 Decide on the correct management of patients with acute coronary syndrome based on the findings of a clinical history, examination and relevant test results such as an ECG  Demonstrate ability to interpret clinical findings in people presenting with acute coronary syndrome  Choose the correct evidence-based management for a number of cases of acute coronary syndrome.

A 57 year old man has intermittent chest pain of minutes duration with minimal exertion Up to 5 times a day over the past 1 week. A particularly prolonged episode precipitated his presentation to hospital. He had a 30 pack year history of smoking, hypertension, hyperlipidaemia and gout. Current medications include aspirin, atorvastatin + NSAIDs

(1) New onset angina markedly limiting physical activity (2) Siesta or rest angina >20 minutes duration (3) Worsening angina more frequent, longer duration or occurs with less exertion than previously

(1) Elderly + diabetes (2) Dyspnoea, syncope or confusion/delirium

He was afebrile, heart rate 65 beats per minute, a blood pressure of 175/110 mm Hg and normal oxygen saturation. No cardiac murmurs were heard and no clinical signs of cardiac failure. An initial serum troponin level was elevated at 0.93 μ g/L. What is the ECG finding?

A 2 mm ST segment depression in II, III, a VF and V5-V6

Unstable anginaNSTEMISTEMI Ischaemic symptoms +++ ( severe onset central chest pain with dyspnoea + diaphoresis) Elevation troponin or CKMB ___+/-( may not be detectable hours after presentation) + ECG changes( ST segment depression, transient elevation or new T wave inversion ___ ST elevation Q waves+/- (depends size infarct, duration occlusion, extent collateral vessels maintain myocardial viability during occlusion)

Suspicion of a STEMI (1) Ischaemic symptoms + elevation troponins + ECG changes (2) Left circumflex coronary artery occlusion (ongoing chest pain + nonspecific lateral ST- T wave changes + not a significant ST elevation + masquerading as a NSTEMI)

(1) Three Risk factors at least for heart disease (hypertension, diabetes, dyslipidaemia, smoking,positive family history) (2) Increasing age >65 years (3) Prior coronary Stenosis of > 50% (4) Serum cardiac biomarkers elevated (5) e K g admission : ST-segment deviation (6) Angina in previous 24 hours(at least 2 episodes) (7) Aspirin use in prior seven days (probably a marker for more severe coronary disease

ScoreRisk of death 0 to 2low 3 or 4intermediate 5 to 7high

(1) Oxygen +glyceryl trinitrate (intravenous glyceryl trinitrate : in patients with persistent pain, hypertension or heart failure). Nitrates used with caution right ventricular infarction, hypotension and severe aortic stenosis. (2) Intravenous morphine sulfate at an initial dose of 2 to 4 mg, with increments of 2 to 8 mg repeated at five to 15 minute intervals for the relief of chest pain and anxiety

(1) Beta blockers within 24 hours of an acute myocardial infarction is recommended, not recommended acutely in haemodynamic instability, cardiogenic shock or heart failure. Intravenous beta blockers should be used only inpatients without contraindications who have ongoing rest pain plus hypertension and tachycardia. (2) Antiplatelet and antithrombotic therapy: refer next slide

(1) Uncoated aspirin ASAP the onset of symptoms (300 mg ) unless this is absolutely contraindicated. The tablet should be chewed to establish a high blood level quickly (2) Clopidogrel with aspirin: 20% reduction in ischaemic endpoints (including death and myocardial infarction) when compared with aspirin alone. Seen in all subgroups in CURE trial, ( elderly + patients not revascularised)

(1) Prasugrel : potential advantage increased potency over clopidogrel when used in patients with acute coronary syndromes undergoing percutaneous coronary intervention (PCI), especially with STEMI + who have diabetes. (2) Intravenous glycoprotein IIb/IIIa inhibitors (abciximab and eptifibatide ) in the prevention of ischaemic complications associated with PCI well documented in patients with acute coronary syndromes. Combination clopidogrel + glycoprotein IIb/IIIa inhibitor reasonable in patients at high risk with recurrent ischaemic discomfort or delay in angiography is anticipated

Invasive approach, UFH + low molecular weight heparin (enoxaparin ) viable options. The advantages of enoxaparin (i) lower incidence of heparin-associated thrombocytopenia, (ii) ease of administration without the need for monitoring, (iii) lesser degree of platelet activation. (iv) fewer recurrent nonfatal myocardial infarction A Disadvantage inability to reverse the anticoagulation of enoxaparin with protamine

Direct thrombin inhibitors : bivalirudin (In the Acute Catheterization + Urgent Intervention Triage Strategy (ACUITY) trial of moderate + high risk acute coronary syndrome: bivalirudin compared with UFH + glycoprotein IIb/IIIa inhibitor. The clinical outcomes similar in terms of ischaemic events but the bivalirudin group had significantly less bleeding.

(1) Patients with an acute coronary syndrome who meet intermediate or high-risk criteria (TIMI Risk score > 2) (2) Optimal timing of intervention not been defined, but likely between 4 – 48 hours of admission (3) PCI is most often performed in patients with an appropriate lesion. (4) CABG is usually preferred for the treatment of patients with left main coronary artery or triple vessel disease, or double Vessel disease involving the left anterior descending coronary artery in patients with left ventricular dysfunction or diabetes

(1 ) Prevention of recurrent ischaemic events with long-term oral antiplatelet therapy. Aspirin recommended lifelong + clopidogrel for at least one month (for at least 12 months or lifelong in selected cases). (2) Prevention of recurrent ischaemia+ life- threatening ventricular arrhythmias with beta blockers. (3) Reduction of cholesterol levels with a statin to prevent or slow disease progression + prevent cardiovascular events (the target level for total cholesterol is below 4.0 mmol/L + LDL, below 2.0 mmol/L).

(4) Long-term oral anticoagulation (warfarin ) is not recommended after an acute coronary syndrome but should be considered if left ventricular thrombus or chronic atrial fibrillation is present to prevent thromboembolisation. In this instance, so called ‘triple therapy’ may be recommended until clopidogrel is ceased (continue aspirin and warfarin). (5) Possible use of an ACE inhibitor in patients at increased risk, in particular those with diabetes, heart failure or left ventricular ejection fraction < 40%. Care should be exercised in those with renal impairment (especially acute renal impairment). Angiotensin receptor blockers are considered a reasonable alternative