ACUTE CORONARY SYNDROME (ACS)
ACUTE CORONARY SYNDROME (ACS)
1. First-line therapy to reduce mortality in STEMI is:
Reperfusion (primary PCI or fibrinolysis) is the only intervention that rapidly restores coronary blood flow and reduces mortality significantly.
2. Door-to-balloon time target for primary PCI is:
Guidelines recommend a door-to-balloon time of ≤ 90 minutes for primary PCI.
3. Absolute contraindication for fibrinolysis:
Previous hemorrhagic stroke is a strict contraindication to fibrinolysis.
4. Preferred P2Y12 inhibitor in ACS managed invasively:
Ticagrelor has rapid onset and mortality benefit in ACS.
5. Oxygen should be given in ACS only if:
Routine oxygen is not recommended; use only if hypoxemia (SpO₂ < 90%).
6. TIMI score is used primarily for:
TIMI is a validated risk tool for NSTEMI/UA.
7. Statin of choice in ACS:
High-intensity atorvastatin reduces early recurrent events after ACS.
8. Inferior MI with hypotension — avoid:
RV infarction causes preload-dependent physiology; nitrates worsen hypotension.
9. Preferred anticoagulant in STEMI thrombolysis:
Enoxaparin improves outcomes in lytic-based STEMI protocols.
10. GRACE score > 140 indicates:
GRACE > 140 mandates early invasive coronary angiography within 24 hours.
11. Drug improving survival in LV dysfunction post-MI:
ACE inhibitors reduce remodeling and improve survival.
12. Most common cause of death within first hours of MI:
VF is the leading early cause of death in MI.
13. In NSTEMI, fibrinolysis is:
NSTEMI lacks an occlusive thrombus; fibrinolysis is contraindicated.
14. Morphine should be used:
Used selectively because it may delay P2Y12 absorption.
15. Post-MI beta-blockers reduce:
Beta-blockers reduce sudden cardiac death and improve survival.
16. PCI is preferred over fibrinolysis if PCI delay is less than:
If FMC-to-device < 120 minutes, PCI is preferred.
17. Definitive management of mechanical complications of MI:
VSR, papillary muscle rupture, and free-wall rupture require urgent surgery.
18. Most beneficial medication post-MI for remodeling:
ACEIs reduce ventricular remodeling significantly.
19. First-line imaging to assess LV function post-MI:
Echo is the first-line assessment tool for EF, RWMA, complications.
20. Mandatory duration of dual antiplatelet therapy (DAPT) post-ACS:
DAPT for at least 12 months is guideline-mandated post-ACS.
Comprehensive Treatment Plan
1. Immediate Assessment & Stabilization (All ACS)
A. Initial Actions
- Ensure airway, breathing, circulation
- Put patient on cardiac monitor
- Establish IV access ×2
- Obtain ECG within 10 minutes
- Check vitals, assess Killip class
- Draw labs: troponin, CBC, electrolytes, renal profile, coagulation panel
B. Oxygen
- ONLY if:
- SpO₂ < 90%
- Dyspnea
- Hypoxemia
- Cardiogenic shock
C. Nitrates
- SL NTG 0.4 mg every 5 minutes ×3
- IV infusion if persistent ischemia or hypertensive
- CONTRAINDICATIONS:
- SBP < 90 mmHg
- PDE5 inhibitors (sildenafil in last 24 hours; tadalafil 48 hrs)
- Suspected RV infarction
D. Analgesia
- Morphine 2–4 mg IV (only for persistent severe pain)
E. Antiplatelet Therapy (DAPT)
- Aspirin:
- 150–325 mg chewable loading
- 75–100 mg daily lifelong
- P2Y12 inhibitor (choose one):
- Ticagrelor 180 mg load → 90 mg BD
- Prasugrel 60 mg → 10 mg daily (only after PCI; avoid in stroke/TIA)
- Clopidogrel 600 mg (if others contraindicated)
F. Statin
- Atorvastatin 80 mg or Rosuvastatin 40 mg immediately
2. STEMI Treatment Plan
Goal: prompt reperfusion (< 12 hours from symptom onset)
2.1 Primary PCI (Preferred Strategy)
Door-to-balloon time ≤ 90 minutes
If transfer: FMC-to-device ≤ 120 minutes
PCI Medications
- DAPT (as above)
- Anticoagulation:
- UFH: 70–100 U/kg IV bolus
- (if GP IIb/IIIa used → 50–70 U/kg)
- OR Bivalirudin if high bleeding risk
- Optional: GP IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide)
- Indicated for large thrombus, no-reflow, or bailout
2.2 Fibrinolysis (If PCI cannot be done in time)
Indication: PCI delay > 120 min
