7-Current-management-of-NSTEACS-dr-Jarot.pptx

NSTEACS

1. Current management of NSTEACS d r. Jarot Widodo, Sp.JP, FIHA

2. Definition of Acute Coronary Syndrome A syndrome largely due to coronary plaque erosion or rupture which is further subdivided into presentations with and without ST-segment elevation on the ECG . Antman , E M. 2004

3. Causes of ACS Atherosclerosis Cause > 95% ACS because of disruption of plaque Platelet agregation Intracoronary thrombus Non Atherosclerosis Cause Vasculitis syndrome Coronary emboli (IE, prosthetic valve) Congenital anomali of coronary artery Coronary trauma or aneurysm Spasm Increased blood viscosity Increased myocardial demand Hurst, 2011

4. 4

5. Clinical presentation Anginal pain in NSTE-ACS patients may have the following presentations: Prolonged ( > 20 min) anginal pain at rest New onset (de novo) angina (class II or III of the Canadian Cardiovascular Society classification) Recent destabilization of previously stable angina with at least Canadian Cardiovascular Society Class III angina characteristics(crescendo angina) Post-MI angina .

6. 6 CK-MB or Troponin Troponin elevated or not ACS with persistent ST-segment elevation ACS without persistent ST-segment elevation Normal ECG in 1/3 cases

7. Cardiac marker

8. Diagnosis ESC 2011

9. ESC 2015

10. 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays. 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

11. Risk Stratification Predict the prognosis S election of the site of care : - C oronary care unit - Intermediate Care Unit - General ward S election of therapy : - I nvasive Vs Conservative strategy - Gp IIb/ IIIa

12. Risk Stratification Focuses on history Physical findings ECG findings Biomarkers of cardiac injury ( hs Troponin) TIMI score , GRACE score

13. TIMI SCORE – RISK QUANTIFICATION 1 Point Given For Each Of The Following Variable : ≥ 65 years of age ≥ 3 risk factors for CAD Prior coronary stenosis ≥ 50% ST deviation on ECG ≥ 2 Anginal events in prior 24 hours Use of aspirin in prior 7 days Elevated cardiac biomarkers 2014 AHA/ACC NSTE-ACS Guideline

14. GRACE SCORE – RISK QUANTIFICATION AGE HEART RATE SYSTOLIC BLOOD PRESSURE KILLIP CLASS CREATININE ST-SEGMENT DEVIATION ELEVATED TROPONIN CARDIAC ARREST AT ADMISSION 2014 AHA/ACC NSTE-ACS Guideline TOTAL SCORE RISK ASSESSMENT >140 HIGH RISK >109 and ≤ 140 INTERMEDIATE RISK ≤ 109 LOW RISK 2015 ESC NSTE-ACS Guideline

15. 2014 AHA/ACC NSTE-ACS Guideline GRACE SCORE – RISK QUANTIFICATION 1. Find points for each predictive factors 2 . Sum points for all predictive factors 3. Look up risk coressponding to total points http://www.outcomes-umassmed.org/grace/

16. Predictor Range Score Baseline Hematocrit (%) < 31 31-33.9 34-36.9 37-39.9 ≥ 40 9 7 3 2 Creatinine Clearance (mL/min) ≤ 15 >15-30 >30-60 >60-90 >90-120 >120 39 35 28 17 7 Heart rate ( bpm ) ≤ 70 71-80 81-90 91-100 101-110 111-120 ≥ 121 1 3 6 8 10 11 Sex Male Female 8 Signs of CHF at presentation No Yes 7 Prior Vascular Disease No Yes 6 Diabetes Mellitus No Yes 6 Systolic blood pressure (mm Hg) ≤ 90 91-100 101-120 121-180 181-200 ≥ 201 10 8 5 1 3 5 CRUSADE Bleeding Score http ://www . crusadebleedingscore.org

17. Risk Quintiles Patients were categorized into quintiles of risk groups based on their CRUSADE Bleeding Score Risk N Min Score Max Score Bleeding Very low 19,486 1 20 3.1% Low 12,545 21 30 5.5% Moderate 11,530 31 40 8.6% High 10,961 41 50 11.9% Very High 15,210 51 91 19.5% http ://www . crusadebleedingscore.org

18. ALGORITHM FOR MANAGEMENT OF PATIENTS WITH DEFINITE OR LIKELY NSTE-ACS 201 4 AHA NSTE-ACS Guideline

19. 2015 AHA NSTE-ACS Guideline

20. ANTITHROMBOTIC DRUGS FOR NSTE-ACS 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

21. P2Y12 INHIBITORS 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

22. RECOMMENDATIONS FOR ANTICOAGULATION IN NON-STELEVATION ACUTE CORONARY SYNDROMES ESC, 2015

23. DOSING OF ANTICOAGULANTS IN PATIENTS WITH NORMAL AND IMPAIRED RENAL FUNCTION 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

24. RECOMMENDATIONS FOR ANTI-ISCHAEMIC DRUGS IN THE ACUTE PHASE OF NON-ST-ELEVATION ACUTE CORONARY SYNDROMES 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

25. Recommendations for long-term management after non-ST-elevation acute coronary syndromes 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

26. PERFORMANCE MEASURES IN NSTE-ACS PATIENTS 2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation

27. Thank you