Acute Coronary Syndrome (NSTEMI)

Acute Coronary Syndrome especially NSTEMI is a very often missed diagnosis in ICU patients. The presentation addresses Emergenc

1. Acute Coronary Syndrome
Non ST Elevation MI
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP
Department of Critical Care Medicine
King Saud Medical City
Riyadh Saudi Arabia

2. Disclosures
We are not
promotional speakers
for any company but
we do accept the
breakfast in our
presentations
(just for fun)
A very special man is here to see U doctor!!

3. Session Objectives
Utilize both clinical evaluation and risk scoring in
selecting the appropriate initial management
strategy for patients with UA/NSTEMI
Identify potential updates to current UA/NSTEMI
critical pathways based on the latest ACC/AHA
UA/NSTEMI guidelines and recent UA/NSTEMI
clinical trial results
Evaluate current approaches to discharge
planning and follow-up, and modify them as
necessary to promote adherence to medical and
rehabilitative therapies

4. ACS
48%
Stroke
17%
Hypertension
5%
others
23%
CHF
5%
0.5%
Atherosclerosis
2%
0.5% Deaths from ACS

5. Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)
Acute Coronary
Syndromes*
1.57 MillionHospital Admissions -ACS
UA/NSTEMI
†
STEMI
1.24 million
Admissions per year
.33 million
Admissions per year
Heart Disease and Stroke Statistics –2007 Update. Circulation 2007; 115:69-171.
*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

6. IschemicHeart Disease Evaluation
Based on the patient’s
•History / Physical exam
•Electrocardiogram
•Biochemical markers
Patients are categorized into 2 groups
Non Cardiac Chest Pain
Pain cardiac in origin
USA/NSTEMI/STEMI

7. Spectrum of Coronary Syndromes
Endstage Heart Disease
Congestive Heart Failure
Ventricular Dilation
Remodeling
Arrhythmia & Loss of Muscle
Myocardial Infarction
Myocardial Ischemia
IHD/Angina Pectoris
Atherosclerosis
Endothelial Dysfunction
Risk Factors + Hypertension
Coronary Thrombosis
Chronic
Coronary
Syndromes
Acute
Coronary
Syndromes
Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2
nd
ed. 2004.

8. Acute Coronary Syndrome
Definition
The term ACS refers to a spectrum of
presentations caused by myocardial
ischemia that includes
Unstable Angina
Non ST elevation myocardial infarction
ST elevation myocardial infarction

9. Diagnosis
Diagnosis requires a rise and/or fall in serum
levels (preferably troponin) together with:
Evidence of Myocardial Ischaemia
Defined clinically by patient history
ECG (new ST-T wave changes, new left bundle
branch block or evolving pathological Q waves)
Imaging evidence of new regional wall motion
abnormality.

10. Acute Coronary Syndromes
Pathophysiology
The embracing term reflects the
common pathophysiologyof
Plaque disruption
Intravascular thrombosis
Impaired myocardial blood supply

11. STEMI
Result of complete
epicardialocclusion
following plaque
disruption & leads to
propagation of
thrombus & epicardial
vasoconstriction
NSTEMI
Incomplete &
transient epicardial
occlusion with
platelet-rich &
phasicdistal
embolisation

12. Pathophysiology

13. Summary of events & outcome

14. Acute ST Elevation MI

15. N Normal ECG

16. Acute Coronary Syndrome
Clinical Diagnosis
MONA
Morphine
Oxygen
NTG
Aspirin
Blood Tests:
Troponinat 12 hoursafter
onset of pain, U&E, cholesterol,
FBC, coagulation
Admission or subsequent ECG

17. High Risk ECG changes:
(2 or more contiguous leads)
ST depression > 1mm
T inversion > 1mm
Transient BBB
Minor/ transient ST elevation
High Risk Clinical
features:
Ongoing rest pain.
Haemodynamicinstability.
Arrythmias
TroponinElevated?
NO
NO
Able to exercise ?
YES
ETT
NO
Consider
investigations:
Perfusion scan
Angiography
Cardiology
Referral
ETT InconclusiveETT Normal
Low Risk Patient
Discharge

18. High Risk ECG changes:
(2 or more contiguous leads)
ST depression > 1mm
T inversion > 1mm
Transient BBB
Minor/ transient ST elevation
High Risk Clinical
features:
Ongoing rest pain.
Haemodynamicinstability.
Arrythmias
Troponin
Elevated
High Risk
1.LMWH
2.Clopidogrel300 stat, 75mg OD
3.Aspirin 75 mg OD
4.Beta Blockers: (metopr)25 mg tds
5.Hyperglycaemiccontrol DIGAMI
protocol, if RBS > 10 mmol
6.Morphine and / or IV nitrates if
continuing pain, titrate to pain and
blood pressure.
High Risk
Stable
Cardiac Cath.
pre-morbid
state and
suitability
for revasc.
High Risk
UnStable
Ongoing pain
ECG changes
GPIIbIIIa
Urgent cath.
pre-morbidity
suitability for
revasc.

