta-blockers

• ACE inhibitors

• statins

• warfarin

• nitrates

• insulin/oral hypoglycaemics

• aldosterone antagonists.
Concluding remarks
• This presentation is designed to ensure consistency of information regarding
best practice ACS management, based upon the 2011 addendum to the
National Heart Foundation of Australia/Cardiac Society of Australia and New
Zealand Guidelines for the management of acute coronary syndromes 2006.
• Understandings of the pathophysiology of ACS have improved, together with
increasingly accurate diagnostic tools, better risk stratification and improved
medical and invasive treatments. However, these advances have led to an
increase in the complexity of possible treatment strategies. This is evolving.
• For more information please visit www.heartfoundation.org.au.

© 2012 National Heart Foundation of Australia ABN 98 008 419 761

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