Unstable Angina and Non–ST Elevation Myocardial Infarction YEDITEPE UNIVERSITY FACULTY OF MEDICINE PHASE 4 CARDIOLOGY COURSE 2014-2015 PROF. MUZAFFER DEGERTEKIN, M.D., PhD. MUSTAFA AYTEK SIMSEK, M.D., Attending Physician

Pathophysiology of ACS Evolution of Coronary Thrombosis

Causes of UA/NSTEMI Thrombus or thromboembolism, usually arising on disrupted or eroded plaque – Most Common Cause. Dynamic obstruction – coronary spasm or vasoconstriction Progressive mechanical obstruction to coronary flow – ie restenosis after PCI Coronary arterial inflammation Coronary artery dissection Secondary UA – Increasing oxygen demands in the setting of a fixed lesion.

Clinical Indicators of Increased Risk in UA/NSTEMI

TIMI Risk Score T: Troponin elevation (or CK-MB elevation) H: History or CAD (>50% Stenosis) R: Risk Factors: > 3 (HTN, Hyperlipidemia, Family Hx, DM II, Active Smoker) E: EKG changes: ST elevation or depression 0.5 mm concordant leads A2:Aspirin use within the past 7 days; Age over 65 T: Two or more episodes of CP within 2 hours

GRACE Prediction Score Card Medical History Age in years (0-100 points) History of congestive heart failure (24 points) History of myocardial infarction (12 points) Findings at initial hospital presentation Resting heart rate (0-43 points) Systolic blood pressure (0-24 points) ST depression (11 points) Findings during hospitalization Initial serum creatinine (1 to 20 points) Elevated cardiac enzymes (15 points) No in-hospital percutaneous coronary intervention (14 points) JAMA 2004:291;2727-33

Deciding between Early Invasive vs a Conservative Strategies Definitive/Possible ACS Initiate ASA, BB, Nitrates, Anticoagulants, Telemetry Early Invasive Strategy TIMI Risk Score >3 New ST segment deviation Positive biomarkers Coronary angiography (24-48 hours) Conservative Strategy TIMI Risk Score <3 (Esp. Women) No ST segment deviation Negative Biomarkers Recurrent Signs/Symptoms Heart failure Arrhythmias Remains Stable ↓ Assess EF and/or Stress Testing EF<40% OR Positive stress Go to Angiography Deciding between Early Invasive vs a Conservative Strategies

General Treatment Measures Antiplatelet Therapy Anticoagulant Therapy Control of Cardiac Pain Analgesics Nitrates Beta Blockers Oxygen Limitation of Infarct Size Early reperfusion Reduction of myocardial energy demand

Antiplatelet Therapy Aspirin  162-325 mg, nonenteric-coated ASA to be chew  maintenance of 75-162 mg daily

Antiplatelet Therapy Clopidogrel 300 mg loading 75 mg/day Prasugrel oral loading dose of 60 mg and 10 mg orally daily Ticagrelor a loading dose of 180 mg and 90 mg twice daily

Anticoagulant Therapy Heparin activated partial thromboplastin time (aPTT) target of 1.5 to 2 times that of control Low-Molecular-Weight Heparins Fondaparinux

Control of Cardiac Pain Analgesics meperidine, pentazocine, and morphine Morphine 2 to 8 mg/ 5 to 15 minutes --until the pain is relieved or there is evident toxicity Nitrates sublingual nitrates, intravenous nitroglycerin systolic pressure <90 mm Hg right ventricular infarction

Control of Cardiac Pain Beta Blockers Killip class II or higher (precipitating cardiogenic shock) Patients with heart failure (rales > 10 cm up from diaphragm), hypotension (blood pressure < 90 mm Hg), bradycardia (heart rate < 60 beats/min),

Control of Cardiac Pain Oxygen pulse oximetry Sao2 < 90% 2 to 4 liters/min of 100% oxygen 6 to 12 hours

Limitation of Infarct Size Early reperfusion Routine Measures for Infarct Size Limitation Beta blocker (HR 50-70) Inhibitors of the renin-angiotensin-aldosterone system (RAAS) Arterial oxygenation

Limitation of Infarct Size  Angiotensin-converting enzyme (ACE) inhibitor   Start ACE inhibitor orally in patients with pulmonary congestion or LVEF <40% if the following are absent: hypotension (SBP <100 mm Hg or <30 mm Hg below baseline) or known contraindications to this class of medications.  Angiotensin receptor blocker (ARB)  Start ARB orally in patients who are intolerant of ACE inhibitors and with either clinical or radiologic signs of heart failure or LVEF <40%