ESC g

uid

elines

2011

ACC/AH

A g

uid

elines

2011

NIC

E g

uid

elines

Marc

h 2

010

MO

H C

PG

2011

NO

N S

T E

LEVATIO

N

MYO

CARD

IAL

INFA

RCTIO

N

Dr.

Akm

al Ars

had

MBChB (

Hons)

Leic

est

er,

MRCP (

UK)

IJN

Card

iolo

gy S

pR

Obje

cti

ves

�The c

urr

ent

evid

ence o

n t

he b

est

pra

cti

ce s

trate

gie

s to

reduce m

orb

idit

y a

nd m

ort

ality

in p

ati

ents

wit

h

UA/N

STEM

I.

�Str

ate

gie

s th

at

are

applicable

to o

ur

local se

ttin

g

consi

deri

ng o

ur

lim

ited h

ealt

hcare

reso

urc

es.

Bre

akdow

n o

f to

pic

s

1.

Epid

em

iolo

gy

2.

Path

ophysi

olo

gy

3.

Dia

gnosi

s

4.

Ris

k s

trati

ficati

on

5.

Managem

ent

6.

Specia

l popula

tions

Applicabilit

y o

f guid

elines

Takin

g into

account

that

our

local healt

h c

are

reso

urc

es

has

all t

he f

ollow

ings

�ECG

machin

es

�M

easu

rem

ent

of

card

iac b

iom

ark

ers

�Tr

eadm

ill st

ress

test

�Echocard

iogra

ms

�M

edic

ati

ons

appro

ved f

or

use

in M

ala

ysi

a

�Id

enti

ficati

on o

f te

rtia

ry c

ente

r ro

le

1.E

pid

em

iolo

gy

�N

ati

onal card

iovasc

ula

r dis

ease

data

base

(N

CVD

)

�In

cid

ence o

f ACS 1

41 p

er

100,0

00 p

opula

tion p

er

year

�In

pati

ent

mort

ality

rate

is

7%

2.P

ath

ophysi

olo

gy

3.D

iagnosi

s

Dia

gnosi

s

�Clinic

al pre

senta

tion

�D

iagnost

ic t

ools

(Physi

cal

exam

inati

on/ECG

/Card

iac

bio

mark

ers

/card

iac im

agin

g)

Clinic

al pre

senta

tions

Physi

cal

exam

inati

ons

�Poss

ible

cause

s

�Pre

cip

itati

ng c

ause

s

�Com

plicati

ons

of

UA/N

STEM

I

Physi

cal

exam

inati

ons

Tria

ge a

ssess

ment

Dia

gnost

ic t

ools

ECG

suggest

ive o

f U

A/N

STEM

I

ECG

ECG

ECG

Card

iac b

iom

ark

ers

�Card

iac t

roponin

s (T

rop T

or

I)

�6 t

o 1

2 h

ours

fro

m t

he o

nse

t of

chest

pain

�Seri

al te

stin

g

�CK/CKM

B

Card

iac b

iom

ark

ers

Card

iac b

iom

ark

ers

Dif

fere

nti

al dia

gnosi

s

4.

Ris

k s

trati

ficati

on

�Ris

k s

trati

ficati

on

�Lik

elihood o

f advers

e o

utc

om

es

�M

anagem

ent

stra

tegie

s (e

.g s

ite o

f care

)

�U

rgency o

f re

vasc

ula

rizati

on s

trate

gy

TIM

I ri

sk s

core

GRACE r

isk s

core

ww

w.m

dcalc

.com

GRACE r

isk s

core

Ris

k s

trati

ficati

on f

or

NSTEM

I

Low

ris

k

1.

No p

revio

us

angin

a

2.

No o

ngoin

g a

ngin

a

3.

No p

rior

use

of

GTN

4.

Norm

al ECG

5.

Norm

al Tro

ponin

6.

Norm

al LV

functi

on

7.

Younger

age g

roup

Medic

al th

era

py +

outp

ati

ent

ass

ess

ment

Inte

rmedia

te o

r H

igh r

isk

1.

