ACS

Background¶

Completely or partially occluding thrombus on a disrupted atherothrombotic coronary plaque leading to myocardial ischemia
STEMI: Elevated troponin & elevation in ST segment or new LBBB with symptoms
> 0.1 mV in at least 2 contiguous leads
Exception, in V2-V3:
- > 0.2 mV in men older than 40 y/o
- > 0.25 in men younger than 40 y/o
- > 0.15 mV in women
NSTEMI: Evidence of myocardial necrosis (elevated troponin) w/o ST segment elevation
Unstable Angina: Angina without evidence of myocardial necrosis (normal troponin)
Other causes of myocardial injury:
Typically due to "supply-demand" mismatch of O2 to the heart
Coronary Spasm, Pulmonary Embolism, Tachycardia, Hypo-/hypertension

Definition
Management
P2Y12
- PLATO²: Ticagrelor > Clopidogrel in ACS including mortality
- DAPT³: Continuing Thienopyridine after 12 months decreased risk of In-stent thrombosis and MI at 18 months, increased risk of bleeding
- WOEST⁴: Bleeding w/AC + Plavix < Triple Therapy w/o change in MI/Stroke/MACE
- COGENT⁵: PPI with DAPT reduces GIB 87%, no CV event change
Statins
- PROVE-IT⁶: Significantly reduced CVD events following MI with High-dose Lipitor vs. Pravastatin
ACEI
- SAVE⁷: ACEI improve survival/morbidity/mortality in LV dysfunction after MI
MADIT-II⁸: ICD improves survival in pts with prior MI and severe LV dysfunction