501

Acute coronary syndrome

(Ischemic Heart disease)
2

2556

1)
2)
3)
4)
5)

6)

1) 1
2)

1)
ESC and ACC/AHA Unstable angina/Non ST-elevation myocardial infarction guidelines

ST elevation
Unstable angina/Non ST elevation myocardial infarction
American Heart Association(AHA) American
College of Cardiology(ACC) European Society Cardiology(ESC)

(Classes of recommendations)

IIa

IIb



III

(Quality and levels of evidence)

A systemic review randomized controlled
meta-analysis
B systemic review non-randomized
controlled randomized-controlled clinical trial
1
C (consensus)

acute coronary syndrome

Atherosclerosis ( 1)
intima(atherosclerotic plaque) stable angina (stable fixed
atherosclerotic plaque)
acute coronary syndrome (unstable
and thin atherosclerotic plaque)
2
(acute myocardial infarction)
(unstable angina)
(presenting ST-T segment changes) ST-segment (ST-elevation acute coronary
syndrome) ST-segment(Non ST-elevation acute coronary syndrome) ST
segment (Transmural ischemia/infarction)
ST-segment

(Non-transmural ischemia/infarction or Sub-endocardial ischemia/ infarction)

ST-segment thrombin (1)
ST-segment ST-
segment 35 15.2 13.8
procoagulant
ST-segment
(2)

1 Stable angina
(stable fixed atherosclerotic plaque)
acute coronary syndrome (unstable plaque) ()
(plaque disruption and platelet aggregation)

Unstable angina (Myocardial infarction)

ST segment
(thrombus) ST segment

ST-segment ST-T
segment
1.
Cardiac biomarkers
Myoglobin, Cardiac specific Creatinine Phosphokinase enzymes (Isoform MB) Troponin T I
2. Cardiac biomarkers
(non coronary cause of myocardial
necrosis) secondary coronary ischemia
3. Cardiac biomarkes
Cardiac biomarkers (rise
and fall of biomarkers) (3)

(),
,
(MVO2) ( 2)

2

,
,

4




/

5

(secondary coronary ischemia)

Cardiac Biomarkers Creatinine Phosphokinase (isozyme MB ),
Myoglobin Cardiac Troponin
Cardiac biomarkers
( 7)
(Universal definition of myocardial infarction)
European Society of Cardiology(ESC), American College of Cardiology Foundation(ACCF),
American Heart Association(AHA) The World Heart Federation(WHF) .. 2012(3)
3
1.
(myocardial necrosis)
(myocardial ischemia) 5
1. (spontaneous myocardial infarction(MI))
,
(dissecting)


Cardiac biomarkers /
(rise/fall
2. (secondary to ischemic imbalance)


() ( 1)
3. (MI resulting cardiac death)

left bundle branch block Cardiac biomarkers
4.
i. (related to
Percutaneous Coronary Intervention, PCI)(4a) PCI
Cardiac Troponin(cTn) 5 99th percentile Cardiac
Troponin 20%
/
1.
2. left bundle branch block
3.

(persistent slow flow or no re-flow)

4.

(new loss of viable myocardium)
ii. (related to stent thrombosis)(4b)
(coronary
artery stenting)
Cardiac biomarkers /
(rise/fall) 99th percentile
5. (related to coronary artery bypass
grafting)
CABG Cardiac biomarker 10 99th percentile
Cardiac Troponin
 1. Q wave left bundle branch block
2. graft

3.

(new loss of viable myocardium)
2.

6. Pathologic Q wave
(absence of non ischemic cause)
7.
(absence of non
ischemic cause)
8.

6 (MI) ST segment (STEMI)

(Non-STEMI) 100000 1999 2008
STEMI Non-STEMI

Unstable angina
((4))

1 Cardiac biomarkers ((3))

/ /
(primary ischemia)

(plaque rupture) Cardiac contusion, , ablation,

,
Rhabdomyolysis

Anthracyclines,
Trastuzumab

(supply/demand imbalance)

(Aortic dissection) Stress (Takotsubo) Cardiomyopathy

/

(subarachnoid
hemorrhage)
/ Infiltrative diseases Sarcoidosis, Amyloidosis

Endothelial dysfunction

2 / ((3))
(False positive) (False negative)