Recurr

ent

chest

pain

2.

Dynam

ic S

T s

egm

ent

changes

3.

Ele

vate

d c

ard

iac b

iom

ark

ers

4.

Dia

bete

s m

ellit

us

5.

Haem

odynam

ically u

nst

able

6.

Depre

ssed L

V f

uncti

on

7.

Majo

r arr

yth

mia

s (V

F/VT)

Medic

al th

era

py +

tra

nsf

er

to c

entr

e

wit

h c

ath

lab f

or

angio

gra

m

5.N

STEM

I M

anagem

ent

goals

�Im

media

te r

elief

of

ongoin

g isc

haem

ia a

nd a

ngin

a

�Pre

venti

on o

f re

curr

ent

ischaem

ia a

nd a

ngin

a

�Pre

venti

on o

f se

rious

advers

e e

vents

ESC A

CS M

anagem

ent

chart

Alg

ori

thm

for

troponin

test

Init

ial

thera

peuti

c m

easu

res

Checklist

of

treatm

ents

Ora

l anti

pla

tlets

Loadin

g d

ose

M

ain

tenance d

ose

R

ecom

mendati

on

Asp

irin

300m

g s

tat

Asp

irin

75-1

50m

g O

D

(I,A

)

P2Y

12 In

hib

itor

Medic

ati

on

Dosa

ge

Recom

mendati

on

CLO

PID

OG

REL

Loadin

g d

ose

of

300 t

o

600m

g,

Main

tenance

dose

- 75m

g O

D

(I,A

)

TIC

LO

PID

INE

250m

g B

D

(II-

a,

B)

TIC

AG

RELO

R

Loadin

g d

ose

180m

g,

Main

tenance d

ose

-

90m

g B

D

(I,B

)

PRASU

GREL

Loadin

g d

ose

of

60m

g,

main

tenance d

ose

of

10m

g O

D

(I,B

)

Activate

d p

late

lets

are

centr

al to

thro

mbus

form

ation in A

CS

Pla

qu

e r

up

ture

lead

s t

o p

late

let

ad

hesio

n t

o t

he

exp

osed

su

ben

do

theli

um

Acti

va

ted

pla

tele

ts l

ead

to

th

rom

bu

s

form

ati

on

Acti

va

ted

pla

tele

ts a

gg

reg

ate

co

veri

ng

th

e t

hro

mb

us

su

rface

[Ad

ap

ted

fro

m

Dav

ies 2

000:

A]

2

1

3

Vo

rch

heim

er

DA

, et

al. M

ayo

Clin

Pro

c. 2006;8

1:5

9-6

8;

Dav

ies M

J. H

eart

. 2000;8

3:3

61-3

66.

Targ

et

for

pla

tele

t in

hib

itio

n

Gene

tic p

oly

morp

his

ms m

ay c

ontr

ibute

to

clo

pid

og

rel re

sp

on

se

vari

abili

ty

Adapte

d f

rom

Schom

ig A

. N

Engl J M

ed

. 2009;3

61:1

108–

11

11.

Tic

agre

lor:

Does

NO

T r

equir

e

meta

bolic a

cti

vati

on t

o

becom

e a

cti

ve d

rug

Clo

pid

ogre

l:

A p

rodru

g;

requir

es

meta

bolism

to

becom

e a

cti

ve d

rug

CY

P-d

ep

en

den

t

oxid

ati

on

CY

P1A

2

CY

P2B

6

CY

P2C

19

CY

P-d

ep

en

den

t

oxid

ati

on

CY

P2C

19

CY

P3A

4/5

CY

P2B

6

Acti

ve c

om

po

un

d

Inte

rmed

iate

meta

bo

lite

Pro

dru

g

Tic

ag

relo

r

Clo

pid

og

rel

Bin

din

g

P2Y

12

Tic

agre

lor:

Does N

ot

Require H

epatic

Meta

bolis

m for A

ctivation

Pla

tele

t

PL

AT

O:

Prim

ary

Effic

acy E

ndp

oin

t

(Com

po

site o

f C

V D

eath

, M

I, o

r S

troke)

Intr

avenous

anti

pla

tlet

thera

py

�Abcix

imab

�Tir

ofi

ban

�Epti

fibati

de

�These

agents

may b

e u

sed in h

igh r

isk p

ati

ents

aw

ait

ing

transf

er

to a

PCI fa

cilit

y f

or

an e

arl

y invasi

ve s

trate

gy.

