acute%20coronary%20syndromes%20w_out%20persistent%20st-segment%20elevation
ACUTE CORONARY SYNDROMES W/OUT PERSISTENT ST-SEGMENT ELEVATION
Acute coronary syndromes refer to any constellation of clinical symptoms compatible with acute myocardial ischemia which may be life-threatening.
It encompasses unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).
Unstable angina is the ischemic discomfort that presents without persistent ST-segment elevation on ECG and without the presence of cardiac markers in the blood.
Non-ST-segment elevation myocardial infarction is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs.
The patient typically presents with ischemic-type chest pain that is severe and prolonged and may occur at rest or may be caused by less exertion than previous episodes.

Surgical Intervention

  •  The timing of invasive strategy can be classified into the following:
    • Immediate invasive strategy (<2 hours) in patients with at least one of the following: Acute heart failure with refractory angina or ST deviation, hemodynamic instability, life-threatening arrhythmias, MI mechanical complications, ongoing or recurrent chest pain unresponsive to medical therapy, recurrent dynamic ST- or T-wave changes
    • Early invasive strategy (<24 hours) in patients with at least one of the following: Changes in cardiac troponin level compatible with MI, dynamic ST- or T-wave changes, GRACE score of >140
    • Invasive strategy (<72 hours) in patients with at least one of the following: DM, early post-infarction angina, eGFR <60 mL/min/1.73 m2, LVEF <40%, previous CABG, recent PCI, GRACE score <140 and >109 

Coronary Angiography

  • Recommended in patients with intermediate- to high-risk features not responsive to intensive medical therapy
    • Angiography is contraindicated when risks of revascularization do not outweigh the benefits (eg liver/ pulmonary/renal failure, cancer) and in patients (especially women) with acute chest pain and a low risk of acute coronary syndrome who have negative troponin
  • Recommended to be done immediately in patients with refractory or recurrent angina associated with dynamic ST-deviation, heart failure, life-threatening arrhythmias or hemodynamic instability despite intensive medical therapy
  • A radial approach is recommended for both coronary angiography and percutaneous coronary intervention

Revascularization

  • Relieve angina or ongoing myocardial infarction and prevent progression of myocardial infarction to death
  • Percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG): Choice of revascularization procedure will depend on extent and severity of lesion based on coronary angiography, condition of patient, and coexisting illness, particularly in patients with multivessel coronary artery disease
  • Appropriate use criteria for revascularization recommended by the American College of Cardiology (ACC), American Association for Thoracic Surgery (AATS), American Heart Association (AHA), American Society of Echocardiography (ASE), American Society of Nuclear Cardiology (ASNC), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), and the Society of Thoracic Surgeons (STS):
    • Patients with evidence of cardiogenic shock with ≥1 coronary arteries for immediate revascularization
    • Stable patients at immediate-/high-risk for clinical event and with ≥1 coronary arteries for revascularization
    • May be considered in stable patients with low risk for clinical events and with ≥1 coronary arteries for revascularization
  • Percutaneous coronary intervention (PCI) is found to be beneficial in patients with 1- to 2-vessel CAD, with or without significant proximal left anterior descending CAD, but with a large area of viable myocardium and high-risk criteria on non-invasive testing
  • Coronary artery bypass grafting (CABG) is recommended in patients with disease of the left main coronary artery, involvement of multiple vessels, and other high-risk patients such as those with ventricular dysfunction or diabetes
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