Esc Acs Guidelines

RECENT ADVANCES IN
MANAGEMENT OF CAD
MODERATED BY DR. MUKTHAR AHMED
CONTENTS
1. Definition
2. Triage
3. Diagnosis
4. Emergency care
5. Management
DEFINITION
• ACS consists of Unstable Angina and Acute Myocardial
Infarction.
• Unstable angina is defined as myocardial ischemia at rest
or minimal exertion in absence of acute cardiomyocyte
injury or necrosis.
• Its characterized by :
• Prolonged (>20mins) angina at rest
• New onset of severe angina
• Angina that occurs after a recent episode of MI
• The diagnosis of Acute Myocardial Infarction is based on
the fourth universal definition of MI.
• It includes detection of an increase and/or decrease of a

cardiac biomarker, high-sensitivity cardiac troponin T or I,
with at least one value above the 99th percentile of the
upper reference limit and at least one of the following:
1. Symptoms of myocardial ischemia.
2. New ischemic ECG changes.
3. Development of pathological Q waves on ECG.
4. Imaging evidence of loss of viable myocardium or new
regional wall motion abnormality in a pattern consistent
with an ischemic etiology (vascular bed distribution).
5. Intracoronary thrombus detected on angiography or
autopsy.
TRIAGE
NSTE-ACS VERY HIGH RISK CRITERIA
(any 1 of the following)
• Hemodynamic instability or CS
• Recurrent or ongoing chest pain refractory to medical

treatment.
• Acute HF presumed secondary to ongoing medical

ischemia.
• Life-threatening arrhythmias or cardiac arrest after
presentation.
• Mechanical complications.
• Recurrent dynamic ECG changes suggestive of ischaemia

(particularly with intermittent ST-segment elevation
NSTE-ACS – HIGH RISK CRITERIA
(any 1 of the following)
• A confirmed diagnosis of NSTEMI based on current

recommended ESC hs-cTn algorithms.
• Dynamic ST-segment or T wave changes.
• Transient ST-segment elevation.
• GRACE risk score >140.

GRACE RISK SCORE
DIAGNOSTIC TOOLS
• ECG
• High sensitive cardiac troponins
• Echocardiography
• CT
• Cardiac MRI
ECG - ST ELEVATION MI
SGARBOSSA CRITERIA
• Concordant ST elevation ≥ 1 mm in ≥ 1 lead

• Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
• Proportionally excessive discordant STE in ≥ 1 lead
anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the
depth of the preceding S-wave
NON – ST ELEVATION MI
HIGH SENSITIVITY CARDIAC
TROPONINS
• Its recommended in patients suspected with ACS, with

compactable clinical presentation.
• If there is a rise and/ or fall in troponins above 99th
percentile of healthy individuals, it points towards
diagnosis of MI.
EMERGENCY CARE – ACUTE
PHARMACOTHERAPY
1. Oxygen
2. Nitrates
3. Pain relief
4. IV Beta Blockers
OXYGEN
• Oxygen supplementation is recommended whenever the

Spo2 is <90%.
NITRATES
• Its antianginal, relieving the ischemic symptoms.
• Nitroglycerin – sublingually 0.3 – 0.6mg, upto 3 doses 5
mins apart.
• If symptoms persists, IV Nitroglycerin (5-10 mcg/min), can
hike up 10mcg/min every 5 min until asymptomatic.
• Contraindications – hypotension, bradycardia, severe AS,
recent PDE 5 inhibitor use.
PAIN RELIEF
• In severe chest pain

• IV opioids – Morphine 5-10mg
• It reduces myocardial oxygen consumption by decreased
preload and negative ionotropy and chronotropy.
BETA BLOCKERS
• It decreases myocardial oxygen need.
• Can be started as IV in patients with severe ischemia
• Metoprolol has greatest protective effect.
• Target HR – 50 to 60 bpm
• Contraindications – Acute heart failure, hypotension, high
degree AV block, bronchospasm.
MANAGEMENT
• Acute phase management

