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ANTITHROMBOTIC THERAPY IN ACUTE CORONARY
SYNDROME
BY:
Topan Binawan
Supervisor :
Prof.DR.dr.Moch.Fathoni,SpJP(K),FIHA,FAsCC,FAPSC
CARDIOLOGY PAPERS
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introduction
Coronary heart disease : a disability premature deathsworldwide
Each year : 1,300,000 non-Qmyocardial infarction,350,000 Q wave myocardial infarction
in the US
Antithrombotic proper handling during myocardial ischemiaacute, cardiac care to help provide safe and effective
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Impact of bleeding ACSpatient outcomesPCIhighlight the importance of
antithrombotic doses,especially vulnerable
populations such as womenand 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 andcardiac enzymes,ACS is classified
into:
STEMI: STelevation, elevatedcardiac enzymes
NSTEMI: STdepression, T-wave
inversion, elevatedcardiac enzymes
Unstable Angina:Non specific EKG
changes, normalcardiac enzymes
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Pathogenesis
UnstableAngina
Plaque Rupture
Thrombosis &
platelet aggregation
Vasospasme
Plaque erotionwithout rupture.
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STEMIInfark : plaque becomefissure and rupture,
thrombogenesismuralthrombus on location ofruptureocclution of
coronary artery.
Location of plaquerupture, agonis
activation of plateletstromboxan A2the
receptor glycoprotein IIb/ IIIa.
The receptor has a highaffinity amino acid
sequence : bind to twodifferent platelets,
platelet aggregation
Tissue factorCoagulation cascade
endothelial cells :damaged.
Activated fo VII and X,conversion of
prothrombin -thrombin,then converts
fibrinogen- fibrin.
Undergo coronaryartery occlusionby a
thrombus composed ofplatelets and fibrin
aggregates
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NSTEMI
Acute thrombosis occurs NSTEMI / processescoronary vasoconstriction.
Acute thrombosis in coronary artery plaquerupture begins with an unstable
This unstable plaque has a large lipid core, alow density of smooth muscle, thin fibrous cap
and a high concentration of tissue factor.
Location of plaque rupture in macrophage and
lymphocyte cell encounteredinflammation ;TNF , and IL-6.
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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 Platelet
glycoprotein IIb / IIIa in Unstable angina
PURSUIT : Receptor Suppression Using Integrilin
Therapy.
To help formulate management better strategies
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High risk scoreearly invasive.
Low risk scoreinitial 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-termmaintenance : aspirin
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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, whilelowering 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 bivalirudinGP IIb / IIIa inhibitor-treated patients with
invasive : thiopyridine early (
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Selection of Anticoagulants: early conservative
strategies in unstable angina / NSTEMI
Guidelines ACC / AHA recommendationof UFH or enoxaparin (Class I, LOE: A)or fondaparinux (Class I, LOE: B) withenoxaparin / fondaparinux are preferred(Class IIa, LOE: B).
Similarly, the ESC guidelinesrecommendation fondaparinux (Class 1,LOE: A) or UFH (Class 1, LOE C) in aconservative, but also loweredrecommendation for enoxaparin (ClassIIa, 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 norecommended for the treatment of non-ST elevation ACS : (ACC / AHAClass I, LOE: A], ESC [Class I, LOE: A], and ACCP [Class 1A]).
Invasive strategy guidelines : the ACC / AHA recommendation UFH orenoxaparin (Class I, LOE: A) or bivalirudin or fondaparinux (Class I,
LOE: B).
ESCurgent 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 (Class1B). 19
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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 nonenteric-aspirin 150-325 mg, daily dose > lowthereafter ( Low high risk for bleeding(Class IIa, LOE: C).
STEMI post-PCI recommendations for 1 yearclopidrogel after drug elution stents and 1month to 1 year bare metal stents (Class I,LOE: B)
ACC / AHA STEMIsupport the addition ofclopidogrel + aspirin STEMI (initiation ofclopidogrel 300 mg
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The selection of anti thrombotic patients with a fibrinolysis
ACC / AHA recommendations fibrinolysisanticoagulant treated patients at least 48 hours
(Class I, LOE: C), continued up to 8 days or untilthe 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 inpatients 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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R d ti f ti l ti STEMI
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Recommendations for anticoagulation on STEMI
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The selection of the antithrombotic primary PCI
ACC / AHA supports thecontinuation of anticoagulants onthe scope of peri-PCI (Class I)
primary PCI of STEMI.Recommendations include UFH
(Class I, LOE: C) with the option ofswitching to bivalirudin (Class I,LOE: C) for the previous UFH.Enoxaparin (Class I, LOE: B) /
fondaparinux (Class I, LOE: C) isreceived anticoagulant STEMI with
PCI
ACCP and strong ESCrecommendation fondaparinux on
primary PCI.
ACCP supports the use of UFH
dosing based on the weight(Class1B) and abciximab (inhibitor of GPIIb / IIIa) IV during primary PCI
(Class 1B) for STEMI.ESC Guidelines recommendationUFH (Class I, LOE: C) / bivalirudin
(Class IIa, LOE: B)
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T iti t P t ACS A ti Th b ti Th f
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Transition to Post-ACS Anti Thrombotic Therapy ofChronic
The guidelines continue to support
low-dose aspirin, ideally 100 mg /day.
Patients in-stent acute coronarysyndrome, the dose of aspirin (162-
325 mg) can be used for the firstmonth 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 andideally for at least 1 year drug-elutingstents.
Oral anticoagulants + dualantiplatelet no recommendation for
secondary prevention in the absence
of a clear indication (ie AF, DVT).
Warfarin may be considered inpatients with a high risk of ischemia
and bleeding risk is low if notintolerant of clopidogrel (Class IIb,
LOE: B).
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RESUME
Using anti-platelet therapy and anti-coagulants on
ACS clinical outcomes associated development ofshort-term and long-term, depending onconservative treatment or acute coronaryrevascularization.
Selecting anti-thrombotic therapy lowers the riskof ischemic while minimizing the risk of bleedingfrom various subtype ACS.
Selecting of appropriate antithrombotic during the
transition from the phase of the sub-acute andchronic secondary prevention can be worthattention
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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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