Acute Coronary

Syndrome
(Focus on early recognition
and initial management)
Muhammad Yolandi Sumadio
Cardiology and Vascular
Department
University North Sumatera

What Is Acute
Coronary
Syndrome?

ACS Definition
Acute coronary syndrome (ACS) = Heart Attack
refers to spectrum of presentations that is consistent to be
caused by myocardial ischemia

By ECG differentiation

NSTE-ACS
Unstable
Angina

NSTEMI

STE-ACS

STEMI

What cause ACS ?

Stable
Angina

Acute Coronary Syndrome

What happened in ACS ?

Why
should we
care?

ACS

is a cardiac emergency

High mortality and morbidity

Global Major Causes of Death

ACS were
responsible
to
half of CVD
deaths

Global Atlas on Cardiovascular Disease Prevention And

ACS Morbidity and Mortality

1/3 of STEMI patients die within 24 hours of onset of
ischemia

15% of UA patients die or experience a reinfarction

within 30 days of diagnosis
up to 30% of discharged patients are rehospitalized
within 6 months

9% - 19% ACS patients die in the first 6 months after

diagnosed, with about one-half of deaths occurring
within 30 days.
18% of men and 23% of women over age
40 may die within 1 year following MI (STEMI & NSTEMI)

STE-ACS vs NSTE-SCS
Incidence : NSTEMI > STEMI
Hospital mortality:
STEMI > NSTEMI (7 % vs 5 % )

6th month mortality :

STEMI = NSTEMI (12 % vs 13 % )

Long Term Follow Up Mortality

NSTEMI > STEMI

Are all bad

news??

Evidence-Based Medical Therapy

Significantly lowered morbidity

& mortality
Started with an adequate
diagnosis (not an
underdiagnosed one) and an
appropriate treatment

How to
diagnose
ACS?

Diagnosing ACS
1. ACS is A CLINICAL
DIAGNOSIS not an ECG
diagnosis
Recognize the symptom
correctly

Symptoms compatible with

ischaemic heart disease

Symtomps compatible with

ischaemic heart disease

Speci
fic
Less
speci
fic

Typical chest
pain/ Angina
pectoris
Angina
equivalent
Complication
s of coronary
heart disease

Typical chest pain

Quality
Location

Duration
Setting

Reliever or
exaggerator

Squeezing, heaviness, pressure, weight,

very strong pain, burning, tightness
Centre of the chest, left chest with
radiation to shoulder, neck, jaw, inner
arm, epigastrium (can occur without
chest pain)
Unstable angina 10-20 min.
Myocardial infarction last longer
Triggered by exercise, sexual activity,
exposure to cold weather, emotional
stress (anger, fright, frustration), or a
large meal.
No effect of position or respiration to
quantity or quality of chest pain.
Lessened by nitrat

Typical chest pain

Typical chest pain

Angina Equivalent

Late Presentation

Atypical Chest Pain

Typical chest
pain orang
Medan
=
ANGIN

Diagnosing ACS

2. Look For Risk

Factors

Diagnosing Heart Disease

Atypical
symptom and
sign
Risk
Factor
s

Typical
symptom
and sign
Risk
Factor
s
Evidence
of heart
disease

Less
likely

More
likely

Most
likely

Defini
te

Diagnosing ACS
3. Evidence of ACS

Role of ECG in ACS

Diagnosing Heart Disease

Atypical
symptom and
sign
With or without
Risk Factors

Typical
symptom
and sign
With or without
Risk Factors

Evidence of heart disease

(diagnostic ECG abnormality)

Definite heart disease

Roles of ECG in ACS

Typical/
Specific
Symptom

Atypical/ Less
Specific
Symptom
But with a
diagnostic ECG

Acute Coronary Syndrome

ECG Changes
STEM
I

Unstable
Angina

NSTE
MI

Normal ECG

ACS
Management

The philosophy of
treating ACS is to
lower the patient
mortality (not only
in-hospital but also
long
term benefit
mortality)
The
mortality
of ACS
treatment started from the
earliest treatment given

