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

1. 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

2. 狹窄 閉鎖不全 心臟病 肥厚性 冠狀動脈疾病（缺血性疾病） 瓣膜疾病 心臟衰竭 心肌病變 心律不整 心包膜疾病 先天性心臟病（心房，心室中膈缺損-----） 擴張性 心博過速 心博過慢

3. 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.

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

5. 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 AMI30 mins • Relieved by rest or sublingual NTG, or not

6. 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)

7. 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)

8. 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.

9. 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).

10. Acute Coronary Syndrome - Nomenclature Acute Coronary Syndrome No ST elevation ST elevation NSTEMI Unstable Angina ST elevation Myocardial Infarction JACC 2000;36:970-1062

11. STEMI--- Diagnostic Criteria • Typical chest pain • Serial ECG changes • Serial cardiac enzymes changes - At least fulfill 2 items in the above 3 criteria

12. 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

13. 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)

15. Current therapy in acute coronary syndrome (UA / NSTEMI) • Bed rest, oxygen, opiate analgesics to relief pain, and anti-ischemic drugs (nitrates, β –blockers, calcium antagonists),CCU admission • Aspirin • IV heparin or SQ low-molecular-weight heparin • Clopidogrel/Prasugrel/Ticagrelor • IV platelet glycoprotein IIb/ IIIa antagonist • Percutaneous coronary interventions (PCI),CABG • ACE inhibitor • Statin

16. 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

17. 2007 ACC/AHAUA/NSTEMIGuideline Update : Key Recommendations on Anti-plateletTherapy • 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)

18. 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