Anti

coagula

nt

thera

py

�U

nfr

acti

oned h

epari

n (

I,A)

�Low

mole

cula

r w

eig

ht

hepari

n (

I,A)

�Anti

Xa inhib

itor-

Fondapari

nux (

I,A)

�Anti

IIa

inhib

itors

- Biv

aliru

din

(I,

A)

Dosi

ng R

egim

en

Agent

NST

EM

I D

uri

ng P

CI

UFH

In

itia

l IV

bolu

s 60

IU/kg (

max 4

000 IU

)

follow

ed b

y infu

sion

to m

ain

tain

APTT 1

.5-

2.0

Em

pir

ical lo

adin

g d

ose

of

5000-1

0,0

00 i

u

EN

OXAPA

RIN

In

itia

l 30m

g IV b

olu

s,

then 1

5 m

inute

s la

ter -

s/c 1

.0 m

g/kg e

very

12 h

ours

(<75 y

ears

)

0.5

-0.7

5m

g/kg IV

bolu

s (n

o p

rior

use

)

FO

ND

APA

RIN

UX

2.5

mg s

/c O

D

Addit

ional 50-6

0 IU

/kg

of

UFH

Anti

isc

haem

ic d

rug t

hera

py

�N

itra

tes-

Consi

der

IV w

hen t

here

is

nor

relief

of

sym

pto

ms

wit

h S

/L

GTN

, D

ynam

ic E

CG

changes,

LV

failure

and h

igh b

lood p

ress

ure

�Beta

blo

ckers

- sh

ould

be a

dm

inis

tere

d e

arl

y

�Calc

ium

channel blo

ckers

- conti

nuin

g a

ngin

a d

esp

ite

bein

g o

n n

itra

tes

and b

eta

blo

ckers

. Printzmetal’s

angin

a

Dosi

ng r

egim

e f

or

Nit

rate

s

Com

pound

Route

D

osa

ge

GTN

Sublingual

0.3

-0.6

Mg (

3-5

min

ute

s)

IV

5-2

00 m

icro

gra

m/m

in

ISO

SO

RBID

E D

INIT

RATE

IV

2-1

2 m

g/hour

ora

l 10-2

0m

g t

ds

ISO

SO

RBID

E

MO

NO

NIT

RATE

ora

l 30-6

0m

g o

d

Dosi

ng r

egim

e f

or

beta

blo

ckers

Type

Init

iati

on d

ose

Targ

et

dose

METO

PRO

LO

L

25 M

G B

D

100M

G B

D

BIS

OPRO

LO

L

1.2

5 M

G O

D

10M

G O

D

CARVED

ILO

L

3.1

25 M

G B

D

25M

G B

D

Dosi

ng r

egim

e f

or

calc

ium

channel blo

ckers

Dru

g

Dose

Dilti

azem

30-9

0m

g t

ds

Vera

pam

il

40-8

0m

g t

ds

Am

lodip

ine

2.5

-10m

g

Nif

edip

ine

SR 3

0-9

0 m

g o

d

Oth

ers

�Lip

id m

odif

yin

g d

rugs

�ACEi/

ARB

6.