Early repolarization Q wave / ST

Left bundle branch block

 Pre-excitation Left bundle branch block

J point elevation Brugada syndrome

Cardiomyopathy

Persistent juvenile pattern

Tricyclic anti-depressants Phenothiazines

ST elevation MI(3)
1. ST segment QRS complex ST segment(J point)
2 leads 2 (0.2 mV) 40 ( 2.5 (0.25 mV)
40 ) 1.5 (0.15 mV) lead V2-3 1 (0.1 mV)
lead bundle branch block/ventricular pacing
2. Bundle branch block ( Left bundle branch block
)
3. ST segment 0.5 (0.05 mV) leads V1-4 2 lead
ST elevation MI posterior wall ST segment V7-9 1
(0.1mV) 0.5 (0.05mV) 40
4. Left bundle branch block (Sgarbossa criteria)
( 3 ST elevation MI 98%)
a. ST segment 1 (0.1 mV) lead QRS complex 5
b. ST segment 1 (0.1 mV) lead V1-3 3
c. ST segment 5 (0.5 mV) lead QRS 2
ST depression T inversion
ST segment 0.5 (0.05 mV) leads T wave
10 (0.1mV) lead R wave R/S 1
ST segment
Pre-excitation, Dilated cardiomyopathy Stress cardiomyopathy, Cardiac Amyloidosis, Left bundle branch
block, Left anterior hemi(fascicular) block, (), ,
Cor pulmonale () /
2
 Cardiac Biomarkers
Cardiac Biomarkers
(), ,
(neurohormonal activation)
30
1 (1) Creatinine phosphokinase isoform MB
Cardiac Troponin
( 28%)(1)
biomarkers
3-4
Troponin troponin 20%
(1 ) 20% 8

6
Unstable angina (Non ST elevation MI) Cardiac biomarkers

(stress test) 8 markers
Cardiac biomarkers
Troponin
6 3 Troponin
3-4 6 3
Troponin Creatinine phosphokinase isoform MB

Troponin
30 1 N terminal-pro B-type Natriuretic peptide(NT-BNP)
() C-reactive protein(CRP) ()
NT-ProBNP 30 1 CRP
1 (5)
biomarkers TIMI risk score(6) GRACE risk score( 9)(1)
GRACE risk score 6
(7)
 7 Cardiac Biomarkers
( multiples of cutoff limit)
() Cardiac biomarkers Myoglobin, Creatinine
Phosphokinase Isoforms Creatinine Phosphokinase isoform MB, Troponin Myoglobin Creatinine
Phosphokinase isoforms biomarkers (1-2 ) biomarkers
Creatinine Phosphokinase isoform MB Troponin Myoglobin Creatinine
Phosphokinase isoform MB 24-72 Troponin
Myoglobin 3-4 2
Troponin (large MI)
(small MI ) (MGB = Myoglobin, CPK = Creatinine phosphokinase, CPK-
MB = Creatinine phosphokinase isoform MB) ((8))
 8 Non ST elevation Acute Coronary syndrome Troponin
(high sensitivity Troponin-hsTn) Grace risk score Troponin
Troponin (> Upper limits of normal) 3

/ invasive
Troponin 6 6
3
() invasive
GRACE risk score GRACE score

Troponin 6
((1))

ST elevation

5 (1)
1.

ST
elevation bundle branch block ST elevation
, Cardiac biomarkers(
Troponin ), , blood chemistry

Chest pain unit Intensive Cardiac Care Unit
2. 5

1.
2. Cardiac biomarkers 3-6
3.
4. Risk score ( GRACE risk score)
5. (Echocardiography)
6.
7. CRUSADE bleeding risk score
3. (Coronary arteriography) 2



4. (Coronary Revascularization) ST elevation


5.
(Coronary Revascularization)

American Heart
Association(AHA) American College of Cardiology(ACC)(6) European Society Cardiology(ESC)(1)

( 3)
Anticoagulant
4 5-8

3 ((1)(6))