19. What is UA/NSTEMI Patients Risk
of inpatient Cardiac Mortality and
ischemic events?

20. •Age ≥ 65 years =1 point
•At least 3 risk factors for CAD =1 point
•Prior coronary stenosis of ≥ 50% =1 point
•ST-segment deviation on ECG presentation =1 point
•At least 2 anginal events in prior 24 hours =1 point
•Use of aspirin in prior 7 days =1 point
•Elevated serum cardiac biomarkers =1 point
Variables Used in the TIMI Risk Score
The TIMI risk score is determined by the sum of the presence of the above 7 variables at
admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more
remained relatively insensitive to missing information and remained a significant predictor
of events. Antman EM, et al. JAMA2000;284:835–42.
TIMI = Thrombolysis in Myocardial Infarction.

21. TIMI Risk Score
Reprinted with permission from Antman EM, et al. JAMA2000;284:835–42. Copyright © 2000, American
Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org.
Anderson JL, et al. J Am Coll Cardiol2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.
TIMI
Risk
Score
All-Cause Mortality, New or Recurrent MI, or Severe
Recurrent Ischemia Requiring Urgent
Revascularization Through 14 Days After
Randomization %
0-1 4.7
2 8.3
3 13.2
4 19.9
5 26.2
6-7 40.9

22. GRACE Risk Score
The sum of scores is applied to a reference monogram to determine the corresponding all-cause
mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA2004;291:2727–33. The GRACE
clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in
Anderson JL, et al. J Am Coll Cardiol2007;50:e1–e157.
GRACE = Global Registry of Acute Coronary Events.
Variable Odds ratio
Older age 1.7 per 10 y
Killip class 2.0 per class
Systolic BP 1.4 per 20 mm Hg ↑
ST-segment deviation 2.4
Cardiac arrest during presentation 4.3
Serum creatinine level 1.2 per 1-mg/dL ↑
Positive initial cardiac biomarkers1.6
Heart rate 1.3 per 30-beat/min
↑

23. Why R U Confusing us?

24. UA/NSTEMI Hospital Care
Let’s Start with the Basics! Assuming the
NSTEMI has been our diagnosis

25. ACC/AHA Guidelines
ACS Treatment Overview: UA/NSTEMI
a
If possible, clopidogrel should be withheld for 5-7 days prior to the procedure.
Anderson JL, et al. Circulation.2007;116:803-877.
Initial invasive
management
Initial conservative
management
Diagnosis of UA or NSTEMI is likely or definite
Aspirin or clopidogrel
(if patient is aspirin intolerant)
PCI or CABG
a
Diagnostic
angiography
Medical
therapy
Long-term medical management:
Clopidogrel, aspirin, β-blocker, ACEI,
statin
Evaluation of LV
Function in pt
with ischemia

26. Selection of Initial Treatment
Wright RS et al. Circ 2011;123;2022-2060.

27. Early Treatment
Class I Indications
Bed rest with continuous ECG Monitoring
O2therapy if saturation <90%, respiratory
distress, or other high-risk features for
hypoxemia
SL NTG 0.4 mg q5min x3 then assessment of
need for IV NTG
IV NTG indicated first 48 hours for treatment of
persistent ischemia, CHF or HTN; should not
preclude Rx with beta-blockers or ACE
Wright RS et al. Circ 2011;123;2022-2060.

28. Early Treatment
Class I Indications
Oral Beta-Blocker in first 24 hours for pt who do not
have
Signs of CHF
Low out-put state
Increased risk of cardiogenicshock
Contraindication to Beta blockers/heart block/COPD
If Beta-Blockers are contraindicated a
nondihydropyridinecalcium channel blocker may be used
if no LV dysfunction
Wright RS et al. Circ 2011;123;2022-2060.

