ACS ACC 2025 part 1 Flashcards
Types of MI ?
Type 1
Caused by acute coronary atherothrombosis, usually precipitated by atherosclerotic plaque disruption (rupture or erosion) and often associated with partial or complete vessel thrombosis.
Type 2
Caused by an imbalance between myocardial oxygen supply and demand unrelated to acute coronary atherothrombosis.
Type 3
Cardiac death, with symptoms of myocardial ischemia and presumed ischemic electrocardiographic changes or ventricular arrythmia, before blood samples for cardiac biomarkers can be obtained or increases in cardiac biomarkers can be identified and/or in whom MI is identified by autopsy.
Type 4
4a: Peri-PCI MI caused by a procedural complication and detected ≤48 h after PCI.
4b: Post-PCI MI caused by coronary stent or stent scaffold thrombosis.
4c: Post-PCI MI caused by coronary stent restenosis.
Type 5
Peri-CABG MI caused by a procedural complication detected ≤48 h after CABG surgery.
Prehospital Assessment and Management Considerations for Suspected ACS ?
12 lead ECG within 10 minutes to identify STEMI
If PCI - capable hospital : FMC–to-first-device time system goal of ≤90min
If transfer to a PCI - capable hospital : FMC–to-first-device time system goal of ≤120min
STEMI ECG findings ?
New or presumed new ST-elevation of ≥1 mm in ≥2 anatomically
contiguous leads (measured at the J-point) in all leads other than
V2-V3
AND
≥2 mm in men ≥40 y
≥2.5 mm in men <40 y
≥1.5 mm in women regardless of age in leads V2-V3.
NSTE-ACS ECG findings ?
New or presumed new and usually dynamic horizontal or downsloping ST-segment depression ≥0.5 mm in ≥2 contiguous leads
and/or T-wave inversion >1 mm in ≥2 contiguous leads with prominent R wave or R/S ratio >1 or transient ST-segment elevation.
When to repeat Trponin measurements ?
the recommended time intervals for repeat
measurements after the initial sample collection :
(time zero) are 1 to 2 hours for hs-cTn and 3 to 6 hours for conventional cTn assays
Risk stratification tools ?
GRACE Risk Score (2.0) for ACS
In-hospital, 6-mo, 1-y, 3-y, death or
death/MI
TIMI Risk Score for Unstable
Angina/NSTEMI
14-d all-cause death, MI, or urgent
revascularization
TIMI Risk Score for STEMI
30-d all-cause death
In case of cardiac arrest ?
- Patients with cardiac arrest and STEMI who have been resuscitated should preferentially be transferred by EMS to a PPCI-capable center.
- Patients who have been resuscitated after cardiac arrest and are noncomatose or who are comatose with favorable prognostic features and with
evidence of STEMI, should undergo PPCI to
improve survival - In resuscitated patients who are comatose after cardiac arrest, electrically and hemodynamically stable, and without evidence of STEMI, immediate angiography is not recommended due to lack of benefit
O2 therapy ?
when oxygen saturation <90%
Nitroglycerin SL ?
Use in hemodynamically stable patients with SBP ≥90 mm Hg
Nitroglycerin IV ?
Consider for :
persistent anginal pain after oral nitrate therapy, or if ACS is accompanied by hypertension or pulmonary edema
Avoid use in :
suspected RV infarction, SBP <90 mm Hg or a change in SBP >30 mm Hg below baseline.
Tachyphylaxis may occur after approximately 24 h
Aspirin ?
In patients with ACS, an initial oral loading
dose of aspirin, followed by daily low-dose
aspirin, is recommended to reduce death
and MACE
Prasugrel ?
half dose if body weight <60 kg or age ≥75 y
contra-indicated if history of stroke or transient ischemic attack
In-Hospital Management of Oral P2Y12 Inhibitors in Patients With ACS ?
In patients with ACS undergoing PCI,
prasugrel or ticagrelor is recommended to reduce MACE and stent thrombosis
In patients with NSTE-ACS who are managed without planned invasive evaluation, ticagrelor is recommended to reduce MACE
In patients with STEMI managed with fibrinolytic
therapy, clopidogrel should be administered
concurrently to reduce death and MACE
In patients with NSTE-ACS planned for an invasive strategy with timing of angiography anticipated to be >24 hours, upstream treatment with clopidogrel or ticagrelor may be considered to reduce MACE (IIb)
Management of Oral P2Y12 Inhibitors for Patients Who Require CABG Surgery
Elective CABG :
Clopidogrel : 5 d before surgery
Prasugrel : 7 d before surgery
Ticagrelor : 3-5 d before surgery
Urgent CABG : 24h
what about cangrelor ?
Among patients with ACS undergoing PCI who have not received a P2Y12 inhibitor, intravenous cangrelor may be reasonable to reduce periprocedural ischemic events IIb
Loading dose of Oral P2Y12 Inhibitors ?
Clopidogrel 600 mg
Prasugrel 60 mg
Ticagrelor 180 mg
Glycoprotein IIb/IIIa Inhibitors place ?
In patients with ACS undergoing PCI with large thrombus burden, no-reflow, or slow flow
