Beruflich Dokumente
Kultur Dokumente
of
Acute Coronary Syndrome
Nahar Taufiq
Bagian Kardiologi dan Kedokteran Vaskuler FK UGM
Yogyakarta
Atherothrombosis* is the
Leading Cause of Death Worldwide1
Injuries 9
AIDS 9.7
Cancer 12.6
Atherothrombosis* 22.3
0 5 10 15 20 25 30
Causes of Mortality (%)
Unstable
angina ACS
MI
Ischemic
stroke/TIA
Atherosclerosis Critical leg
ischemia
Intermittent
claudication
CV death
MI = Myocardial infarction
ACS = Acute coronary syndromes
Adapted from Libby P. Circulation 2001; 104: 365–372
CV = Cardiovascular
Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Old
Terminology: UAP NQMI STE-MI
UAP or STEMI-ACS
NON STEMI-ACS
Initial Recognition
in the Emergency Department
P Ex ED Evaluation of Patients
Panic attack
Dx Electrocardiogram
10 Clopidogrel
5
P=0.03
0
0 5 10 20 25 30
Days
* Cardiovascular death, recurrent MI, or recurrent ischemia leading to
the need for urgent revascularization
ASA + CLO
ASA P=0.24
4
P=0.80 3.4
P=0.12
3 2.7
% of patients
2
1.9
1.7 1.6
1
0.9
0
Major bleeding Minor bleeding Major or minor
bleeding
Tx Onset of antiplatelet
Agent Dose Onset
dose3 dose
1 Dabaghi SF et al. Am J Cardiol 1994;74:720-3. 2. Savcic M et al. Semin Thromb Hemost 1999;25:15-19
Mona_C
o
1 2 3
1
Reperfusion Therapy and
Recommendations
STEMI
Tx Reperfusion
Late presentation
> 3 hours from symptom onset
Antithrombin Therapy
and Recommendations
Non-STEMI & UAP
ACC/AHA Recommendations for
Antithrombin Therapy in Patients with
NSTE-ACS
• Class I
– Anticoagulation with subcutaneous LMWH or intravenous
UFH should be added to antiplatelet therapy
– Dose of UFH 60-70 U/kg (max 5000) IV followed by
infusion of 12-15 U/kg/hr (initial max 1000 U/hr) titrated
to aPTT 1.5-2.5 times control
– Dose of enoxaparin 1 mg/kg subcutaneously q12 hr; the
first dose may be preceded by a 30-mg IV bolus
– Fundaparinoux SC
• Class IIa
– Enoxaparin is preferable to UFH as an anticoagulant
unless CABG is planned within 24 hours
Goals Recommendations
Goals Recommendations
If TG is ≥ 500 mg/dL:
Consider fibrate or niacin before LDL-C–lowering
therapy.
Consider omega-3 fatty acids as adjunct for high
TG.
NCEP ATP III Guidelines
Initiate TLC* Drug therapy LDL
Patients with if LDL considered if LDL treatment
goal
†
100 mg/dL = 2.6 mmol/L; 130 mg/dL = 3.4 mmol/L; 160 mg/dL = 4.1 mmol/L
National Cholesterol Education Program, Adult Treatment Panel III. JAMA 2001;285:2486–2497
* TLC: therapeutic lifestyle changes
Secondary Prevention and Long Term Management
Goals Recommendations
Weight
management: Calculate BMI and measure waist
Goal: circumference as part of evaluation. Monitor
BMI 18.5 to 24.9 response of BMI and waist circumference to
kg/m2 therapy.
Goals Recommendations
Diabetes Appropriate hypoglycemic therapy to
management: achieve near-normal fasting plasma
Goal: glucose, as indicated by HbA1c.
HbA1c < 7%
Treatment of other risk factors (e.g.,
physical activity, weight management,
blood pressure, and cholesterol
management).
Guidelines for the Use of Enoxaparin in Patients
with NSTE-ACS
Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Risk ≥ Benefit
Additional studies with Additional studies with No additional studies
focused objectives broad objectives needed; needed
needed Additional registry data
would be helpful Procedure/Treatment
Procedure/ Treatment IT IS REASONABLE to should NOT be
SHOULD be perform Procedure/Treatment performed/administered
performed/ procedure/administer MAY BE CONSIDERED SINCE IT IS NOT
administered treatment HELPFUL AND MAY BE
HARMFUL
0.5 1 2
Relative risk (RR) of death
Beta blocker Placebo
better better
RISC
Cohen 1990
ATACS
Holdright
Gurfinkel
Summary Relative Risk
0.67 (0.44-0.1.02)
0.1 1 10
Heparin + ASA RR: ASA Alone
55/698=7.9% Death/MI 68/655=10.4%
ASA indicates acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic Therapy in Acute
Company Syndromes; RR, relative risk; and MI, myocardial infarction.
Data from Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in
patients with unstable angina: a meta-analysis. JAMA. 1996;276:811-815. Slide reproduced with permission from Cannon CP.
Atherothrombosis slide compendium. Available at: www.theheart.org.
ESSENCE Results
Tx
Unfractionated Heparin
30% Enoxaparin (Lovenox)
25%
Recurrent Angina
Death, MI or
20%
15%
P = 0.02
10%
Risk Reduction 16.2%
5%
0
5 9 13 17 21 25 29
Days After Randomization
Adapted with permission from Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight
heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous
Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337:447-452. Copyright © 1997,
Massachusetts Medical Society. All rights reserved.
TIMI 11B: Enoxaparin vs.
Heparin in NSTE-ACS
20 Unfractionated Heparin
16.7 %
Urgent Revascularization
Enoxaparin (Lovenox)
16
Death, MI or
12 14.2 %
8
p = 0.03
4 Relative Risk Reduction = 15%
0 2 4 6 8 10 12 14
Days
Adapted from Antman EM, et al. Circulation. 1999;100:1593-1601.