1. ACS differentiation: With or without ST- elevation STEMI NSTEMI UAP

2. Myocardial Nekrosis Starts 30-45min after occlusion 90min: 40-50% nekrotized 6 hrs: nekrosis often complete However collaterals can modify time-course Occlusion can be subtotal/fluctuating Protective agents ? AHA Textbook of Advanced Cardiac Life Support, 1999 Courtesy Dr. Lars Aaberge, Oslo

3. Primary PCI preferred treatment if performed by experienced team <90min after first medical contact indicated for patients in shock and those with contraindications to fibrinolytic therapy

4. Treatment before PPCI –ASA 300 mg –Clopidogrel 300-600 mg –Unfractioned heparin 5000 - (70 IE/kg) < 70 år Treatment during PPCI –Heparin 100 IE/kg bolus or Enoxaparin 30 mg iv + 1 mg/kg sc –Ev. Abciximab bolus, reduce Hep 70 IE/kg Treatment after PPCI –Evt Abciximab infusion 12 hrs –ASA + Clopidogrel 75 mg x 1 P(rimary)PCI Courtesy Dr. Lars Aaberge, Oslo

5. Reperfusion therapy  Reperfusion therapy is indicated in all patients with history of chest pain/discomfort of <12h and associated with ST-segment elevation or (presumed) new bundle-branch block on the ECG

6. Thrombolysis  Within the first 3 hours after onset of chest pain fibrinolysis is a viabale alternative.  Within the first 3 hours of chest pain primary PCI and fibrinolysis are equally effective in reducing infarct size and mortality.

7. Kontraindikationer mot trombolys · Tidigare intracerebral blödning · Inom 2 månader efter övriga stroke eller cerebrovaskulära händelser · Känt intrakraniellt neoplasm · Pågående invärtes blödning (inkluderar icke menstruation)

8. –ASA 300 mg –Clopidogrel 300-600 mg –One-dose rTPA (tenecteplase) + Enoxaparin 30 mg iv + 1 mg/kg sc –Morphin - Oxgen – Nitrates - Betablokker Pre-hospital Thrombolysis

9. Resuce PCI  after failed thrombolysis in patients with large infarcts

10. Reperfusion  50 % av ST höjningen går i regress 90 min efter start av trombolys.  Om ej reperfusion efter trombolys, ställningstagande till rescue PTCA

14. STEMI

15. NSTEMI

16. KIT  Koagulation  Ischemi  Trombocyter

17. Behandling Icke ST höjnings infarkt ST höjningsinfarkt KoagulationEnoxaparin PCI (Trombolys) IschemiBetablockad Ev nitroglycerin Betablockad TrombocyterASAClopidogrelASAClopidogrel

19. Antithrombotic Trialists’ Collaboration: Evidence Supports Low Dose ASA (75–150mg) 1 1. Antithrombotic Trialists’ Collaboration. BMJ 2002; 324: 71–86. ASA dose% odds reduction 500–1500 mg daily 160–325 mg daily 75–150 mg daily < 75 mg daily Any ASA dose23% ±2 (p < 0.0001) 1.00.50.01.52.0 Control better ASA better

20. 1. The CURE Study Investigators. Eur Heart J 2000; 21:2033–41 CURE-trial Double-blind treatment up to 12 months ASA 75–325 mg od Clopidogrel 75mg od (n = 6,259) Placebo 1 tab od (n = 6,303) ASA 75–325 mg od Day 1 6 month visit 9 month visit 12 month or final visit Clopidogrel 300mg loading dose 3 month visit Discharge visit 1 month visit Patients with ACS (unstable angina or non-Q-wave MI) Placebo loading dose R = randomisation n = 12,562 28 countries R NON-STEMI

21. CURE: early and long-term benefits of clopidogrel 1 1. The CURE Trial Investigators. N Engl J Med 2001; 345:494–502 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 036912 Months of follow-up Cumulative hazard rate Placebo * (n = 6,303) Clopidogrel * (n = 6,259) 20% relative risk reduction p = 0.00009 Cumulative events (MI, stroke or cardiovascular death) *On top of standard therapy (including ASA)

22. Revascularization in NSTEMI/UAP

23. Risk stratification –High (GPIIb/IIIa and fast PCI) –Intermediate (neg trop, delayed invasive dx) –Low (elective invasive dx or search for ischemia) Basistreatment –ASA 300 mg, 75-160 mg –Clopidogrel 300 mg  75 mg for 9-12mths –LMWH (Enoxaparin/Dalteparin) –(Betablokker, Nitrates, Statins) UAP / NSTEMI - Treatment Courtesy Dr. Lars Aaberge, Oslo

24. Treatment prior to PCI –ASA 300 mg  75 x1 –Clopidogrel 300-600 mg  75x1 –Enoxaparin / Dalteparin sc Treatment during PCI –Heparin 100 IE/kg bolus or Enoxaparin 30 mg iv + 1 mg/kg sc (ACT 250-350) –Possible: GPIIb/IIIa (reduce Hep to 70 IE/kg, ACT<250) Treatment post PCI –ASA + Clopidogrel 75 mg x 1 –(GP IIb/IIIa) UAP/NSTEMI

25. Cholesterol

26. 0 50 40 30 20 10 0 0.5 LRC CARE POSCH WOS 4S LIPID AFCAPS 1.01.52.02.5 HPS Adapted from: LRC, JAMA 1984;251:351-364Downs JR et al., JAMA 1998;279:1615-1622 LIPID Study Group, N Engl J Med 1998;339:1349-57Shepherd J et al., N Engl J Med 1995;333:1301-7 Sacks FM et al., N Engl J Med 1996;335:1001-9Buchwald H et al., N Engl J Med 1990;323:946-955 4S Group, Lancet 1994;344:1383-89HPS Collaborative Group, Lancet 2002;360:7-22 Reduction in cholesterol (mmol/l) Reduction in cardiovascular events (%) Relationship between reduction of cholesterol and decrease of cardiovascular events in various trials 1 mmol LDL-   21% CHD- 