Specia

l popula

tion

�N

STEM

I in

wom

en

�N

STEM

I in

Chro

nic

kid

ney d

isease

pati

ents

�N

STEM

I in

the e

lderl

y

NSTEM

I in

Wom

en

0.0

%

5.0

%

10.0

%

15.0

%

20.0

%

25.0

%

30.0

%

1999

2000

2001

2002

2003

2004

2005

2006

CV

Dis

eas

eA

ll C

an

ce

rs

Death

am

ong w

om

en d

ue t

o C

ard

iovasc

ula

r D

isease

*

and a

ll C

ancers

Com

bin

ed *

in M

ala

ysi

a**

(1999 –

2005)

CV

Dis

ease

26.8

%

27.5

%

26.7

%

25.9

%

26.4

%

25.9

%

25.4

%

26.1

%

All

Can

cers

10.1

%

10.5

%

10.6

%

10.9

%

11.4

%

11.3

%

11.8

%

11.9

%

Ab

ou

t 2

5%

of

fem

ale

de

ath

s in

gove

rn

me

nt

ho

sp

ita

ls

(a

bo

ut

1 in

4)

is d

ue

to

CV

D

W

om

en’s

He

art H

ealt

h A

wa

re

ne

ss

Pro

gra

m I

n M

ala

ysia

NSTEM

I in

wom

en

�Aty

pic

al pre

senta

tion

�Pra

sugre

l is

ass

ocia

ted w

ith m

ore

ble

edin

g in w

om

en

who w

eig

h less

than 6

0kg (

I,B)

�M

eta

analy

sis

indic

ate

s a lack o

f benefi

t of

GPIIb/IIIa

inhib

itors

in w

om

en.

The b

leedin

g r

isk is

hig

her

(I,B

)

NSTEM

I in

Chro

nic

kid

ney d

isease

�In

cre

ase

d r

isk o

f ble

edin

g.

Fondapari

nux s

eem

to b

e

ass

ocia

ted w

ith less

ble

edin

g t

hat

hepari

n/enoxapari

n

(I,B

)

�M

eta

analy

sis

show

ed t

hat

pati

ent

wit

h C

KD

- earl

y

invasi

ve s

trate

gy h

ad b

ett

er

outc

om

es.

(IIa,B

)

Loadin

g d

ose

M

ain

tenance d

ose

UFH

N

o c

hange

No c

hange

Enoxapari

n

30m

g IV

1m

g/kg s

/c e

very

24

hours

if

CrC

l

<30m

l/m

in

Fondapari

nux

Avoid

if

CrC

l

<30m

l/m

in

Avoid

if

CrC

l

<30m

l/m

in

NSTEM

I in

dia

bete

s

�D

iabeti

cs

should

be t

reate

d a

ggre

ssiv

ely

�Pra

sugre

l fo

und t

o b

e m

ore

eff

ecti

ve in d

iabeti

cs

(I,B

)

�Earl

y invasi

ve a

ppro

ach (

I,A)

NSTEM

I in

the e

lderl

y

�Aty

pic

al pre

senta

tion

�Pra

sugre

l sh

ould

be a

void

ed in p

ati

ents

old

er

than 7

5

years

old

(I,

B)

�Eld

erl

y h

ave m

ore

ble

edin

g c

om

plicati

ons

Sum

mary

�The d

iagnosi

s of

UA/N

STEM

I is

base

d o

n h

isto

ry +

/-

dynam

ic

ECG

changes

(Wit

hout

pers

iste

nt

ST e

levati

on)

+/-

rais

ed

card

iac b

iom

ark

ers

�Ris

k s

trati

ficati

on is

import

ant

for

pro

gnosi

s and t

o g

uid

e

managem

ent

�In

itia

l m

anagem

ent

should

inclu

de o

xygen,

asp

irin

, clo

pid

ogre

l or

ticagre

lor,

UFH

or

LM

WH

or

Fonda.

�In

term

edia

te o

r hig

h r

isk p

ati

ent

should

be c

onsi

dere

d f

or

transf

er

to c

ard

iac c

entr

e w

ith a

ngio

gra

phy f

acilit

y.

�O

pti

miz

ati

on o

f anti

angin

al su

ch a

s nit

rate

s, b

eta

blo

ckers

, calc

ium

channel blo

ckers

.

�Consi

dera

tion in s

pecia

l popula

tions

Thank y

ou

Dr.

akm

al@

ijn.c

om

.my

htt

p:/

/w

ww

.facebook.c

om

/re

sist

anth

ypert

ensi

on