Updated of ACS management

Daniel P.L. Tobing, MD National

Cardiovascular Centre
Harapan Kita Hospital
 CVD Is a Leading Cause of Death Worldwide

Injuries Cancer

Respiratory 9.0% 13.0%

Diseases Stroke
13.0%
Diabetes 30.0% 33.0%
2.0% 43.0%
CVD CHD
Other 9.0% (16.7 M)
Chronic
Diseases 14.4%
30.0%
Other
CVD

Rheumatic Heart Disease 2.4%

All Other Inflammatory Heart Disease
2.4%
Hypertensive Heart Disease
5.4%

Adapted from WHO. Preventing Chronic Diseases A Vital Investment 2005.

Adapted from WHO. The Atlas of Heart Disease and Stroke 2004.
Percentage of patient diagnosed
with ACS admitted to emergency
room

(35%)
(28%)

Source: JAC registry data base 2010, NCCHK

 Tingkat mortalitas In-hospital
P<0.001
P<0.03
13,3

Persentase
(%)
6,2
5,3

PPCI Fibrinolitik Tanpa reperfusi

Source: JAC registry data base 2010, NCCHK

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)
Scope of the problem

Cardiovascular diseases are currently the leading cause of death

CAD is the most prevalent manifestation and is associated with high

mortality and morbidity.

Patients with chest pain represent a very substantial proportion of all

acute medical hospitalizations

Despite modern treatment, the rates of death, MI, and readmission of

patients with ACS remain high

5
Hamm CW et al.
Mechanisms of thrombosis

Thrombosis caused by Thrombosis caused by

erosion disruption.

7
Davies MJ. Heart
 Miokard yang dapat diselamatkan dengan reperfusi

Lama Oklusi

Becker LC, Ambrosio G: Myocardial consequences of reperfusion, Prog Cardiovasc Dis 30:23-49,
1987
 Options for Transport of Patients With STEMI
and Initial Reperfusion Treatment

Not PCI
capable

Onset of 9-1-1 EMS on-scene

symptoms of EMS Encourage 12-lead ECGs.
STEMI Dispatch Consider prehospital fibrinolytic if
capable and EMS-to-needle within 30
min. PCI
capable
5 8
min. EMS Transport
min.

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Antman EM, et al. J Am Coll Cardiol 2008. P9ublished ahead of print on December 10,
2007. Available at http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001.
Importance of GP role in ACS management

Play a major role in the early care of acute myocardial

infarction
Often the first to be contacted by patients
What GP should do
Can perform and interpret the ECG
Alert EMS
Administer opioids and antithrombotic drugs (including
fibrinolytic)
Undertake defibrillation if needed

11 Steg PG, et al. European Heart Journal. 2012;33:2569-2619

Early detection and
Risk stratification
The spectrum of ACS

13
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
Unstable Angina

Thrombosis caused by
disruption.

The cap of a plaque has torn

and projects up into the
lumen.

Thrombus does not totally

occlude, the lumen

14
Davies MJ. Heart
Acute Myocardial Infarction

Thrombosis caused by
disruption. The cap of the
plaque has torn and thrombus
within the lipid
Core extends into and occludes
the lumen.

15
Davies MJ. Heart
Diagnosis

1. Clinical presentation Chest Pain

- Prolonged (.20 min) anginal pain at rest
- New onset (de novo) angina (CCS II or III)
- Crescendo angina
- Post-MI angina.

2. Diagnostic tools
- Physical examination
- EKG
- Biomarkers
- Imaging

16 Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Typical vs Atypical Chest Pain
TYPICAL CHEST PAIN
Retrosternal pressure or
heaviness (angina) Radiating to
the left arm, neck, or jaw, which
may be intermittent (usually
lasting for several minutes) or
persistent.
These complaints may be
accompanied by other symptoms
such as diaphoresis, nausea,
abdominal pain, dyspnoea, and
syncope
17 Hamm CW, et al. European Heart Journal (2011) 32, 29993054
ATYPICAL CHEST PAIN
Atypical presentations are not
uncommon.
These include epigastric pain,
indigestion, stabbing chest pain,
chest pain with some pleuritic
features, or increasing dyspnoea
More often observed in older (.75
years) patients, in women, and in
patients with diabetes, chronic
renal failure, or dementia
Location of chest pain

18
Author | 00 Month Year
ECG

Resting 12-lead ECG is the first-line diagnostic tool

Performed 10 min after first medical contact

Repeated in the case of recurrence of symptoms, and

after 69 and 24 h, and before hospital discharge

ST-segment depression or transient elevation and/or T-

wave changes.

If the initial ECG is normal or inconclusive, additional

recordings should be obtained if the patient develops
symptoms
19 Hamm CW, et al. European Heart Journal (2011) 32, 29993054
Patterns of ischemia

ST depression

T-wave inversion

Horizontal ST with
STT angulation

Tall, wide based T

waves

U-wave inversion

20
Jacobson C. AACN Advanced Critical
Acute Injury Patterns

ST elevation 1 mm or more
in 2 contiguous leads

ST segment pulled up to peak

of T wave with no J point

Tall, peaked T waves

Symmetrical T-wave inversion

21 Jacobson C. AACN Advanced Critical Care 2008; 19(1); 101-108

ECG CHANGES OF INJURY ACUTE MYOCARDIAL INFARCTION

In early stage of AMI , ECG may be

normal or near normal

5- 30 min after onset of

infarction

Changes
< 1 mm - > 10 mm

1-2 hours of onset

symptoms

ST resolves - anterior up to
2 weeks; posterior > 2 weeks
T wave : many months

22
Morris F, Brady WJ. BMJ
Localisation of site of infarction

23
Morris F, Brady WJ. BMJ
Biomarkers

Troponins are more specific and sensitive

Elevation of cardiac troponins reflects myocardial
cellular damage
An initial rise in troponins occurs within 4 h after
symptom onset
Aware on possible non-acute coronary syndrome
causes of troponin elevation (eg. Chronic or acute renal
dysfunction, heart failure, Hypertensive crisis, Tachy- or
bradyarrhythmias, Pulmonary embolism, myocarditis,
stroke)