ST ESC ACC/AHA I A

biomarkers
Chest pain unit ESC ACC/AHA I C
Coronary Care unit (Intensive Cardiac Care unit
ACC/AHA)
 ESC I B
risk score
10 First ESC I B
medical contact
6-9 24

V3R, V4R ESC I C

V7-9
Cardiac Biomarkers ESC I A
60 (6-9
12-24 )
( 3 ) ESC I B
high sensitive Cardiac Troponin
(Echocardiography) ESC I C

( ACC/AHA) ACC/AHA I B
ESC I C

(culprit lesion)
Cardiac biomarkers ESC ACC/AHA I A
Stress test
Coronary CT angiography ESC IIa B

Biomarkers
stress test ACC/AHA IIa B
(Echocardiography) Left
Ventricular Ejection Fraction > 0.4
ACC/AHA IIa B
(Echocardiography)
(Left Ventricular Ejection Fraction < 0.4)
 4 ST
((1) (6))

Aspirin Aspirin 150-300 non enteric coat ()

75-100
P2Y12 inhibitors
Clopidogrel 300 (loading dose) 75 1
1
300 (supplymentary loading dose) loading dose

Ticagrelor 180
Clopidogrel
90 2
Prasugrel 60 Primary PCI 10
1

(coronary anatomy) Prasugrel
60

Fondaparinux 2.5 2.5

8 ()
( 30-60 )
( 20 )
Enoxaparin 1 ( 100 ) 12

1 30
Anti-Xa activity
Unfractionated heparin
Unfractionated Enoxaparin Fondaparinux
heparin
60-70 ( 5000 ) 12-15
( 1000 ) aPTT 1.5-2
48
Fondaparinux 85 Activated Clotting time
(ACT), 60 Glycoprotein IIb/IIIa inhibitors

Bivalirudin Unfractionated heparin

0.75 1.75
4 ( 0.3
)

( 30-59 )

( 30 )
1
0.25

5 ((1,6))

ACC/AHA I C

, ACC/AHA I B
90
Nitrates ESC ACC/AHA I C
3 5
( ACC/AHA )
Nitrates ESC ACC/AHA I C
/( 48 ( B
ACC/AHA) ACC/AHA)
blocker 24 * ACC/AHA I B

blocker ESC I B
(Killip III )
B blocker ESC I B

blocker Nitrates ESC I B

Calcium channel blockers ( Dihydropyridines)
blocker Calcium channel ESC I B
blockers ( nondihydropyridine)
( blocker Nitrates ACC/AHA IIa C
)
 Angiotensin Converting Enzyme inhibitor pulmonary ACC/AHA I A
congestion
$
Angiotensin Receptor blocker Angiotensin ACC/AHA I A
Converting Enzyme inhibitors

Calcium channel blocker Vasospastic ESC I C

angina
steroids nonsteroidal anti- ACC/AHA I C
inflammatory drug Aspirin
blocker ESC IIa C

(Killip < III)

ACC/AHA IIa B
Nitrates
blocker ACC/AHA IIa B
*
Angiotensin Converting Enzyme inhibitor ACC/AHA IIa B
pulmonary congestion
$ ( 24 )
6 ACC/AHA IIa C

Nitrates ACC/AHA IIa C

(Intra-aortic ACC/AHA IIa C

Balloon Pump counterpulsation)

Nifedipine Dihydropyridines ESC III B

blocker ACC/AHA III A
blocker ACC/AHA III A
, *,$
Angiotensin Converting Enzyme inhibitor ACC/AHA III B
24

 Nitrates $ ACC/AHA III C

Phosphodiesterase III inhibitor (Sildenafil 24 ,
Tadalafil 48 )
* 1 1) 2) cardiac output 3)
70 , 60 110 120
4) blocker PR 0.24 , 2nd 3rd degree AV block, reactive airway disease
asthma $ 100 30

6 ST
((1,6))

Aspirin ESC ACC/AHA I

A
P2Y12 inhibitor ACC/AHA I C
Aspirin (Clopidogrel Ticagrelor
Prasugrel ) loading
P2Y12 inhibitor Aspirin(Dual Anti-Platelet ESC I A
therapy DAPT)
12
() ACC/AHA I A
P2Y12 inhibitor Aspirin(Dual Anti-Platelet ACC/AHA I B
therapy DAPT)
Proton pump inhibitor( ESC I B
Omeprazole)
, peptic
( Helicobacter pylori, 65
steroid )
P2Y12 inhibitor 12 ESC I C

