ANTITHROMBOTIC THERAPY IN ACUTE CORONARY

SYNDROME

CARDIOLOGY PAPERS

BY:
Topan Binawan
Supervisor :
Prof.DR.dr.Moch.Fathoni,SpJP(K),FIHA,FAsCC,FAPSC
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introduction
Coronary heart disease : a disability premature deaths
worldwide

Each year : 1,300,000 non-Q myocardial infarction,

350,000 Q wave myocardial infarction
in the US

Antithrombotic proper handling during myocardial ischemia

acute, cardiac care to help provide safe and effective
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Impact of bleeding ACS

patient outcomes PCI
highlight the importance of
antithrombotic doses,
especially vulnerable
populations such as women
and the elderly
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Acute Coronary Syndrome (ACS)

Manifestation of spectrum acute and hard is an

emergency condition of coronary because of
imbalance oxygen myocard need & blood
flow.
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Classification

Based on ECG and

cardiac enzymes,
ACS is classified
into:

STEMI: ST
elevation, elevated
cardiac enzymes

NSTEMI: ST
depression, T-wave
inversion, elevated
cardiac enzymes

Unstable Angina:
Non specific EKG
changes, normal
cardiac enzymes

Pathogenesis
Plaque Rupture

Unstable
Angina

Thrombosis &
platelet aggregation

Vasospasme

Plaque erotion
without rupture.
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STEMI
Infark : plaque become
fissure and rupture,
thrombogenesis mural
thrombus on location of
rupture occlution of
coronary artery.

Undergo coronary
artery occlusion by a
thrombus composed of
platelets and fibrin
aggregates

Location of plaque
rupture, agonis
activation of platelets
tromboxan A2 the
receptor glycoprotein IIb
/ IIIa.

Activated fo VII and X,

conversion of
prothrombin -thrombin,
then converts
fibrinogen- fibrin.

The receptor has a high

affinity amino acid
sequence : bind to two
different platelets,
platelet aggregation

Tissue factor
Coagulation cascade
endothelial cells :
damaged.

NSTEMI
Acute thrombosis occurs NSTEMI / processes
coronary vasoconstriction.
Acute thrombosis in coronary artery plaque
rupture begins with an unstable
This unstable plaque has a large lipid core, a
low density of smooth muscle, thin fibrous cap
and a high concentration of tissue factor.
Location of plaque rupture in macrophage and
lymphocyte cell encountered inflammation ;
TNF , and IL-6.

Therapy antithrombotic in ACS

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Non Stable Angina/NSTEMI

The intensity of medical therapy based risk
doctor assessment ischemia and bleeding
events.
This factor combined approach physicians to
the most appropriate strategy risk assessment
early invasive versus early conservative.

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 TIMI : Trombolysis risk score in Myocardial

Infarction,

GRACE : risk score Global Registry of Acute

Coronary Events, and risk models
glycoprotein IIb / IIIa in Unstable angina

Platelet

PURSUIT : Receptor Suppression Using Integrilin

Therapy.

To help formulate management better strategies

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High risk score early invasive.

Low risk score initial conservative.

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Antiplatelet Strategy on unstable angina / NSTEMI

ACC / AHA, ESC, and ACCP : the highest
aspirin immediately on non-stable angina /
NSTEMI. Start ; > 160 mg, the long-term
maintenance : aspirin <100 mg.

Aspirin and clopidogrel in non-stable angina

/ NSTEMI guideline recommended
regardless of the conservative / invasive

Guidelines ACC / AHA and ACCP :

clopidogrel or glycoprotein (GP) IV IIb / IIIa
inhibitor (eptifibatide or tirofiban) to
invasive (grade ACC / AHA I, [LOE]: A;
ACCP class 1A).

