1. Acute coronary syndromes
Radka Adlová

2. ACS - introduction
includes any condition where the blood flow to the heart muscle is reduced
the most feared complications of coronary artery disease (CAD)
are associated with high mortality and morbidity
Cardiovascular diseases (CVD) - presently
the leading cause of death in developed countries
Coronary artery disease is the cause of 13% of deaths worldwide, every sixth man and every seventh woman
in Europe die because of acute myocardial infarction (AMI)

3. Cardiovascular Mortality

4. Definiton The clinical presentations of CAD include: silent ischaemia
stable angina pectoris
heart failure
unstable angina
myocardial infarction (MI)
sudden death

5. Acute coronary syndromes
ACS are usually divided into:
UNSTABLE ANGINA PECTORIS - characterized by the presence of ischemia, lack of necrosis of heart muscle
STEMI - ST - elevation MI
NSTEMI - non-ST elevation MI
Sudden death - due to cardiac arrhythmias

6. Acute coronary syndromes

7. Definition ST - elevation ACS (STE - ACS):
typical acute chest pain and persistent (for >20 min)
ST-segment elevation
Mostly reflect an acute total coronary occlusion

8. ST elevation on the ECG

9. Definition Non – STE - ACS (NSTE - ACS): acute chest pain
without persistent
ST-segment elevation
persistent or transient ST segment depression or T- wave inversion

10. ST depresion on the ECG

12. Pathophysiology = Vulnerable plaque

13. Epidemiology The annual incidence of NSTE-ACS is higher than STEMI
The annual incidence of hospital admissions for NSTE-ACS is in the range of 3 per 1000 inhabitants
sex differences - men account for more than 90% of patients with AMI under the age of 40y.
(a hormonal profile of woman has a protective effect)
age differences - in patients aged under 40y. only one heart artery is affected

14. Prognosis of STE vs. NSTE-ACS
Hospital mortality
- higher in patients with STEMI than among those with NSTE-ACS (7 vs. 5%)
6 months mortality
- the mortality rates are very similar in both conditions (12 vs. 13%)
Long-term follow-up
- death rates higher among those with NSTE-ACS than with STE- ACS

15. Prognosis of STE vs. NSTE-ACS
The causes of the higher death rates of NSTE-ACS than of STE-ACS pts. during long-term follow-up are:
older pts.
more co-morbidities (diabetes and renal failure).
a greater extent of coronary artery and vascular diseases
persistent triggering factors such as inflammation

16. Classification of MI
Type 1 - spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection
Type 2 – MI secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension
Type 3 – sudden unexpected cardiac death, including cardiac arrest
but death occurring before blood samples could be
obtained
Type 4 – associated with PCI:
Type 4a – MI associated with the procedure of PCI
Type 4b – MI associated with stent thrombosis
Type 5 – MI associated with CABG

18. Myocardial infarction
1. Atherosclerotic aetiology (type 1)
2. Non-atherosclerotic aetiology: (type 2-5)
arteritis
trauma
dissection
congenital anomalies
cocaine abuse
complications of cardiac catheterization, CABG

20. Diagnosis of acute MI 2 from 3 criteria must be fulfilled :
Clinical symtoms
Chest pain
ECG changes
ST elevation or depression
negative T wave
Elevated cardiac biomarkers
Troponin I or T
CK-MB
myoglobin

21. Clinical presentation
STE/NSTE-ACS:
- intense prolonged (20 min) pain at rest - retrosternal pressure or heaviness (‘angina’) radiating up to the neck, shoulder and jaw and down to the ulnar aspekt of the left arm
- May be accompanied by other symptoms such as nausea,
sweating, abdominal pain, dyspnoea,…
Unstable angina:
- New onset severe angina (class III of CCS)
- Recent destabilization of previously stable
angina with at least CCS III angina
characteristics

22. Location of MI

23. Location of the various types of MI
ST elevation in:
Anteroseptal - V1-V3
Anterolateral - V1-V6
Inferior wall - II, III, aVF
Lateral wall - I, aVL, V4-V6
Right ventricular - RV4, RV5
Posterior- R/S ratio >1 in V1 and T wave inversion

24. Location of MI

25. Location of MI

26. Location of MI

27. Biochemical markers cardiac troponins (I and T)
Markers of myocardial injury:
cardiac troponins (I and T)
creatinine kinase (CK)
CK isoenzyme MB (CK-MB)
Myoglobin
We have to perform repeated blood sampling and measurements are required 6-12 h after admission and after any further episodes of severe chest pain