• Invasive therapy
• Reperfusion therapy
• Antithrombotic therapy
• Long term management
ACUTE PHASE MANAGEMENT
• STEMI
• Immediate reperfusion therapy – PPCI or Fibrinolysis
• PPCI - Within 120 mins of diagnosis
• NSTE – ACS
• Immediate invasive strategy if any very high risk factors are
present.
• Early (within 24hr) invasive strategy if any high risk factors
are present.
STEMI
• PPCI is preferred reperfusion strategy.
• Within 120 mins of ECG based diagnosis.
• PPCI is superior to fibrinolysis in reducing mortality,
reinfarction or stroke.
• If PPCI not available as immediate option, then Fibrinolysis
can be done if within 12hr of symptom onset.
FIBRINOLYSIS
• Within 12 hour of symptom onset.
• If PPCI is not feasible within 120 min, patients should undergo
immediate fibrinolysis within 10mins, followed by transfer to a
PCI centre.
• Successful fibrinolysis
• ST segment resolution of >50-60% at 60—90min
• Reperfusion arrhythmia
• Disappearance of chest pain
• Routine early (within 2-24hr) angiography is indicated for
all patient who underwent fibrinolysis as it reduces the
rates of reinfarction, recurrent ischemia.
DRUG DOSE
STREPTOKINASE 1.5 million units over 30-60mins
IV
ALTEPLASE 15mg IV bolus
0.75mg/kg IV over 30 mins
Then 0.5mg/kg IV over 60 mins
TENECTEPLASE Single IV bolus based on weight
30mg if <60kg
35mg if 60-70kg
40mg if 70-80kg
45mg if 80-90kg
50mg if >90kg
NSTE - ACS
ANTITHROMBOTIC THERAPY
• Antiplatelets
• Anticoagulation
• Maintenance
ANTIPLATELETS
• Loading dose of Aspirin (150-300mg) is to given as soon as
possible, followed by maintenance dose (75-100mg OD).
• Based on PLATO and TRITON-TIMI 38 trial, Aspirin and potent
P2Y12 receptor inhibitor (Prasugrel or Ticagrelor) is
recommended as default DAPT strategy for ACS patients.
• Clopidogrel should be used if Prasugrel or Ticagrelor is
contraindicated or unavailable, it may be considered in older
patients (>70yrs)
DRUG LOADING DOSE MAINTENANCE
DOSE
ASPIRIN 150-300mg 75-100mg OD
CLOPIDOGREL 300-600mg 75mg OD
PRASUGREL 60mg 10mg OD
TICAGRELOR 180mg 90mg BD
SHORTENING DAPT
• TWILIGHT TRIAL
• Ticagrelor alone or Ticagrelor with aspirin for 1 year after 3 months DAPT
• Ticagrelor monotherapy had significantly less bleeding risk with no
increase in ischemic risk
• STEMI cases were excluded.
• STOPDAPT-2-ACS TRIAL
• Clopidogrel monotherapy following DAPT for 1-2m(<3m) vs DAPT for 12
months.
• Non inferiority for composite outcome for cardiovascular event or
bleeding was not proven.
• Recommendations:
• Continue 12 month DAPT
• Primary focused on bleeding outcomes
• Non inferiority design and not powered to detect potentially relevant
differences in ischemic outcomes.
• High risk / STEMI cases excluded or under represented.
DE-SCALATION FROM POTENT P2Y12
INHIBITOR TO CLOPIDOGREL
• Need to switch –
• Bleeding risk
• Dyspnea on Ticagrelor
• Allergic reactions
• Not recommended in initial 30 days
ANTICOAGULATION
• Important component of initial treatment and of peri-

procedural treatment of ACS.
• UFH has been established as standard of care in patients
with STEMI undergoing PPCI.
• Enoxaparin and bivalirudin should be considered as
alternatives to UFH in STEMI patients but fondaparinux is
not recommended.
• For NSTE-ACS, UFH and Enoxaparin are recommended in
patients anticipated to undergo immediate or early
angiography.
• In patients who don’t undergo early invasive management
(within 24hr) Fondaparinux therapy is recommended over
enoxaparin.
DRUG DOSE
UFH Loading – 70-100U/kg, followed

by infusion to achieve APTT 0f 6
—80s
ENOXAPARIN 1mg/kg BD Subcutaneously
FONDAPARINUX 2.5mg/day Subcutaneously