Clinical diagnosis of ACS is likely

Atypical presentation but with diagnostic ECG

Give initial pharmacological treatment

(MONACO)
1. O2 nasal 4 lpm
2. Aspirin 300 mg chew (*)
3. Clopidogrel 300 mg if available (*)
4. ISDN 5 mg sublingual (interval 5 min,
max 3 dose)
5. Morphin 2-4 mg iv (if pain isnt
responding to nitrate)

Refer to Hospital with cardiologist

ECG Analysis

ECG Analysis
STEMI
> 12 hours
of onset

STEMI
< 12 hours of
onset

Reperfusion:
Fibrinolytic
Primary PCI

(*) gives mortality and

morbidity benefit

NSTE ACS

Manage conservatively:
ICU/ICCU (*)
Continuos nitrat infusion
Dual antiplatelet regimen (aspirin and
clopidogrel) (*)
Anticoagulant
(heparin/fondaparinux/enoxaparin) (*)
High intensity statin (*)
ACE inhibitor (*)
Beta blocker (*)

PCI in selected high-risk feature patient (*)

Initial Pharmacological Treatment for

Acute Coronary Syndrome

MONACO
Morphin-Oxygen-Nitrate-AspirinClopidogrel

1. Oxygen
a. Indication
: All ACS Patient
b. Contraindication : COPD (high dose
O2)
c. Dosage :
1 6 L/min via nasal cannula
4 L/min for AMI
6 10 L/min via non-breathing face
mask

Initial Pharmacological Treatment for

Acute Coronary Syndrome
2. Nitrate [Isosorbid dinitrate (ISDN)]
a. Indication
:
Ischemic chest pain
b. Contraindication :
Hipotension (SBP < 90 mmHg)
< 48 hours use of PDE (Viagra)
c. Caution
:
Beware of hypotension, give bolus of
saline if it happen
Right ventricular infatction
d. Dosage
:
5 mg sublingually (interval 5 min, max 3
doses)
e. Target therapy :
Relieve of ischaemic symptomps

Initial Pharmacological Treatment for

Acute Coronary Syndrome
3. Aspirin
a. Indication
:
All ACS patient for antiplatelet
agregation
b. Contraindication :
Active bleeding or bleeding
tendency
c. Dosage :
Loading dose of 162-325 mg
(usually 300mg) chew
Continue 85-100 mg once daily
e.
Therapy benefit:
Improve survival and outcome

ASPIRIN

ASPIRIN
Compared with placebo in the ISIS-2
trial, up to 1 month of aspirin 162 mg
daily after suspected acute MI
prevented about 40 deaths, nonfatal
reinfarctions, or strokes per 1000
patients treated (and these early
benefits persisted for at least 10
years).

Initial Pharmacological Treatment for

Acute Coronary Syndrome
4. Clopidogrel
a. Indication
:
All ACS patient for antiplatelet
agregation
b. Contraindication :
Active bleeding or bleeding
tendency
c. Dosage :
Loading dose of 300 mg on time
Patient > 70 yo: use maintenance
dose of 75 mg
e.
Therapy benefit:
Improve survival and outcome

Clopidogrel

Initial Pharmacological Treatment for

Acute Coronary Syndrome
5. Morphine
a. Indication
:
Chest pain not responding to nitrate
Pulmonary oedema
b. Contraindication :
Hipotension
Right ventricular infarction
c. Dosage :
2-4mg IV Q5-30min, titrate to effect
e.
Close monitor to:
Blood pressure
CNS/respiratory depression

Resume
ACS is a fatal cardiac emergency with a rising
incidence and high mortality and morbidity
ACS diagnosis is a clinical diagnosis;
ECG role is not important in diagnosing ACS

Recent advances in treatment of ACS has

proven to have a huge mortality benefit

The treatment mortality benefit starts

even from the initial treatment given

Saving peoples from

heart attack starts from you

Thank You