28. Biochemical markers over time

29. Non-invasive myocardial imaging
Echocardiography
- to evaluate LV systolic function, complications,
aortic stenosis, aortic dissection, pulmonary
embolism, or hypertrophic cardiomyopathy
- should be routinely used in emergency units
for the risc stratification

30. Imaging of the coronary anatomy
The imaging of the coronary anatomy is the most importat diagnostics method in evaluation of acute coronary syndrome
The gold standard of patients with ACS is conventional invasive coronary angiography

31. Decesion-making algorithm in ACS

32. Treatment of MI
while STEMI is an urgent situation with turbulent symptomatology, NSTEMI may have symptoms much milder and above its immediate prognosis is better
Pts. should stay on coronary care unit days, than standard cardiology department
the total length of hospitalization is around 1 week
even after leaving the CCU patients are able to move around the room and in the following days rehabilitate and before discharge they are able to walk up the stairs
return to job possible approximately one month after the onset of the symptoms

33. Treatment of STEMI
Open the occluded artery as soon as possible to restore blood flow for the heart = primary PCI
‘‘Time is muscle“
Check for complication of myocardial infarction and treat them:
arrhythmia
heart failure
bleeding

34. Reperfusion Strategy Reperfusion therapy 37-93%
PPCI rate varies between 5 and 92%; Thrombolysis 0-55%
EUROPE IS VERY HETEROGENOUS!!!

35. Process of the percutaneous coronary intervention

36. Process of the implantation of stent

37. Aspiration trombectomy
procedure for elimination of trombus to prevent embolisation
a special hollow catheter is introduced into the affected artery
and thrombotic masses are aspirated under pressure

38. Pre-hospital management
Antiplatelet therapy
Acetylosalicid acid mg (i.v. or p.o.),
Clopidogrel 600mg or ticagrelor 180mg or prasugrel 60mg
Antithrombin therapy
Heparin IU i.v. or enoxaparine
Resolve pain and fear
analgesic drugs
benzodiazepine

39. Pre-hospital management
Nitrate - pain, hypertesion, heart failure
Isosorbide dinitrate 1-5 mg i.v.
Monitoring vital function and ECG
ventricular fibrilation
terminated by cardioversion

40. Pre-hospital management
Betablockers - tachycardia, hypertension
Metoprolol - dose 25-50mg oral or 2 mg i.v.
ACE inhibitors - hypertension
Perindopril - dose 5 mg oral
Diuretic - heart failure
Furosemide mg i.v.
Anti-arrhythmic drugs -no prophylaxis
Mesocain 1% 10 mL i.v.
Amiodarone 150 mg i.v. bolus

41. Hospital and discharge therapy
Antiplatelet therapy
Acetylosalicid acid - dose 100 mg p.o. (for life)
Clopidogrel 75mg or ticagrelor 90mg twice a day or prasugrel 10mg (1 year)
Statins - benefit for all patients with IM
Atorvastatin 40-80mg, rosuvastatin 20-40mg (for life)
ACE inhibitors - benefit for all patient with IM, more expressed in left ventricular dysfunction
perindopril - dose 5-10 mg oral
Betablockers years after MI, longer for pts. With left ventricular dysfunction, tachyarrhythmia

42. Case report - 1
57-old female smoker, family history of CAD, pain 6 hours, nausea

43. Coronary angiography

44. Trombus aspiration

45. Stent implantation

46. Case report - 2
61-year old male with hypertension, pain 4 hours, vomiting, sweating

47. Coronary angiography of LCA

48. Trombus aspiration

49. Stent implantation and final result

50. Complications of MI Early complications include:
Heart failure, cardiogenic shock
Mechanical complications :
- rupture of free wall of left ventricle
- ventricular septal defect
- acute mitral regurgitation
Arrhythmia
- ventricular (up to 48 h)
- bradycardia (9-25% of pts)
Late complications include:
pericarditis
Aneurysm of left or right ventricle

51. Tamponade

52. VSD

53. VSD

54. Aneurysm

55. Treatment of NSTE-ACS
To immediate examination are indicated patients with:
history of CAD or previous revascularization
severe recurrent angina
left ventricular dysfunction, heart failure or ventricular arrhythmias

56. Treatment of NSTE – ACS vs. STE
thrombolysis is not at NSTEMI used
There are 3 options of revascularization strategy:
Conservative treatment - non-significant stenosis
PCI - percutaneous coronary intervention - the base of treatment is again antithrombotic therapy and revascularization - DES, BMS
Surgical revascularization - in patients with diffuse coronary artery involvement, for diabetics pts.

57. Case report - 3

58. Stenosis of LMCA

59. CABG - LIMA ad RIA,SVG ad RMS

60. Thank you for your attention