29. Early Treatment (Cont.)
ACE inhibitor within 24 hours with pulmonary congestion or
LVEF < 40% in the absence of hypotension or
contraindication
Because of the increased risk of mortality, reinfarction, HTN,
CHF, and myocardial rupture NSAIDS except for ASA should
be discontinued at presentation
Class II indications:
It is reasonable to admin O2to all UA/NSTEMI pts in first 6
hours. IIa
Morphine (1-5 mg IV) remains Class I for STEMI although
may increase adverse events in UA/NSTEMI (1,2)
It is reasonable to administer morphine sulfate IV if there
is uncontrolled ischemic Chest Pain despite NTG. IIa
1.Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.
2.Meine T el al. Am Heart J 2005;149:1043-9

30. Early Hospital Care
2011 Focused update Antiplatelettherapy
ASA should be administered to USA/NSTEMI as
soon as possible after hospital presentation and
continued indefinitely (LOE A)
Clopidogrel(loading dose followed by
maintenance dose) should be administered to
USA/NSTEMI patients who are unable to take
ASA because of hypersensitivity or major
gastrointestinal intolerance (LOE B)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Rx for all NSTEMI

31. Look who is sleeping

32. Hospital Care
2011 Focused update Antiplatelettherapy
For USA/NSTEMI patients in whom an
initial conservative strategy is selected
clopidogrel(loading dose followed by
maintenance dose) should be added to
ASA and anticoagulant therapy as soon as
possible after admission and administered
for at least 1 month and ideally up to 1
year
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Conservative Rx

33. Hospital Care
Initial Conservative Strategy:
Anticoagulant Therapy
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Conservative Rx
Anticoagulant therapy should be added to antiplatelet
therapy in UA/NSTEMI patients as soon as possible after
presentation.
For patients in whom a conservative strategy is selected,
regimens using either enoxaparin* or UFH (LOE A) or
fondaparinux(LOE: B) have established efficacy.
In patients in whom a conservative strategy is selected
and who have an increased risk of bleeding,
fondaparinuxis preferable.
*Limited data are available for the use of other low-
molecular-weight heparins (LMWHs), e.g., dalteparin.

34. Time to use your grey matter
An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponinis mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are not
contraindicated:
a. Clopidogrel
b. Prasugrel
c. Enoxaparin
d. Eptifibatide
e. An intravenous fibrinolyticdrug

36. Time to use your grey matter
An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her blood pressure is 180/100. She has bibasilar rales and an S3
gallop. Her serum troponinis mildly elevated. Her CXR shows
pulmonary congestion. The patient does not want to undergo
invasive diagnostic studies. Which of the following therapies are
most appropriate
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel75 mg daily
c. Intravenous unfractionatedheparin
d. ASA 325 mg daily and Intravenous heparin
e. ASA 325 mg OD & Clopidogrel75mg OD & IV heparin

37. Time to use your grey matter
An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her ECHO showed EF 30% & small pericardial effusion.
Which of the following drugs should be discontinued?
a. Metoprolol
b. Diltiazem
c. Hydralazine
d. Lisinopril

38. Time to use your grey matter
Oral beta blockers should be initiated within first 24 hrs
for those pts who do not have
1) Signs of heart failure
2) Evidence of low output state
3) Increased risk of cardiogenicshock
4) other contraindications to beta blockers
Risk Factors for CardiogenicShock
Age > 70yrs
BP <120
Heart rate >110 or < 60
Increased time since onset of symptoms

39. Time to use your grey matter

40. Time to use your grey matter
An 65 year-old woman presented to the ED at 6 AM with a history
of intermittent chest pain x 1 week. She has long-standing
hypertension and chronic kidney disease, and started hemodialysis
recently. Her anti-hypertensive medications are: metoprolol,
diltiazem, hydralazine, and lisinopril. She has been taking aspirin
325 mg daily since having a TIA one year ago.
Her ECHO showed EF 30% & small pericardial effusion.
Which of the following is indicated?
a. Transe-esophageal echo
b. Biventricular pacing
c. Implantable cardioverterdefibrillator
d. Cardiac catheterization

41. Initial Conservative strategy
Additional Management considerations

42. Hospital Care
2011 Focused update
For USA/NSTEMI patients in whom an
initial conservative strategy is selected if
recurrent symptoms/ischemia, CHF, or
serious arrhythmias subsequently appear,
then diagnostic angiography should be
preformed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Conservative Rx

43. Hospital Care
2011 Focused update
For patients with USA/NSTEMI treated
conservatively without recurrent symptoms, CHF
or arrhythmia a stress test should be performed
If the pt is not classified as low risk after the
stress test then angiography should be
performed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Conservative Rx

44. Hospital Care
2011 Focused update
If at low risk Post Stress Test:
Continue ASA
Continue clopidogrelfor at least 1 month and
ideally up to 1 year
Discontinue GP IIb/IIIainhibitor if started
Continue UFH for 48 hours or administer
enoxaparinor fondaparinuxfor the duration
of hospitalization up to 8 days and then
discontinue
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Conservative Rx

45. Pharao gets prescription

46. Time to use your grey matter
An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal , ECG is below
What would you recommend?
a. A resting sistamibi scan
b. A nuclear stress test
c. Intravenous fibrinolytic drug
d. Cardiac Cath

47. Selection of Initial Treatment
Wright RS et al. Circ 2011;123;2022-2060.

48. Time to use your grey matter
An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & CreatininNormal, CTn2.9
Which of the following therapies are most appropriate?
a. ASA 325 mg daily
b. ASA 325 mg daily and clopidogrel75 mg daily
c. ASA 325 mg daily and prasugrel10 mg OD
e. Clopidogrel75mg OD & IV eptifabatide

49. Early Hospital Care
2011 Focused update Antiplatelettherapy
Pt with definite USA/NSTEMI at medium or
high risk and in whom an initial invasive
strategy is selected should receive dual-
antiplatelettherapy on presentation (LOE A)
ASA on presentation
The second should be given before PCI as
follows…..
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Medium to High
Risk patients…..

