Acute Coronary Syndrome

Front 1

Canadian Cardiovascular Society Angina Classification

Back 1

Class I: no angina with ordinary physical activity

Class II, slight limitation of normal activity

Class III: Severe limitation of ordinary physical activity (Walking 1-2 blocks or climbing 1flight of stairs)

Class IV: Unable to perform any physical activity/rest angina

Front 2

Unstable angina

Back 2

(1) Rest angina (>20 min, within 1 week of presentation)

(2) New onset-angina (at least class 2, within past 2 months)

(3) Worsening angina (frequency, duration, or class to at least III)

Front 3

Prinzmetal's angina

Back 3

Coronary ischemia secondary to vasospasm without a fixed coronary artery lesion

Front 4

Diagnosis of acute myocardial infarction

Back 4

1. Typical rise and gradual fall or more rapid rise and fall of biochemical markers with at least one value above the 99th percentile of the upper reference limit (URL) and with at least one of the following clinical parameters:

• Ischemic symptoms
• ECG changes indicative of ischemia (T wave changes or ST segment elevation or depression)
• Development of pathologic Q waves on the ECG
• Imaging evidence of presumably new findings, such as a loss of viable myocardium or a regional wall motion abnormality

2. Pathologic findings of an AMI

Front 5

Diagnosis of established MI

Back 5

• Development of new pathologic Q waves on serial ECGs.

• Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of a nonischemic cause.
• Pathologic findings of a healed or healing MI.

Front 6

Five primary types of myocardial infarction

Back 6

Spontaneous myocardial infarction (MI type 1)

atherosclerotic plaque rupture with resulting
intraluminal thrombus in one or more of the coronary arteries, leading to decreased myocardial blood flow

Myocardial infarction secondary
to an ischemic imbalance (MI type 2)

Cardiac death due to
myocardial infarction (MI type 3)

Myocardial infarction associated with
revascularization procedures (MI types 4 and 5)

4 - PCI

5 - CABG

Front 7

Causes of Elevated Troponin

Back 7

Front 8

Determinants of myocardial oxygen consumption

Back 8

HR

Afterload

Contractility

Wall Tension (directly proportion to pressure/radius)

Front 9

Components of GRACE score

Back 9

AGE

HR

SBP

Creatinine

Killip Class

ST segment deviation

Cardiac enyzmes

Cardiac arrest

Front 10

Killip classes and mortality

Back 10

I: No CHF (6%)
II: Crackles/JVD (17%)
III: ACPE (38%)
IV: Cardiogenic shock (67%)

Front 11

TIMI SCORE

Back 11

AMERICA:

Age > 65
Markers (increased serum cardiac markers)
EKG (ST depression)
Risk factors (3 or more CAD risk factors)

Ischemia (2 or more anginal events/24 hours)
CAD (prior coronary stenosis of 50% or more)
Aspirin use within past 7 days

Front 12

Positive Family History of CAD

Back 12

<55 years old in 1st degree male relative

<65 years old in 1st degree female relative

Front 13

Age as risk factor for CAD

Back 13

>45 years old in male

>55 years old in female

Front 14

TIMI SCORE Interpretations

Back 14

Score Interpretation:

% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization

Score of 0-1 = 4.7% risk

Score of 2 = 8.3% risk

Score of 3 = 13.2% risk

Score of 4 = 19.9% risk

Score of 5 = 26.2% risk

Score of 6-7 = at least 40.9% risk

Front 15

Classic Angina

Back 15

Front 16

Risk factors for atypical presentations of ACS

Back 16

diabetes mellitus

older age

female gender,
nonwhite ethnicity

dementia

previous history of congestive heart failure (CHF) or stroke

Front 17

Complications of myocardial infarction

Back 17

1. Bradyarythmia/AV block
2. Tachyarythmia
3. Cardiogenic shock
4. LV free wall rupture
5. Septal rupture

6. MV/papillary muscle rupture

7. Pericarditis
a. Infarct pericarditis
b. Dressler’s syndrome
8. Ischemic stroke
9. Hemorrhagic stroke following fibrinolysis
10. Hyperglycemia

11. Complications of ACS treatment

Front 18

When do troponin rise after mycoardial injury

Back 18

~ 3 hours

Front 19

Recommended FMC to balloon time if STEMI seen at PCI Capable hospital

Back 19

< 90 Minutes

Front 20

Recommendation for STEMI initially seen at non-PCI capable hospital

Back 20

(1) Transfer to PCI hospital if anticipated FMC to balloon time <120 minutes with DIDO goal <30 minutes

(2) Fibronlysis within 30 minutes of arrival if anticipated FMC to balloon time >120 minutes

Front 21

Indications for Primary PCI

Back 21

- Ischemic symptoms <12 hours

- Cardiogenic shock/severe acute HF irrespective of time since symptoms onset

- Consider for ongoing ischemia 12-24 hours after symptom onset

Front 22

Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI

Back 22

ASA 325MG LOAD

PLAVIX 600mg LOAD (or alternate)

IV GP IIb/IIIa receptor antagonists

Anticoagulant (Heparin 70 units/kg)

Front 23

Indications for Fibrinolytic therapy

Back 23

- Ischemic symptoms <12 hours

- Evidence of ongoing ischemia 12 to 24 h after symptom onset, and a large area of myocardium at risk or hemodynamic instability

Front 24

Indications for Transfer for Angiography After
Fibrinolytic Therapy

Back 24

- Immediate transfer for cardiogenic shock or severe acute HF irrespective of time delay from MI onset
- Urgent transfer for failed reperfusion or reocclusion
- As part of an invasive strategy in stable* patients with PCI between 3 and 24 h after successful fibrinolysis