Best within 12 hours (can consider up to 24 h if ongoing ischemia)
Drugs
- Tenecteplase (preferred): weight-based bolus
- Aspirin + Clopidogrel
- < 75 years: clopidogrel 300 mg load
- ≥ 75 years: no load (75 mg daily)
Anticoagulation after lysis
- Enoxaparin (preferred): 1 mg/kg SC BD
- OR UFH infusion
- OR Fondaparinux 2.5 mg daily
2.3 Pharmaco-Invasive Strategy
After successful fibrinolysis:
- Angiography in 3–24 hours
If failed lysis (persistent pain, < 50% ST resolution at 60–90 min): - Rescue PCI immediately
3. NSTEMI / UNSTABLE ANGINA Treatment Plan
3.1 Risk Stratification
High Risk
- Dynamic ST-T changes
- Elevated troponin
- GRACE > 140
- Refractory chest pain
- CHF, hypotension
- Ventricular arrhythmias
Intermediate Risk
- Diabetes
- CKD
- EF < 40%
- Prior MI/PCI/CABG
- GRACE 109–140
3.2 Management Algorithm
A. Invasive Strategy
- Immediate (< 2 hours): hemodynamic instability, shock, refractory angina
- Early (< 24 hours): troponin elevation, GRACE > 140, dynamic ECG change
- Delayed (24–72 hours): diabetes, CKD, EF < 40%, recurrent symptoms
B. Medications
1. Antiplatelet Therapy
Same DAPT as STEMI (ticagrelor preferred unless high bleed risk)
2. Anticoagulation
- Enoxaparin 1 mg/kg SC BD
- OR UFH infusion to maintain aPTT
- OR Fondaparinux 2.5 mg daily (must add UFH bolus during PCI)
3. Beta-Blockers
- Start within 24 hours unless:
- Acute HF
- Shock
- PR prolongation
- HR < 60
4. Anti-Ischemic Agents
- Nitrates
- Beta-blockers
- CCBs (non-DHP) if refractory + contraindication to beta-blockers
5. ACE Inhibitors / ARBs
Start within 24 hours if:
- EF ≤ 40%
- Diabetes
- CKD
- Anterior MI
- Hypertension
6. Aldosterone Antagonists
(Eplerenone preferred)
- EF ≤ 40% + HF or diabetes
- Already on ACEI/ARB + beta-blocker
7. Statins
High-intensity for all patients
4. Complications Management (All ACS)
Cardiogenic Shock
- Immediate PCI
- Vasopressors: norepinephrine
- Inotropes: dobutamine
- Mechanical Circulatory Support:
- IABP (selected cases)
- Impella
- VA-ECMO
Arrhythmias
- VT/VF → defibrillation
- TdP → magnesium
- Bradyarrhythmias → atropine → temporary pacing
Mechanical Complications
- VSR, papillary muscle rupture, free-wall rupture → emergent surgery
5. Secondary Prevention (Discharge Plan)
Medications
- Aspirin lifelong
- P2Y12 inhibitor for 12 months
- High-intensity statin
- Beta-blocker for ≥ 3 years
- ACEI/ARB based on indications
- Aldosterone antagonist if EF ≤ 40%
- SGLT2 inhibitors (in HF or diabetes)
Lifestyle
- Smoking cessation
- Cardiac rehabilitation
- Weight/BP/diabetes control
- Diet: low saturated fat, high fiber
- Physical activity 150 min/week
Follow-up
- Review in 2 weeks, then 4–6 weeks
- Repeat echo at 40–90 days for EF re-assessment
| Parameter | STEMI | NSTEMI |
|---|---|---|
| Pathophysiology | Complete coronary artery occlusion with transmural ischemia. | Partial occlusion or severe stenosis with subendocardial ischemia. |
| ECG Changes | Persistent ST-segment elevation or new LBBB. | ST depression, T-wave inversion, or normal ECG. |
| Cardiac Biomarkers | Troponins elevated. | Troponins elevated. |
| Infarction Type | Transmural MI. | Subendocardial MI. |
| Urgency of Reperfusion | Immediate reperfusion required (PCI ≤90 min; fibrinolysis ≤30 min). | No fibrinolysis. Early invasive strategy within 24 hrs depending on risk. |
| Preferred Initial Treatment | PCI or fibrinolysis + antiplatelet + anticoagulation. | Antiplatelet + anticoagulation + early PCI based on risk stratification. |
| Fibrinolysis | Indicated when PCI unavailable within 120 min. | Contraindicated. |
| GRACE Score Use | Not mandatory for reperfusion decision. | Determines timing of invasive strategy (low, intermediate, high risk). |
| Prognosis | Higher early mortality. | Lower early mortality but higher long-term recurrent risk. |
| Complications | Cardiogenic shock, VF/VT, mechanical complications more common. | Recurrent angina, reinfarction more common. |
1. Initial Assessment
- Airway, breathing, circulation (ABC check).