MAINTENANCE ANTITHROMBOTIC
THERAPY
• Following PCI, DAPT is recommended for 12 months,

followed by Aspirin monotherapy.
• Anticoagulation need not be continued after PCI, unless
there is an indication for long term OAC.
ANTIPLATELETS AND OAC
• In 6-8% patients undergoing PCI long term OAC is

indicated.
• Long term indications :
• AF
• Mechanical heart valve
• Recent/ history of recurrent or unprovoked DVT or PE
MANAGEMENT OF PATIENTS WITH
MULTIVESSEL DISEASE
• Approximately half of ACS patients have MVD.
• Multiple RCTs have provided clinical evidence that
supports preventive revascularization of non-IRA after
successful PPCI of the IRA.
• PRAMI, CvLPPRIT, COMPARE-ACUTE.
• A systematic review of 10 randomized trials that included 7030
patients with STEMI and MVD showed complete revascularization
was associated with reduced CV mortality compared with IRA-
only PCI.
• SHOCK trial – emergency revascularization in acute MI with
cardiogenic shock – lower 6 month mortality in revascularization
arm when compared to medical management
MI WITH NON OBSTRUCTIVE
CORONARY ARTERIES (MINOCA)
• Symptoms suggestive of ACS, with Trop I elevation,
however has non obstructive coronaries during
angiography.
• Prevalence – 1-14% of patients with ACS
• Can be due to coronary / non coronary cardiac / non
cardiac causes.
• If angiography is inconclusive, cardiac MR is a key
diagnostic tool
• Coronary embolism
• Coronary microvascular dysfunction
Coronary •
•
Coronary spasm
Spontaneous coronary artery
dissection
Non - •
•
Cardiac trauma
Cardiomyopathy
coronary
• Myocarditis
• Tokatsubo cardiomyopathy
• ARDS
Non - cardiac •
•
•
Hypersensitivity reactions
ESRD
Pulmonary embolism
LONG TERM TREATMENT
• Lifestyle management :
• Tobacco – abstinence is associated with reduced risk of
re-infarction (30-40%) and death (35-45%)
• Alcohol – abstainers has lowest risk, recommended to
restrict maximum of 100g/week in both males and
females.
• Physical exercise :
• 150-300 mins of moderate intensity exercise per week.
• Or 75-150 mins of high intensity exercise per week.
• Muscle strengthening exercises for >2 days/week
PHARMACOLOGICAL TREATMENT
• Antithrombotic therapy :
• DAPT for 12 months, followed by Aspirin
• Lipid lowering therapy:
• Medications to keep LDL <55mg/dl and to achieve >50%
reduction from baseline
• If goals not achieved by 4-6 weeks with maximum dose statin
therapy, then to add Ezetimibe
• Beta blockers :
• Post MI beta blocker therapy reduced the risk of death by >20%.
• Nitrates :
• No long term survival benefits, only restricted to control of residual
angina
• RAAS Inhibitors :
• Improve clinical outcomes with reduction of 30 day mortality in STEMI,
especially Anterior MI.
• Recommended in HFrEF patients
• SGLT2 i :
• Reduces the risk of worsening HF regardless of the diabetes
status
• GLP 1 agonist :
• Reduced the incidence of death, MI and stroke.

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RECENT ADVANCES IN

• It includes detection of an increase and/or decrease of a

• Recurrent or ongoing chest pain refractory to medical

• Acute HF presumed secondary to ongoing medical

• Recurrent dynamic ECG changes suggestive of ischaemia

• A confirmed diagnosis of NSTEMI based on current

• Dynamic ST-segment or T wave changes.

• Transient ST-segment elevation.

• GRACE risk score >140.

• Concordant ST elevation ≥ 1 mm in ≥ 1 lead

• Its recommended in patients suspected with ACS, with

• Oxygen supplementation is recommended whenever the

• In severe chest pain

• Acute phase management

• Important component of initial treatment and of peri-

UFH Loading – 70-100U/kg, followed

ENOXAPARIN 1mg/kg BD Subcutaneously

FONDAPARINUX 2.5mg/day Subcutaneously

• Following PCI, DAPT is recommended for 12 months,

• In 6-8% patients undergoing PCI long term OAC is

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