Acute coronary syndrome Milad RSIJCP Acute coronary syndrome is a term that describes a range of conditions related to sudden reduced blood flow to the heart. These conditions include a heart attack and unstable angina, a type of chest pain..pptx

Acute coronary syndrome is a term that describes a range of conditions related to sudden reduced blood flow to the heart. These conditions include a heart attack and unstable angina, a type of chest pain.

1. Acute Coronary Syndrome dr. Indra Budi Perkasa, Sp.JP, FIHA 06/16/2024

2. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

3. Definition ACS ACS encompass a spectrum conditions that include patients presenting with recent changes in clinical symptoms or sign , with or without changes on 12 lead ECG and with or without acute elevation in cardiac troponin ( cTn ) concentration. Suspected ACS may eventually receive a diagnosis AMI or UA . MI (myocardial infarction) is associated with cTn release based on fourth UDMI. UA is defined as myocardial ischemia at rest or on minimal exertion in the absence of acute cardiomyocyte injury/necrosis. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

4. Epidemiology CVD are the leading cause of death globally. An estimated 17.9 million people death from CVDs in 2019, representing 32% of all global death . Of these death, 85% were due to heart attack and stroke . Over three quarters of CVD death take place in low and middle income countries. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

5. Definition terms related to invasive strategy 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

6. Definition terms related to invasive strategy 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

7. Definition terms related to invasive strategy 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

8. Triage and Diagnosis Acute chest discomfort ( Pain, pressure, tightness, or burning ) is the leading presenting symptom of ACS. Chest pain equivalent symptoms include dyspnea, epigastric pain, and pain in the left or right arm or neck/jaw. Physical examination to eliminate differential diagnosis and to identify very high risk and high risk ACS features ( cardiac arrest, sign of CS, and/or hemodynamic and electrical instability ). 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

9. Acute chest discomfort is the leading symptom of ACS. Careful history taking are crucial and may help to facilitate an early and accurate diagnosis. Red flag symptoms are prolong chest pain (>15 min) and/or recurrent pain within 1 hour. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

10. A.C.S assessment for the initial evaluation of patient with susp. ACS 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

11. ‘ACS’ assessment I nitial ‘A.C.S. assessment’ that can be performed for a patient presenting with suspected ACS. ‘A’ stands for ‘Abnormal ECG?’ : an ECG should be performed within 10 min of FMC and assessed for evidence of abnormalities or ischemia. ‘C’ stands for ‘Clinical Context?’: it is important to consider the clinical context of the patient’s presentation and the results of any investigations that are available. ‘S’ stands for ‘Stable Patient?’: the patient should be quickly assessed to determine if they are clinically stable—this should include assessment of the clinical vital signs, including heart rate, blood pressure, and oxygen saturations , if possible, as well as checking for potential signs of CS. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

12. Electrocardiogram First line diagnostic tools. Obtain immediately and interpreted within 10 min of FMC. Based on the initial ECG , pt with suspected ACS can be differentiated into two WD. ST segment elevation MI (STEMI) Non ST elevation ACS (NSTE-ACS) 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

13. ECG STEMI

14. ST segment evolution in STEMI 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

15. ECG NSTE-ACS ECG may be normal (1/3 patient NSTE-ACS). May exhibit other ECG alteration Transient ST segment elevation Persistent or transient ST segment depression T wave abnormalities (hyperacute Twaves , T wave inversion, biphasic T waves, Flat T waves) 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

16. ST segment depression pattern 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

17. Diagnostic tools Electrocardiogram Cardiac biomarker (Troponin, Hs Troponin) Non-invasive imaging 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

18. Cardiac biomarkers 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

19. Cardiac biomarkers NSTE-ACS, biomarkers play a complementary role in the diagnosis, risk stratification, and management of patients with suspected ACS. If the clinical presentation is compatible with myocardial ischaemia , then a rise and/or fall in cTn above the 99th percentile of healthy individuals points to a diagnosis of MI as per the criteria in the fourth universal definition of MI . 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

20. MI type 1 MI caused by atherothrombotic coronary artery disease (CAD) and usually precipitated by atherosclerotic plaque disruption (rupture or erosion) is designated as a type 1 MI. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

21. cTnT and cTnI detected by conventional assays (non–high-sensitivity) can be detected approximately 3 hours after the onset of chest pain. E levations in cTnI may persist days after MI; elevations in cTnT m for 7 to 10 ay persist for up to 10 to 14 days. hsTn assays facilitate the adoption of criteria for rapidly changin concentration of troponin over periods as short as 1 to 3 hours that aid in discriminating acute myocardial injury from chronically elevated values.

22. Rapid ‘Rule IN’ and ‘Rule OUT’ Due to their higher sensitivity and diagnostic accuracy for the detection of MI at presentation, the time interval to the second cTn assessment can be shortened with the use of hs-cTn assays. reduces the delay to diagnosis, translating into shorter stays in the ED, lower costs , and less diagnostic uncertainty for patients. It is recommended to use the 0 h/1 h algorithm (best option) or the 0 h/2 h algorithm (second-best option). Optimal thresholds for rule-out were selected to allow a sensitivity and NPV of at least 99%. Optimal thresholds for rule-in were selected to allow a positive predictive value (PPV) of at least 70%. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

23. The ESC 0 h/1 h and 0 h/2 h algorithms are based on two underlying concepts: F irstly , hs-cTn is a continuous variable and the probability of MI increases with increasing hs-cTn values. Secondly , early absolute changes in the levels within 1 h or 2 h can be used as surrogates for absolute changes over 3 h or 6 h and provide incremental diagnostic value to the single cTn assessment at presentation. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

24. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

25. ACS from working to final diagnosis 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

26. Echo = TTE can be useful to identify signs suggestive of ongoing ischaemia or prior MI, TTE can also be useful to suggest alternative aetiologies associated with chest pain (i.e. acute aortic disease, RV signs in pulmonary embolism [PE]). Computed tomography = CT is often the diagnostic tool of choice for ruling out alternative potentially life-threatening differential diagnoses of ACS, like PE or aortic dissection. CMR = CMR is the imaging test of choice when poor echocardiographic windows preclude diagnostic echocardiographic evaluation. CMR allows direct visualization of infarcted regions, providing information on scarring and viability that can be differentiated from other forms of myocardial injury (e.g. myocarditis). 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

27. Acute pharmacotherapy Oxygen; Oxygen supplementation is recommended in ACS patients with hypoxaemia (oxygen saturations <90%). Nitrates; Sublingual nitrate may be helpful to relieve ischaemic symptoms. Pain relief; Intravenous opioids (e.g. morphine 5–10 mg) should be considered for the relief of severe chest pain. i.v. beta-blockers; (preferably metoprolol) should be considered at the time of presentation in patients with a working diagnosis of STEMI undergoing PPCI with no signs of acute HF, a systolic blood pressure (SBP) >120 mmHg, and without other contraindications. Antiplatelet drugs play a key role in the acute phase of treatment for ACS.

28. Selection of invasive strategy and reperfusion therapy Depending on the initial assessment of the ECG, the clinical context and hemodynamic stability, patients with suspected ACS should be classified as either: Patients with a working diagnosis of STEMI. These patients should be triaged for immediate reperfusion therapy (i.e. a PPCI strategy or fibrinolysis if PPCI is not possible within 120 min of diagnosis). Or Patients with a working diagnosis of NSTE-ACS . For these patients: An inpatient invasive strategy is recommended. An immediate invasive strategy is recommended when any very high-risk feature is present. An early (i.e. within 24 h) invasive strategy should be considered when any high-risk features are present. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

29. Primary percutaneous coronary intervention strategy for ST-elevation myocardial infarction

30. STEMI pts after fibrinolysis 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

31. I nvasive management and myocardial revascularization in patients presenting with STEMI. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

32. I nvasive strategies for patients with non-ST elevation acute coronary syndrome

33. Selection of invasive strategy and reperfusion therapy in patients presenting with NSTE-ACS. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

34. Recommended default antithrombotic regimens in patients with acute coronary syndromes

35. 10 commandments ACS 1) Acute coronary syndromes (ACS) should be considered as a clinical spectrum, encompassing unstable angina (UA), non–ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). While there are some differences in the timing of invasive strategies, the basic principles underpinning the assessment, diagnosis, and management of ACS are similar for all three ACS subtypes. 2) Think ‘A.C.S.’ when initially assessing patients presenting with suspected ACS. This involves performing an electrocardiogram (ECG) to assess for electrocardiographic evidence of ischaemia (Abnormal ECG), considering the Clinical context of the patients’ presentation (including presenting symptoms, the results of any available investigations, and the clinical background), and performing a focused clinical examination to assess if the patient is clinically Stable. 3) Invasive coronary angiography (ICA) during the index hospitalization is generally recommended for patients with ACS. A key component of the ACS care pathway is identifying patients who require immediate ICA and revascularization, including patients presenting with STEMI and non–ST-segment elevation ACS (NSTE-ACS) with very high-risk features . 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

36. 10 commandments ACS 4) For patients who are not presenting with STEMI or NSTE-ACS with an indication for immediate ICA, an algorithmic approach, using the ESC 0/1- or 0/2-h algorithms should be used to rule in or rule out NSTEMI. 5) All patients with a diagnosis of ACS are recommended to be treated initially with a combination of antiplatelet therapy and parenteral anticoagulation. While anticoagulation does not need to be continued beyond the acute hospitalization phase in patients without a separate indication for long-term oral anticoagulation, oral antiplatelet therapy is recommended to be continued beyond the acute hospitalization phase in all ACS patients. 6) Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 receptor inhibitor (preferably one of the potent P2Y12 receptor inhibitors, prasugrel or ticagrelor), for 12 months remains the default recommended DAPT regimen for patients with a diagnosis of ACS. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

37. 10 commandments ACS 7) Complete revascularization (via percutaneous coronary intervention or coronary artery bypass grafting) is generally recommended for patients with ACS, although the timing and guidance of this can vary slightly depending on the clinical presentation. 8) All patients presenting with ACS require aggressive secondary prevention to reduce their risk of recurrent events. Prevention of the next cardiovascular event begins at the time of the ACS diagnosis. 9) All patients with ACS should be discharged on cardioprotective medications, with information on lifestyle management, a referral to cardiac rehabilitation, and a follow-up outpatient appointment. The treatment goals at outpatient follow-up should be to support healthy lifestyle choices, to promote adherence to and persistence with pharmacological cardioprotective therapies, and to reach and sustain risk factor treatment targets. Key treatment targets for patients with ACS include a blood pressure of <130 mmHg systolic and <80 mmHg diastolic, a LDL cholesterol (LDL-C) of <1.4 mmol/L (55 mg/dL), and, for diabetic patients, a HbA1c of <53 mmol/L (7%). 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)

38. 10 commandments ACS 10) The care of patients presenting with ACS should not only reflect the best scientific evidence but should also try to promote care that is respectful of, and responsive to, the individual patients’ preferences, needs, and values. This should be applied to all aspects of the care of patients with ACS, from the initial presentation throughout the hospital inpatient journey, extending through to long-term outpatient follow-up. 2023 ESC Guidelines for the management acute coronary syndromes (European Heart Journal 2023 – doi : 10.1093/ eurheartj /ehad191)