Front 25

Indications for Coronary Angiography in Patients
Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

Back 25

- Cardiogenic shock or acute severe HF that
develops after initial presentation
- Intermediate- or high-risk findings on
predischarge noninvasive ischemia testing

- Spontaneous or easily provoked myocardial ischemia

Front 26

Contraindications to beta blockade in ACS

Back 26

1) signs of HF, 2) evidence of low-output state, 3) increased risk for cardiogenic shock, or 4) other contraindications to beta blockade (e.g., PR interval >0.24 second, second- or third-degree heart block without a cardiac pacemaker, active asthma, or reactive airway disease)

Front 27

Anticoagulation for NSTEMI

Back 27

(1) Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial intravenous loading dose is 30 mg

(2) Fondaparinux: 2.5 mg SC daily, continued for the duration of hospitalization or until PCI is
performed

(3) UFH IV: initial loading dose of 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed

Front 28

Who gets invasive intervention for their NSTEMI in an ischemia guided strategy

Back 28

1) fail medical therapy (refractory angina or angina at rest or with minimal activity despite vigorous medical therapy),

2) have objective evidence of ischemia (dynamic electrocardiographic changes, myocardial perfusion defect) as identified on a noninvasive stress test, or

3) have clinical indicators of very high prognostic risk (e.g., high TIMI or GRACE scores)

Front 29

Whom should an early invasive strategy be used for UA/NSTEMI

Back 29

patients who have refractory angina or hemodynamic or electrical instability or high risk for adverse clinical events

Front 30

Selecting invasive versus ischemia driven - GUIDELINES

Back 30

Front 31

Risks and complications of coronary angiography

Back 31

Allergic reaction

CIN

HIT

Cholesterol emboli

Infection

Local vascular injury

- Hematoma

- Retroperitoneal hemorrhage

- Pseudoaneurysm

- AV Fistula

- Thrombosis/Embolism

- Dissection

Arrhythmias

Death

MI

CVA

Hypotension

Cardiac/Vascular injury

Front 32

Vancouver Chest Pain Rule

Back 32

Front 33

HEART score

Back 33

History
Highly suspicious 2
Moderately suspicious 1
Slightly or non-suspicious 0

ECG

Significant ST-depression 2
Nonspecific repolarization disturbance 1
Normal 0

Age

≥65 years 2
>45–b65 years 1
≤45 years 0

Risk factors (DM, smoker, HTN, Cholesterol, Fam Hx, obesity)

≥3 risk factors, or history of atherosclerotic disease 2
1 or 2 risk factors 1
No risk factors known 0

Troponin

≥3× normal limit 2
>1–b3× normal limit 1
≤Normal limit 0

Low Risk (0 - 3)

Front 34

Trial for ASA and mortality benefit

Back 34

ISIS-2

23% RRR compared with placebo

42% RRR compared with placebo when combined with streptokinase

NNT 42

Front 35

Glycoprotein IIb/IIIa Receptor Inhibitors

Back 35

E.g: abciximab, eptifibatide, and tirofiban

Benefit for those undergoing mechanical revascularization

Given in cath lab

Front 36

MOA of Aspirin

Back 36

irreversibly acetylates platelet cyclooxygenase,
thereby removing all activity for the life span of the platelet (8-10 days)

Thereby production of Thromboaxane A2 and less platelet activation/thrombosis

Front 37

thienopyridines/PSY12 Receptor Inhibitor Agents

Back 37

Inhibit transformation of PSY12 Receptor onto ligad binding state inhibiting aggregation for duration of platelet lifecycle`

Front 38

Plavix in ACS Trial

Back 38

CURE

Front 39

Highest Xa:IIa ratio among LMWH

Back 39

Enoxaparin

Front 40

Absolute Contraindications for Fibrinolysis in Acute MI

10 Total
5 Neurology
3 Bleeding/Trauma
1 Hypertension
Streptokinase

Back 40

Neurology
● Any prior ICH
● Known structural cerebral vascular lesion
● Known malignant intracranial neoplasm
● Ischemic stroke within 3 months (EXCEPT acute ischemic stroke within 4.5 h)
● Intracranial/intraspinal surgery within 2 mo

Bleeding/trauma
● Suspected aortic dissection
● Active bleeding or bleeding diathesis
● Significant closed-head or facial trauma within 3 mo

Hypertension
● Severe uncontrolled hypertension (unresponsive to emergency therapy)
​
Other
● For streptokinase, prior treatment within the previous 6 mo

Front 41

Relative Contraindications for Fibrinolysis in acute MI

12 Total

2 Hypertension

3 Neurology

6 Trauma/Bleeding

Pregnancy

Back 41

Hypertension related

● History of chronic, severe, poorly controlled hypertension
● Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)

Neurology related
● History of prior ischemic stroke >3 mo
● Dementia
● Known intracranial pathology not covered in absolute contraindications

Trauma/Bleeding related
● Traumatic or prolonged (>10 min) CPR
● Major surgery (<3 wk)
● Recent (within 2 to 4 wk) internal bleeding
● Noncompressible vascular punctures
● Active peptic ulcer
● Oral anticoagulant therapy

● Pregnancy

Front 42

Contraindications to systemic anticoagulation

Back 42

Active bleeding

High risk of bleeding (hemophilia, thrombocytopenia)

History of GI bleeding

Severe hepatic disease

Allergy

On current anticoagulation

Palliative

High falls risk

Pregnancy is relative