Unstable Angina and Non

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Unstable Angina and NonST Elevation Myocardial
Infarction

• YEDITEPE UNIVERSITY FACULTY OF MEDICINE
• PHASE 4 CARDIOLOGY COURSE 2014-2015
• PROF. MUZAFFER DEGERTEKIN, M.D., PhD.
• MUSTAFA AYTEK SIMSEK, M.D., Attending Physician

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Pathophysiology of ACSEvolution of Coronary
Thrombosis
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Causes of UA/NSTEMI

• Thrombus or thromboembolism, usually arising on
  disrupted or eroded plaque Most Common Cause.
• Dynamic obstruction coronary spasm or
  vasoconstriction
• Progressive mechanical obstruction to coronary
  flow ie restenosis after PCI
• Coronary arterial inflammation
• Coronary artery dissection
• Secondary UA Increasing oxygen demands in the
  setting of a fixed lesion.

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Clinical Indicators of Increased Risk in UA/NSTEMI
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TIMI Risk Score
T Troponin elevation (or CK-MB elevation) H
History or CAD (gt50 Stenosis) R Risk Factors
gt 3 (HTN, Hyperlipidemia, Family Hx, DM II,
Active Smoker)
E EKG changes ST elevation or depression 0.5
mm concordant leads A2Aspirin use within the
past 7 days Age over 65 T Two or more episodes
of CP within 2 hours
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GRACE Prediction Score Card

• Medical History
• Age in years (0-100 points)
• History of congestive heart failure (24 points)
• History of myocardial infarction (12 points)
• Findings at initial hospital presentation
• Resting heart rate (0-43 points)
• Systolic blood pressure (0-24 points)
• ST depression (11 points)
• Findings during hospitalization
• Initial serum creatinine (1 to 20 points)
• Elevated cardiac enzymes (15 points)
• No in-hospital percutaneous coronary intervention
  (14 points)

JAMA 20042912727-33
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Deciding between Early Invasive vs a Conservative
Strategies
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General Treatment Measures

• Antiplatelet Therapy
• Anticoagulant Therapy
• Control of Cardiac Pain
• Analgesics
• Nitrates
• Beta Blockers
• Oxygen
• Limitation of Infarct Size
• Early reperfusion
• Reduction of myocardial energy demand

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Antiplatelet Therapy

• Aspirin
•  162-325 mg, nonenteric-coated ASA to be chew
•  maintenance of 75-162 mg daily

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Antiplatelet Therapy

• Clopidogrel 300 mg loading 75 mg/day
• Prasugrel oral loading dose of 60 mg and 10 mg
  orally daily
• Ticagrelor a loading dose of 180 mg and 90 mg
  twice daily

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Anticoagulant Therapy

• Heparin activated partial thromboplastin time
  (aPTT) target of 1.5 to 2 times that of control
• Low-Molecular-Weight Heparins
• Fondaparinux

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Control of Cardiac Pain

• Analgesics
• meperidine, pentazocine, and morphine
• Morphine 2 to 8 mg/ 5 to 15 minutes --until the
  pain is relieved or there is evident toxicity
• Nitrates
• sublingual nitrates, intravenous nitroglycerin
• systolic pressure lt90 mm Hg
• right ventricular infarction

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Control of Cardiac Pain

• Beta Blockers
• Killip class II or higher (precipitating
  cardiogenic shock)
• Patients with heart failure (rales gt 10 cm up
  from diaphragm),
• hypotension (blood pressure lt 90 mm Hg),
• bradycardia (heart rate lt 60 beats/min),

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Control of Cardiac Pain

• Oxygen
• pulse oximetry
• Sao2 lt 90
• 2 to 4 liters/min of 100 oxygen
• 6 to 12 hours

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Limitation of Infarct Size

• Early reperfusion
• Routine Measures for Infarct Size Limitation
• Beta blocker (HR 50-70)
• Inhibitors of the renin-angiotensin-aldosterone
  system (RAAS)
• Arterial oxygenation

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Limitation of Infarct Size

•  Angiotensin-converting enzyme (ACE) inhibitor  
• Start ACE inhibitor orally in patients with
  pulmonary congestion or LVEF lt40
• if the following are absent hypotension (SBP
  lt100 mm Hg or lt30 mm Hg below baseline) or known
  contraindications to this class of medications.
•  Angiotensin receptor blocker (ARB) 
• Start ARB orally in patients who are intolerant
  of ACE inhibitors and with either clinical or
  radiologic signs of heart failure or LVEF lt40

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