Current treatment of acute

coronary syndrome

林口長庚醫院 心臟內二科謝宜璋醫師

March,6, 2012

心臟病1. 冠狀動脈疾病（缺血性疾病）

2. 瓣膜疾病

3. 心臟衰竭

4. 心肌病變

5. 心律不整

6. 心包膜疾病7. 先天性心臟病（心房，心室中膈缺

損 -----）

狹窄

閉鎖不全

肥厚性

擴張性心博過速

心博過慢

Coronary Artery Disease (CAD)

Etiology:• Atherosclerotic disease of epicardial coronary arteries.• Luminal narrowing by other mechanism, e.g. coronary

spasm, dissection of aorta, etc.• Embolization.• Arteritis of coronary arteries, e.g. Granulomatous

disease, kawasaki syndrome, SLE, RA, etc.• Trauma to coronary arteries.• Intimal proliferative disease, e.g. amyloidosis,

homocystinuria, etc.

Risk factors for CAD• Male • Ageing • Hypertension• Diabetes Mellitus• Smoking• Obesity• Dyslipidemia• Family history• Sedentary• Uremia• Homocysteinemia

CAD--- Symptoms

• Exertional chest discomfort (squeezing, pressure, heaviness sensation) --- typical

• Crescendo-decrescendo pattern

• May radiate to the left shoulder, both arms, back, neck, or jaw

• Lasting 1-10 minutes, if AMI30 mins

• Relieved by rest or sublingual NTG, or not

Diagnosis of CAD• History: typical symptoms• Physical exam: non-specific signs• Laboratory: Resting EKG (electrocardiogram)

Exercise treadmill test

Thallium-201 scan

Dobutamine stress test (echo)

Multi-slices CT

Angiogram (coronary)

CAD --- Management

• Explanation and reassurance• Reduction of risk factors: Hypertension, Diabetes,

dyslipidemia, smoking, exercise---• Treatment of coexisting condition capable of

aggravating angina• Adaptation of activities• Drug therapy• Mechanical revascularization (PCI): PTCA,

stenting, atherectomy, etc.• Coronary artery bypass surgery (CABG)

CAD --- Drug therapy

• Antiplatelet agents: Aspirin, Clopidogrel• B-adrenoreceptor blockade: Propranolol, Atenolol,

Nadolol, Bisoprolol , Carvedilol, Metoprolol • ACEI/ARB• Statin• Nitrate• Ca-channel blockers: Diltiazem, Nifedipine.

Clinical Manifestation of CAD (IHD)

• Asymptomatic (silent ischemia)

• Chronic stable angina pectoris

• Acute coronary syndrome (ACS): unstable angina, non-ST elevation myocardial infarction (NSTEMI)

• ST-elevation myocardial infarction (STEMI).

Acute Coronary Syndrome - Nomenclature

Acute Coronary Syndrome

No ST elevation ST elevation

NSTEMI

Unstable Angina

ST elevation Myocardial Infarction

JACC 2000;36:970-1062

STEMI--- Diagnostic Criteria

• Typical chest pain

• Serial ECG changes

• Serial cardiac enzymes changes

- At least fulfill 2 items in the above 3 criteria

STEMI --- Management (1)

• Admit to coronary care unit• Absolute bed rest• Reperfusion therapy - Pharmacologocal: thrombolytic therapy - Mechanical: Primary PTCA, stenting• Drug therapy: - Analgesia, sedation - Oxygen - Anti-platelet agent and anticoagulants - B-blockers - Angiotensin-converting enzyme (ACE) inhibitor/ARB - Antiarrhythmic agents

Unstable Angina• New onset (< 2 months) angina • Accelerating angina (severity, frequency)• Resting angina• Pathophysiology: - progression of atherosclerosis - platelet aggregation - thrombus formation - changes in vasomotor tone (spasm)

Current therapy in acute coronary syndrome (UA / NSTEMI)

1. Bed rest, oxygen, opiate analgesics to relief pain, and anti-ischemic drugs (nitrates, β –blockers, calcium antagonists),CCU admission

2. Aspirin

3. IV heparin or SQ low-molecular-weight heparin

4. Clopidogrel/Prasugrel/Ticagrelor

5. IV platelet glycoprotein IIb/ IIIa antagonist

6. Percutaneous coronary interventions (PCI),CABG

7. ACE inhibitor

8. Statin

2007 ESC NSTE-ACS Guideline Update Key Recommendation on Clopidogrel Therapy

• Clopidogrel• For all patients, immediate 300 mg loading dose of clopidogrel is

recommended, followed by 75 mg clopidorel daily (I-A). Clopidogrel should be maintained for 12 months unless there is an excessive risk of bleeding (I-A).

• For all patients with contraindications to aspirin, clopidogrel should be given instead (I-B).

• In patients considered for an invasive procedure/PCI, a loading dose of 600 mg clopidogrel may be used to achieve more rapid inhibition of platelet function (IIa-B).

• In patients pretreated with clopidogrel who need to undergo CABG, surgery should be postponed for 5 days for clopidogrel withdrawal if clinically feasible (IIa-C).

Task Force Members et. al, European Heart Journal 2007;28(!3):1598-1660

2007 ACC/AHA UA/NSTEMI Guideline Update : Key Recommendations on Anti-platelet Therapy

• Medical therapy without stenting ASA 75-162 mg/d indefinitely (Class I, A)

Clopidogrel 75 mg/d, at least 1 mo (Class I, A), ideally up to 1 yr (Class I, B)

• Bare metal stent ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely

(Class I, A)

Clopidogrel 75 mg/d, at least 1 mo (Class I, A), ideally up to 1 yr (Class I, B)

• Drug-eluting stent

ASA 162-325 mg/d at least 3 (sirolimus)-6 (paclitaxel) mo, 75-162 mg/d indefinitely (Class I, A)

Clopidogrel 75 mg/d > 1 yr (Class I, B)

Conclusions• CAD is an important, life-threatening disease • Risk factors control/life style modification are the best policy for

prevention• Typical symptom is the keypoint for diagnosis, which can be

confirmed by (non)invasive tests • Medications include anti-platelet agents, beta-blocker, ACEI/ARB,

statin, nitrate• ACS should be treated early and aggressively• For STEMI patients, primary PCI (angioplasty) is better than

thrombolysis• CABG is preserved for complicated/complex patient • Early detect and early treatment are crucial for CAD