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Antiplatelet Strategy on unstable angina / NSTEMI

Guidelines ACC / AHA and ACCP
recommends Class I / class 1A, consecutive
use of aspirin and clopidogrel, while
lowering the therapeutic use of GP IIb / IIIa
inhibitors (ACC / AHA Class IIb, LOE; B;
ACCP class 2B) : initial conservative
strategy.
The option to use a replacement bivalirudin
GP IIb / IIIa inhibitor-treated patients with
invasive : thiopyridine early (<6 hours)
(ACC / AHA Class IIa, LOE: B; ACCP class
2B).
ESC Guidelines for recommendation of
aspirin and clopidogrel "soon"
(Class I, LOE: A)
The addition of inhibitors of GP IIb / IIIa IV
(eptifibatide or tirofiban) can be added to the
high-risk features
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Selection of Anticoagulants: early conservative

strategies in unstable angina / NSTEMI
Guidelines ACC / AHA recommendation
of UFH or enoxaparin (Class I, LOE: A)
or fondaparinux (Class I, LOE: B) with
enoxaparin / fondaparinux are preferred
(Class IIa, LOE: B).
Similarly,
the
ESC
guidelines
recommendation fondaparinux (Class 1,
LOE: A) or UFH (Class 1, LOE C) in a
conservative,
but
also
lowered
recommendation for enoxaparin (Class
IIa, LOE: B)

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The Fifth Organization to Assess Strategies in

Acute Ischemic Syndromes (OASIS-5)

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Guideline recommendations and level of evidence

for anticoagulation in non-ST elevation ACS

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Selection of anticoagulants: an early invasive strategy in

unstable angina / NSTEMI
Anticoagulants are one of the 4 currently available > than no
recommended for the treatment of non-ST elevation ACS : (ACC / AHA
Class I, LOE: A], ESC [Class I, LOE: A], and ACCP [Class 1A]).
Invasive strategy guidelines : the ACC / AHA recommendation UFH or
enoxaparin (Class I, LOE: A) or bivalirudin or fondaparinux (Class I,
LOE: B).

ESC urgent invasive UFH (Class I, LOE: C), enoxaparin (Class IIa,
LOE: B), bivalirudin (Class I, LOE: B) recommendation.

ESC : urgent invasive no recommendation Fondaparinux

Early invasive strategy ACCP recommendations UFH with GP IIb /

IIIa inhibitor IV use in than LMWH (enoxaparin) or fondaparinux (Class
1B).

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Superior Yield of the New Strategy of Enoxaparin,

Revascularization and Glycoprotein IIb/IIIa inhibitors
(SYNERGY)

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Guideline recommendations and level of evidence for

anticoagulation in non-ST elevation ACS

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Antiplatelet drugs in patients with STEMI

All the guidelines, a starting dose of non
enteric-aspirin 150-325 mg, daily dose > low
thereafter (<150 mg aspirin).
ACC / AHA STEMI recommendation aspirin
STEMI patients post-PCI dose of 162-325 mg
for at least 1 month metal stent bare metal,
sirolimus eluting stents 3 months, and 6
months of paclitaxel eluting stent (Class I,
LOE: B).

Doses of aspirin > Low high risk for bleeding

(Class IIa, LOE: C).
STEMI post-PCI recommendations for 1 year
clopidrogel after drug elution stents and 1
month to 1 year bare metal stents (Class I,
LOE: B)

ACC / AHA STEMI support the addition of

clopidogrel + aspirin STEMI (initiation of
clopidogrel 300 mg <75 years) is not
reperfusion / treated with fibrinolysis (Class
IIa, LOE: C).
Can be up to 1 year (Class IIa, LOE: C).
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Antiplatelet drugs in patients with STEMI

ACCP recommendation of clopidogrel is similar
patients with non-reperfusion or fibrinolysis
based on age (Class 1A) for up to 28 days
(Class 1A) or up to 1 year (Class 2B).
Primary PCI clopidogrel recommendations, the
initial dose of 300 mg followed by 75 mg per
day, and aspirin (Class 1B).

