Acute coronary syndrome

Pathophysiology

• ACS result from diminished myocardial blood

flow secondary to Plaque rupture and clot
formation
• Unstable angina with normal troponin while STE
MI and NSTE MI with elevated troponin level
• According to ECG, MI is classified into STE MI and
NSTE ACS (MI and UA)
• NSTE is usually smaller than STE MI
• Ventricular remodeling following acute MI
 Unstable Angina
• Cardiac enzymes (Troponine and CK MB) are
NOT elevated
• Treatment Goal (main): restoration of blood flow
• Prevention of death
• Prevention of coronary artery occlusion
• Relief of ischemic chest discomfort
• Restoration of ST segment and T wave changes
on ECG
 STE MI
• Elevated Troponin
• Early pharmacologic therapy for STE MI:
• Fibrinolytic therapy:
• Within the 1st 12 hrs
• If within 6 hrs, more specific agent is
recommended (alteplase, reteplase)
• Side effect: ICH and systemic bleeding
 Aspirin

• Drug of choice for all ACS patients

• Other NSAIDs should be discontinued at the
time of STE MI
• Side effects: dyspepsia, nausea, bleeding
• Platelets P2Y12 inhibitors:
• Clopidogril, prasugrel and ticagrelor
• prasugrel and ticagrelor more potent than cloppidogril
• Coadministration of aspirin with P2Y12 inhibitors is
recommended for all pts with STE MI
• For STE MI with undergoing PCI coadministration is
recommended to prevent stent thrombosis
• Prasugrel is contraindicated in the presence of previous
history of stroke
• Duration of treatment: at least 12 month after stent
• Nonadherence is a major risk factor for stent thrombosis
• Side effect of ticagrelor is dyspnea
 Glycoprotien IIb/ IIIa receptor inhibitors:

• In patients with STE MI undergoing PCI who

have treated with UFH, abxiximab,
eptifibatide, or tirofiban may be administered
• Bleeding is the most significant side effect
 Anticoagulants

• If undergoing PCI, either UFH or bivalirudin is

preferred
• For fibrinolysis, enoxaparin is preferred
• Bivalirudin has similar efficacy but better safety
than UFH
• Side effect: Bleeding (highest risk with UFH), HIT
(Except Bivalirudine and Fondaparinux)
• Fondaparinux is contraindicated when GFR is
declined
 Nitrates

• SL NTG every 5 minutes

• IV NTG should be initiated for all pts with ACS
and persistent ischemia, HF, uncontrolled BP
 BP Control

• B blockers and ACE/ARB are drug of choice for

patients with ACS
• CCBs Usually should be avoided, but If
contraindications to Β-blockers
• Nefidipine should be avoided
 Pharmacotherapy of NSTE MI:

• Elevated troponine levels

• Similar pharmacotherapy to that of STE MI
• In absence of contraindications, all pts should
be treated with intranasal oxygen, SL NTG,
aspirin, and anticoagulant
• Fibrinolytic therapy is not indicated in any pt
with NSTE ACS
 Prevention following MI

• The long term goals after MI are:

• Control modifiable CHD risk factors
• Prevent development of HF
• Prevent recurrence
• Prevent death
• Prevent stent thrombosis following PCI
• Following MI, all patients should receive indefinite
treatment with aspirin, B-blockers and ACEI for
secondary prevention of death, stroke or recurrent
infarction
• ALL pts will receive statins
• P2Y12 inhibitor should be continued for at least 12
months after PCI
• Clopidogril should be continued for 14 days in pts with
STE MI not undergoing PCI
• Treatment of modifiable risk factors
• The use of meneralocorticoid receptor
antagonists:
• Administration of eplerenone or
spironolactone should be considered within
the 1st 2 wks following MI in all pts who
already receive ACEI and B-blocker and have
LVEF less than 40% and either HF or DM
 Lipid lowering agents

• All pts with CAD should receive dietary

counceling and pharmacotherapy to reduce
LDL cholesterol to less than 100 mg/dL
• Statins shown anti-inflammatory and
antithrombotic properties
• Studies with fibrates have produced less
definitive results