50. Early Hospital Care
2011 Focused update Antiplatelettherapy
Before PCI:
Clopidogrel(LOE B)
An IV GP IIb/IIIainhibitor (LOE A) eptifibatide
or tirofibanare the preferred agents
At the time of PCI:
Clopidogrelif not started before PCI (LOE A)
Prasugrel(LOE B)
An IV GP IIb/IIIainhibitor (LOE A)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Medium to High
Risk patients…..

51. Time to use your grey matter
An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & CreatininNormal, CTn2.9
Which of the following therapies are not appropriate?
a. IV unfractionatedheparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

52. Initial Invasive Strategy
Anticoagulation

53. Continue Smiling

54. Time to use your grey matter
An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, Creatininclearance is <30
ml/min, CTn2.9
Which of the following therapies are not appropriate?
a. IV unfractionatedheparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

55. Time to use your grey matter
An 80 year-old man presented to the ED at 2 AM with a history of
intermittent chest pain x 2 days. He is not taking any medicine.
Physical exam is normal.
Labs: RBS 150 mg%, CBC Normal, BUN & Creatininnormal but
there is history of heparin induced thrombocytopenia
Which of the following therapies is appropriate?
a. IV unfractionatedheparin
b. Enoxaparin
c. Foundaparinux
e. Bivalirudin

58. Hospital Care
2011 Focused update
For patients with USA/NSTEMI in whom CABG is
selected post angiography
Continue ASA
Discontinue IV GP IIb/IIIainhibitor 4 hours before
CABG
Continue UFH
Discontinue enoxaparin12-24 hours before CABG and
dose with UFH per institution practice
Discontinue fondaparinux24 hours before CABG and
dose with UFH per institution practice
Discontinue bivalirudin3 hours before CABG and dose
with UFH per institution practice
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

59. Hospital Care
2011 Focused update
In patients taking thienopyridinein whom
CABG is planned and can be delayed…
Discontinue clopidogrelfor at least 5 days
Discontinue prasugrelfor at least 7 days
Unless the need for revascularization and or
the net benefit of the thienopyridine
outweighs the potential risks of excess
bleeding… (LOE C)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

60. ACC/AHA Guidelines update 2011
UA/NSTEMI: Long-Term Medical Management
UA or NSTEMI at hospital discharge
Inhospital management with
medical therapy (without
stenting)
Inhospital therapy with bare-
metal stent implantation
Inhospital therapy with
drug-eluting stent
implantation
Aspirin
a
75-162 mg/d
indefinitely plus
clopidogrel
b
75 mg/d for at
least 1 mo, ideally up to 1 yr
Aspirin
a
162-325 mg/d for at
least 1 mo, then
75-162 mg/d indefinitely plus
clopidogrel
b
75 mg/d or
prasugrel 10 mg/d for at
least12 months*
Aspirin
a
162-325 mg/d for at
least 3 mo with Sirolimus and
6 mo paclitaxel, then
75-162 mg/d indefinitely plus
clopidogrel
b
75 mg/d or
prasugrel 10 mg/d for at
least 12 mo
Is an indication for
anticoagulation present?
If yes: add
warfarin
c,d
If no: continue dual
antiplatelet therapy
a
If patient is allergic
to aspirin, use
clopidogrel alone
(indefinitely) or try aspirin
desensitization.
c
Continue aspirin indefinitely
and warfarin long term, if
indicated for specific conditions.
d
If warfarin is added to aspirin
and clopidogrel, the
recommended INR is 2.0-2.5.
b
If patient is allergic to clopidogrel,
use ticlodipine 250 mg PO bid.
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

62. Dear Doctor!

63. Evaluating Recurrent Risk
Secondary Prevention Strategies
Broad Goals during Hospital discharge phase
Prepare the patient for normal activities
Use the acute event as an opportunity to
reevaluate the plan of care -lifestyle and
risk factor modification
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

64. Can U Revise

65. Take all these pills daily until a new clinical
trial is published
Evidence based medicine

66. Questions?
No questions?
Good!
Then let’s go home
& try some herbal Rx