STEMI patients treated with clopidrogrel, ESC

supports the initiation of primary PCI (Class I,
LOE: C)/primary fibrinolysis if patients aged
75 years (Class I, LOE: B).
The maintenance dose is started without
initiation in the elderly (> 75 years) (Class IIa,
LOE: B).
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The selection of anti thrombotic patients with a fibrinolysis

ACC / AHA recommendations fibrinolysis
anticoagulant treated patients at least 48 hours
(Class I, LOE: C), continued up to 8 days or until
the patients home (Class I, LOE: A).
UFH (Class I, LOE: C) enoxaparin (Class I, LOE:
A), / fondaparinux (Class I, LOE: B)
recommendation on fibrinolysis

ACCP recommendations antithrombin therapy than

no antithrombin therapy (Class 1A).
Regarding the use of LMWH, ACCP >
recommendation reviparin than no treatment
(Class 1B).

ESC for co-STEMI anticoagulant therapy in

patients with fibrinolysis (non-streptokinase)
include enoxaparin and UFH (Class I, LOE: A).
Patients with streptokinase, fondaparinux or
enoxaparin (Class IIa, LOE: B) or UFH (Class IIa,
LOE: C) recommendation.

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Recommendations for anticoagulation on STEMI

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The selection of the antithrombotic primary PCI

ACC / AHA supports the

continuation of anticoagulants on
the scope of peri-PCI (Class I)
primary PCI of STEMI.
Recommendations include UFH
(Class I, LOE: C) with the option of
switching to bivalirudin (Class I,
LOE: C) for the previous UFH.
Enoxaparin (Class I, LOE: B) /
fondaparinux (Class I, LOE: C) is
received anticoagulant STEMI with
PCI

ACCP and strong ESC

recommendation fondaparinux on
primary PCI.
ACCP supports the use of UFH
dosing based on the weight(Class
1B) and abciximab (inhibitor of GP
IIb / IIIa) IV during primary PCI
(Class 1B) for STEMI.
ESC Guidelines recommendation
UFH (Class I, LOE: C) / bivalirudin
(Class IIa, LOE: B)

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Transition to Post-ACS Anti Thrombotic Therapy of

Chronic
The guidelines continue to support
low-dose aspirin, ideally 100 mg /
day.
Patients in-stent acute coronary
syndrome, the dose of aspirin (162325 mg) can be used for the first
month of bare metal stents, and for
3-6 months of drug-eluting stents.

Clopidogrel is recommended at least

one month at a bare metal stent and
ideally for at least 1 year drug-eluting
stents.
Oral anticoagulants + dual
antiplatelet no recommendation for
secondary prevention in the absence
of a clear indication (ie AF, DVT).

Warfarin may be considered in

patients with a high risk of ischemia
and bleeding risk is low if not
intolerant of clopidogrel (Class IIb,
LOE: B).

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RESUME
Using anti-platelet therapy and anti-coagulants on
ACS clinical outcomes associated development of
short-term and long-term, depending on
conservative treatment or acute coronary
revascularization.
Selecting anti-thrombotic therapy lowers the risk
of ischemic while minimizing the risk of bleeding
from various subtype ACS.
Selecting of appropriate antithrombotic during the
transition from the phase of the sub-acute and
chronic secondary prevention can be worth
attention
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Thank you

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Karakteristik pasien strategi invasif awal pedoman

ACC/AHA dan ESC.

Pedoman ACC/AHA dan ESC

Angina menetap /kambuhan meskipun ada
terapi medis intensif, tanpa menghiraukan
perubahan gelombang ST atau T
Troponin meningkat
Perubahan gelombang ST atau T dinamis,
tanpa menghiraukan gejalanya.
Fraksi ejeksi < 40%
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 Tanda-tanda atau gejala kegagalan jantung /

regurgitasi mitral baru
Ketidakstabilan hemodinamik
VT atau VF berkelanjutan
PCI dalam 6 bulan
CABG sebelumnya

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Pedoman ACC/AHA
Temuan beresiko tinggi pengujian non-invasif
Skor resiko iskemia tinggi
Pedoman ESC
DM
Disfungsi ginjal (eGFR < 60 ml/menit/1,73
m2)
MI sebelumnya
Skor resiko GRACE menengah hingga tinggi
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