Ticagrelor ESC I B
Clopidogrel
( Clopidogrel)
Prasugrel Clopidogrel ESC I B

Clopidogrel loading dose(300 ) ESC I A

Ticagrelor Prasugrel
 loading dose(600 ) ESC I B
( 300
supplementary loading dose 300
) Ticagrelor Prasugrel
P2Y12 inhibitor Aspirin(Dual Anti-Platelet ACC/AHA I B
therapy DAPT) 12
(conservative therapy)
P2Y12 inhibitor Aspirin ACC/AHA I B

ACC/AHA I C
Clopidogrel Ticagrelor 5 ESC IIa C
7 Prasugrel

Clopidogrel ESC IIa B

(150 )
7
Ticagrelor Clopidogrel ESC IIa B

/ ESC ACC/AHA IIb B

Clopidogrel
()
NSAID( ESC III C
Cyclooxygenase-2) Aspirin
Prasugrel Aspirin ACC/AHA III B

7 Glycoprotein IIb/IIIa inhibitor ST

((1,6))

, ESC I
Glycoprotein IIb/IIIa inhibitor C

Dual Anti-Platelet therapy ESC I B

DAPT
(, Troponin
)
 Eptifibatide Tirofiban Aspirin ACC/AHA I B
ESC IIa C
P2Y12 inhibitor
Eptifibatide Tirofiban Aspirin ACC/AHA I A

P2Y12 inhibitor
()
Glycoprotein IIb/IIIa inhibitor ACC/AHA IIa C
P2Y12 inhibitor Aspirin(Dual Anti-Platelet therapy
DAPT)

()
Glycoprotein IIb/IIIa inhibitor ACC/AHA IIa C
P2Y12 inhibitor Aspirin(Dual Anti-Platelet therapy
DAPT) Bivalirudin

()
Eptifibatide Tirofiban Dual Anti-Platelet ESC IIb C
therapy DAPT

Glycoprotein IIb/IIIa inhibitor ESC III A

Glycoprotein IIb/IIIa inhibitor ESC III A

(Conservative treatment)
Abciximab ACC/AHA III A

Glycoprotein IIb/IIIa inhibitor ACC/AHA III B

Dual Anti-Platelet therapy DAPT

8 ST
((1,6))

ESC ACC/AHA I
A,B
ESC I C

 Fondaparinux 2.5 ESC I A

( ) ACC/AHA I B
Fondaparinux Unfractionated ESC I B
heparin

Enoxaparin 1 2 ESC I B
Fondaparinux
Fondaparinux Enoxaparin ESC I C
Unfractionated heparin aPTT 50-70
Low molecular weight heparin
Bivalirudin Glycoprotein IIb/IIIa inhibitors ESC I B

Unfractionated heparin Glycoprotein IIb/IIIa inhibitors

ESC I A
(purely conservative therapy)

Unfractionated heparin Enoxaparin ACC/AHA I A

Bivalirudin Fondaparinux I B

Enoxaparin Unfractionated heparin ACC/AHA I A

Fondaparinux () I B
stress test

48 Unfractionated heparin ACC/AHA I A

8 I B
Enoxaparin Fondaparinux ( Fondaparinux)
ACC/AHA I B
(invasive treatment) ESC IIa C
 ACC/AHA I B

Unfractionated heparin
Enoxaparin 12-24
Unfractionated heparin
Fondaparinux 24
Unfractionated heparin
Bivalirudin 3 Unfractionated
heparin
Fondaparinux ACC/AHA I B

( IIa B
24 )
Unfractionated heparin Enoxaparin ESC III B

Aspirin P2Y12
inhibitor Fondaparinux
Enoxaparin Unfractionated heparin
Glycoprotein IIb/IIIa inhibitor
(invasive therapy)
Bivalirudin
Glycoprotein IIb/IIIa inhibitor

Fondaparinux
Unfractionated heparin
Bivalirudin Unfractionated heparin Enoxaprin
Enoxaparin Unfractionated heparin