- Attach monitor + obtain 12-lead ECG within 10 minutes.
- Check vitals, O₂ saturation, capillary refill, GCS.
- Establish IV access ×2, obtain blood for troponin + baseline labs.
- Give oxygen only if SpO₂ < 90%, respiratory distress, or shock.
2. Immediate Pharmacotherapy
- Aspirin 325 mg (chewed) → lifelong maintenance 75–100 mg.
- P2Y12 inhibitor: Ticagrelor, Prasugrel, or Clopidogrel.
- Anticoagulation: UFH, Enoxaparin, or Bivalirudin as per plan.
- Nitrates for pain unless hypotension/RV infarct/PDE-5 inhibitors.
- Morphine if pain persists despite nitrates.
- Beta-blocker unless signs of shock, HF, bradycardia, or AV block.
3. ECG-Based Stratification
a. STEMI (Persistent ST elevation or new LBBB)
- Immediate reperfusion required.
- Primary PCI within 90 min door-to-balloon.
- If PCI unavailable: Fibrinolysis within 30 min (door-to-needle).
b. NSTEMI / UA (ST depression, T inversion, normal ECG)
- Risk stratify (GRACE score).
- High risk: Early invasive strategy ≤24 hrs.
- Intermediate risk: Invasive 24–72 hrs.
- Low risk: Conservative strategy + CT-coronary angiography if needed.
4. STEMI Reperfusion Pathway
Primary PCI Strategy
- Preferred when available rapidly.
- Use aspirin + potent P2Y12 inhibitor + parenteral anticoagulation.
- Consider GP IIb/IIIa inhibitor for high thrombus burden.
Fibrinolysis Strategy
- Tenecteplase preferred (weight-based).
- Absolute contraindications: prior ICH, active bleeding, etc.
- Successful lysis → Routine PCI in 2–24 hrs (pharmaco-invasive).
- Failed lysis → Rescue PCI.
5. NSTEMI/UA Management Pathway
- Dual antiplatelet therapy (DAPT) + anticoagulation.
- Beta-blockers within 24 hrs unless contraindicated.
- Statin: High-intensity atorvastatin 80 mg or rosuvastatin 40 mg.
- ACE-I/ARB in LV dysfunction, diabetes, or hypertension.
- Glycemic control (avoid routine insulin drip unless hyperglycemic crisis).
6. Post-Reperfusion / Post-PCI Care
- Continue DAPT (12 months preferred).
- Monitor for arrhythmias, shock, HF, mechanical complications.
- Start high-intensity statin unless contraindicated.
- Start ACE-I/ARNI for LV dysfunction (EF <40%).
- Add aldosterone antagonist in EF <40% + DM/HF.
- Enroll in cardiac rehabilitation.
7. Discharge Planning
- Medication optimization: DAPT, statin, ACE-I/ARB, beta-blocker.
- Smoking cessation + lifestyle counselling.
- Assess LVEF for ICD consideration (≥40 days post-MI if EF <35%).
- Follow-up within 7–14 days.