24 Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Biomarkers : Troponin vs CKMB vs Myoglobin and CK

25
Author | 00 Month Year
10/3/12
 99th percentile of hs TnT assay
12

Assessment ot total imprecision:

5 patient pools collected. Each pool analysed tw ice daily
10
over a period of 5 separate days.
Total CV calculated by ANOVA.

14 ng/L (0.014 g/L) is Limit of

Total imprecision CV(%)

8
99th percentile of URL detection
of old TnT
6
assay

0
0.000 0.005 0.010 0.015 0.020 0.025 0.030 0.035 0.040

Troponin T ug/L

3 ng/L is the detection

limit (0.003g/L)
hsTnT assay detects an increase in
cTnT earlier than the 4th gen. assay
Management of
NSTEMI/UAP
Management strategy

Step 1. initial evaluation

Step 2. Diagnosis validation and risk

assessment

Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge

and post-discharge management

30 Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Decision Making Algorithm in ACS

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

 GRACE RISK SCORE
Non-ST elevation acute coronary syndrome
Predictor Score Predictor Score Predictor Score

Age, years Systolic Blood Pressure (mmHg) Killip class

< 40 0 < 80 63 I 0

40 - 49 18 80 89 58 II 21

50 - 59 36 100 - 119 47 III 43

60 - 69 55 120 - 139 37 IV 64

70 - 79 73 140 - 159 26
80 91 160 - 199 11
> 200 0

Predictor Score Predictor Score Predictor Score

Heart Rate , beats/min Creatinine (mol/L) Cardiac 43
< 70 0 arrest at
0 - 34 2
admission
70-89 7 35 70 5
Elevated 15
90-109 13 71 105 8 cardiac
110 - 149 23 markers
106 140 11
150 - 199 36 ST Segment 30
141 176 14 deviation
> 200 46 177 353 23
354 31

Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 e30

Mortality in hospital based on GRACE RISK
SCORE NSTEMI 2011

33 Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Risk score of CRUSADE In-Hospital major bleeding

34
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
CRUSADE

Parameter

Baseline
haematocrit
Creatinine
clearance
Heart rate (b.p.m.)
Sex
Signs of CHF at
presentation
Prior vascular
disease
Diabetes mellitus
Systolic blood
pressure,

35 Hamm CW, et al. European Heart Journal (2011) 32, 29993054

10/3/12
10/3/12
10/3/12
10/3/12
10/3/12
Decision Making Algorithm in ACS

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Invasive strategy

An invasive strategy (within 72 h after first presentation) is

indicated in patients with: IA
at least one high-risk criterion (Table 9);
Recurrent symptoms.
Urgent coronary angiography (<2 h) is recommended
in patients at very high ischaemic risk (refractory angina, IC
with associated heart failure, life-threatening ventricular
arrhythmias, or haemodynamic instability).
An early invasive strategy (<24 h) is recommended in
Patients with a GRACE score >140 or with at least one 1A
primary high-risk criterion

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Conservative strategy (no or elective
angiography)
Patients that fulfil all of the following criteria may be regarded as low
risk and should not routinely be submitted to early invasive
evaluation:
No recurrence of chest pain.
No signs of heart failure.
No abnormalities in the initial ECG or a second ECG (at 69 h).
No rise in troponin level (at arrival and at 69 h).
No inducible ischaemia.

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

STEMI Management
ESC 2012 STE-ACS Guideline
 The focus is now on systems improvement for
reperfusion in patients with STEMI
45 Antman EM. J Am Coll Cardiol 2008;52:121621
The spectrum of ACS

46
Hamm CW, et al. European Heart Journal (2011) 32, 29993054
STEMI Management
Prevention of delays is critical in STEMI
Treatment goals in STEMI management
Reperfusion therapy

A. Restoring coronary flow and myocardial tissue

reperfusion
B. Selection of a strategy for reperfusion
Primary PCI
Fibrinolysis and subsequent interventions
CABG
Non-reperfused patients
 Fibrinolytic Therapy

51 Steg PG, et al. European Heart Journal. 2012;33:2569-2619

 PRIMARY PCI vs FIBRINOLYTIC

Fibrinolytic Primary PCI

12 hours of symptom onset if Performed within 120 min of FMC

primary PCI cannot be performed Contraindication to fibrinolytic
within 90 min
Door to balloon 90 min
within 2 hours from FMC
Patients with STEMI and
no contraindications cardiogenic shock or acute severe
30 min (door-to-needle time) HF

52 1.Steg PG, et al. European Heart Journal. 2012;33:2569-2619 ; 2. Anderson JL, et al. Circulation. 2007;116:e148-e304.
 Checklist of treatments when an ACS
diagnosis appears likely

Hamm CW et al. Eur Heart J 2011;32:2999 3054

 Checklist of antithrombotic treatments
prior to PCI

Hamm CW et al. Eur Heart J 2011;32:2999 3054

 Measures checked at discharge

Hamm CW et al. Eur Heart J 2011;32:2999 3054

 THANK YOU

Hamm CW et al. Eur Heart J 2011;32:2999 3054