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Pharmacy & Acute Care University
Pharmacy & Acute Care University
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Acute Care Cardiology

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  1. Acute Coronary Syndrome
    8 Topics
  2. ADHF
  3. Lesson
  4. Hypertensive Crisis
  5. Atrial Arrythmias
  6. Ventricular Arrythmias
  7. Bradycardia
  8. Lesson
  9. Aortic Dissection

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Acute Care Cardiology Acute Coronary Syndrome Summary and Key Takeaways: Acute Coronary Syndrome
Lesson 1, Topic 8
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Summary and Key Takeaways: Acute Coronary Syndrome

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Summary & Key Takeaways

Summary & Key Takeaways on Acute Coronary Syndrome

Course Overview

This comprehensive course on Acute Coronary Syndrome (ACS) covers clinical presentations, pathophysiology, diagnostic approaches, and both pharmacologic and non-pharmacologic interventions. It emphasizes the role of healthcare providers in managing ACS, particularly in emergency department settings. The course details various aspects of ACS, including risk factors, high-risk features, differential diagnoses, and the main types of ACS: STEMI, NSTEMI, and unstable angina. It also provides in-depth information on diagnostic approaches, immediate interventions, and a wide range of pharmacologic treatments.

Key Takeaways:

Clinical Presentation and Pathophysiology:

  • ACS involves acute reduction in coronary blood flow, leading to myocardial ischemia or infarction.
  • Three main types: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina.

Diagnostic Approach:

  • Focus on thorough history, physical exam, and ECG interpretation.
  • Use cardiac biomarkers, particularly troponin levels, for diagnosis and risk stratification.
  • Consider additional tests like echocardiography and coronary angiography as needed.

Immediate Management:

  • Provide oxygen therapy if oxygen saturation is low.
  • Administer aspirin and nitroglycerin for chest pain relief.
  • Initiate anticoagulation therapy as appropriate.
  • Consider immediate reperfusion therapy (PCI or fibrinolysis) for STEMI patients.

Pharmacologic Interventions:

  • Antiplatelet therapy: Aspirin and P2Y12 inhibitors (e.g., clopidogrel, ticagrelor) are cornerstone treatments.
  • Anticoagulants: Heparin or low-molecular-weight heparin to prevent further thrombosis.
  • Beta-blockers to reduce myocardial oxygen demand and improve outcomes.
  • ACE inhibitors or ARBs for patients with left ventricular dysfunction.
  • Statins for lipid management and plaque stabilization.

Treatment Guidelines:

  • Follow evidence-based guidelines from organizations like the American Heart Association and European Society of Cardiology.
  • Implement timely reperfusion strategies for STEMI patients (door-to-balloon time <90 minutes for PCI).
  • Use risk stratification tools (e.g., TIMI, GRACE scores) to guide management decisions in NSTEMI/UA.

Monitoring and Follow-up:

  • Continuous cardiac monitoring during the acute phase.
  • Assess for complications such as arrhythmias, mechanical complications, or recurrent ischemia.
  • Provide patient education on lifestyle modifications, medication adherence, and cardiac rehabilitation.

Special Considerations:

  • Manage high-risk patients, including those with cardiogenic shock or mechanical complications.
  • Consider alternative diagnoses such as aortic dissection, pulmonary embolism, or myocarditis.
  • Tailor treatment for specific populations (e.g., elderly, diabetics, chronic kidney disease patients).

Final Remarks:

ACS requires prompt recognition, risk stratification, and initiation of evidence-based therapies to restore coronary blood flow, reduce myocardial oxygen demand, inhibit thrombus extension, prevent adverse outcomes, and relieve ischemic symptoms. Immediate reperfusion for STEMI is critical. Combination antiplatelet and anticoagulant therapy form the foundation of ACS pharmacotherapy. Secondary prevention with statins, beta blockers, ACE inhibitors/ARBs, and dual antiplatelet therapy significantly improves long-term outcomes.

References

  1. Hollander JE, Diercks DB, et al. The Acute Coronary Syndrome Chapter from Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th edition. Elsevier; 2018.
  2. Yusuf S, Zhao F, Mehta SR, et al; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494-502.
  3. Wallentin L, Becker RC, Budaj A, et al; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045-1057.
  4. Wiviott SD, Braunwald E, McCabe CH, et al; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-2015.
  5. Mega JL, Braunwald E, Wiviott SD, et al; ATLAS ACS 2–TIMI 51 Investigators. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med. 2012;366(1):9-19.
  6. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4).
  7. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25).
  8. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016;134(10).
  9. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177.
  10. Bates ER, Nallamothu BK. Commentary: The role of percutaneous coronary intervention in ST-segment-elevation myocardial infarction. Circulation. 2008;118(6):567-72.
  11. Eagle KA, Nallamothu BK, Mehta RH, et al. Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go. Eur Heart J. 2008;29(5):609-17.
  12. Larson DM, Duval S, Sharkey SW, et al. Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers. Eur Heart J. 2012;33(10):1232-40.
  13. Mehta SR, Granger CB, Eikelboom JW, et al. Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: results from the OASIS-5 trial. J Am Coll Cardiol. 2007;50(18):1742-51.
  14. White HD, Chew DP, Hoekstra JW, et al. Safety and efficacy of switching from either unfractionated heparin or enoxaparin to bivalirudin in patients with non-ST-segment elevation acute coronary syndromes managed with an invasive strategy: results from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am Coll Cardiol. 2008;51(17):1734-41.
  15. Giugliano RP, White JA, Bode C, et al; EARLY ACS Investigators. Early versus delayed, provisional eptifibatide in acute coronary syndromes. N Engl J Med. 2009;360(21):2176-90.
  16. Wang TY, White JA, Tricoci P, et al. Upstream clopidogrel use and the efficacy and safety of early eptifibatide treatment in patients with acute coronary syndrome: an analysis from the Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome (EARLY ACS) trial. Circulation. 2011;123(6):722-30.
  17. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2(8607):349-60.
  18. Sabatine MS, Cannon CP, Gibson CM, et al; CLARITY-TIMI 28 Investigators. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005;352(12):1179-89.
  19. Chen ZM, Jiang LX, Chen YP, et al; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1607-21.
  20. Bell RM, Swinburn JM, Rodgers A, et al. Impact of morphine on the outcome of patients with acute coronary syndrome. Heart. 2021;107(18):1481-1487.
  21. Deharo P, Quilici J, Camoin-Jau L, et al. Impact of morphine on antiplatelet therapy and ischemic events in acute coronary syndrome: Insights from the RICO survey. Int J Cardiol. 2018;263:29-32.
  22. Zeymer U, Huber K, Fu Y, et al. Morphine use in myocardial infarction: Clinical characteristics, treatment, and outcomes from the PLATO trial. Eur Heart J Cardiovasc Pharmacother. 2016;2(4):249-257.
  23. Steg PG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569-619.