Unfractionated heparin Enoxaparin

( 9)(1)
1. (Urgent < 2 )
i.
 ii. ST-T segment T wave
iii.
iv. (Life threatening arrhythmias)
2.
i. 24 GRACE risk score > 140 /
Primary
1. Troponin
2.
ii. 72 Secondary
1.
2. (GFR < 60 mL/min/1.73 m2)
3.
4. early post infarct angina
5.
6.
7. Intermediate GRACE risk score (109-140)

ACC/AHA (6)(invasive
therapy) 1) 2) Troponin
3) ST segment 4) 5) 6)
stress test 7) 8)Ventricular tachycardia
9)
6 10)Risk-score 11)
12) 13)(LVEF 40)
3.
i.
ii.
iii.
iv. Cardiac biomarkers
v. stress test ( inducible ischemia)

9 Acute
Coronary syndrome (ACS) (Operational term)
ST (ST elevation Acute coronary syndrome)
ST


(1))
 9 ST TIMI GRACE
risk score ((5) (9) (1))
GRACE
TIMI risk score // risk score ()

14 (%)
0-2 7.7 <109 <1
3-4 32.7 109-140 1-3
5-7 56.6 > 140 >3

10 ST GRACE risk score

6 ((9))
GRACE risk score 6 ()

<89 <3

89-118 3-8

> 118 >8

 11 TIMI risk score ST
4 ((5))

> 65 1

3 # 1

Aspirin 7 1

( 50%) 1

1 24 1

ST segment 1

Biomarkers (Troponin) 1

12 GRACE risk score 6

ST ((9, 10))
GRACE (In hospital) GRACE (post discharge to 6 month)

() 29 0 () 29 0

30-39 8 30-39 0

40-49 25 40-49 18

50-59 41 50-59 36

60-69 55 60-69 55

70-79 75 70-79 73

80-89 91 80-89 91

90 100 90 100

(/) < 50 0 (/) 49.9 0

50-69 3 50-69.9 3

70-89 9 70-89.9 9
 90-109 15 90-109.9 14

110-149 24 110-149.9 23

150-199 38 150-199.9 35

> 200 46 > 200 43

() < 80 58 () < 80 24

81-99 53 80-99.9 22

100-119 43 100-119.9 18

120-139 34 120-139.9 14

140-159 24 140-159.9 10

160-199 10 160-199.9 4

200 0 200 0

0-0.39 1 0-0.39 1
(/) (/)
0.4-0.79 4 0.4-0.79 3

0.8-1.19 7 0.8-1.19 5

1.2-1.59 10 1.2-1.59 7

1.6-1.99 13 1.6-1.99 9

2-3.99 21 2-3.99 15

>4 28 >4 20

Class I 0
(Killip
classification) Class II 20

Class III 39

Class IV 59

12

24
 Cardiac 39
arrest
Cardiac Biomarkers 14 Cardiac Biomarkers 15

ST segment 28 ST segment 11
* 9-10

13 CRUSADE bleeding risk score

www.crusadebleedingscore.org ((1))

<31 9 () 70 0
()
3133.9 7 7180 1

3436.9 3 8190 3

3739.9 2 91100 6

40 0 101110 8

15 39 111120 10
()
>1530 35 121 11

>3060 28 0

>6090 17 8

>90120 7

>120 0

90 10 0
()
91100 8 6

101120 5 0

121180 1 6

181200 3 0

201 5 7
 13
ST ((11))

<21 21-30 31-40 41-50 >50

3.1 5.5 8.6 11.9 19.5

()*
* 12, ,
(retroperitoneal hemorrhage), 28
28

1.



(invasive treatment)
2.
30-40%

90 180-200
(1)

(invasive therapy)


3.
30-40%(1)
4

4.
15%
,

Tako-Tsubo cardiomyopathy
Syndromre X

5.



 25

Angiotensin Converting
P2Y12 inhibitors Enzyme inhibitors/Angiotensin Receptor
blocker
(invasive therapy)


blocker (secondary prevention)
Cardiac Rehabilitation
Statin program

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College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction):
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Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007 Aug
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