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

2. Pathophysiology of ACS Evolution of Coronary Thrombosis

3. 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.

7. Clinical Indicators of Increased Risk in UA/NSTEMI

8. 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

9. 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;

10. 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

12. 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

13. Antiplatelet Therapy Aspirin
  mg, nonenteric-coated ASA to be chew
 maintenance of  mg daily

14. 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 mg and 90 mg twice daily

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

16. 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

17. 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),

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

19. 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

20. 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%