acute coronary syndrome 2015 overview
TRANSCRIPT
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Acute Coronary SyndromesMagdy El-Masry.
Prof. of Cardiology.
Tanta University.
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What Do the Guidelines Say ?
Acute Coronary Syndromes Guidelines : Are the US and Europe in Harmony ?
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STEMI
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NSTEmi
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Based on the ECG, two groups of patients should be differentiated:
(1)Patients with acute chest pain and persistent (>20 min) ST-segment elevation (ST-elevation ACS )
(2) Patients with acute chest pain but no persistent ST-segment elevation (Non-ST-elevation ACS) ECG changes may include transient ST-segment elevation,
persistent or transient ST-segment depression, T-wave inversion, flat T waves or pseudo-normalization of T waves or the ECG may be normal.
The leading symptom that initiates the diagnostic and therapeutic cascade in patients with suspected acute coronary syndromes is chest pain.
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Initial assessment of patients with suspected acute coronary syndromes
“Other cardiac” includes, among other, myocarditis, Tako-Tsubo cardiomyopathy, or tachyarrhythmias. “Non-cardiac” refers to thoracic diseases such as pneumonia or pneumothorax. . If the initial evaluation suggests aortic dissection or pulmonary embolism, D-dimers and MDCT angiography are recommended
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Differential diagnoses of acute coronary syndromes in the setting of
acute chest pain
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Differential diagnoses of acute coronary syndromes in the setting
of acute chest pain
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STEMI
Reperfusion goals:
Door-to-balloon inflation(pPCI)goal of 90 minutes
Door-to-needle (fibrinolysis)goal of 30 minutes
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STEMI time delays (Time is Myocardium ) “You may delay, but time will not, and lost time is never found again.”
Patient Delay System Delay
FMC
door-to-balloon time
door-to-needle time
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STEMI diagnosis
Primary PCI capable center
Primary - PCI
Non primary-PCI capable center
PCI possible <120 min? Yes
Primary - PCI
Transfer to PCI center
DIDO time
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STEMI diagnosisNon primary-PCI capable
center
PCI possible <120 min? No
Thrombolytic Therapy
Failed or Reocclusion Successful
Rescue PCICoronary angiography
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NSTEmi
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Initial risk stratification
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Initial risk stratification
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Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification.
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A few words about antiplatelet therapy
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Pathophysiology of ACS: The Role of Platelets
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Rivaroxaban
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Antiplatelet Agents—Oral P2Y12 Inhibitors
++ +++
+ Bleeding Risk
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Ischemic RiskBleeding Risk
Balanced Benefit/Risk Ratio
Tailoring antiplatelet therapy : a step toward individualized therapy to improve clinical outcome?
Thus, the thousand dollar question is : Where is the sweet spot between
ischaemia and bleeding?
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A call for individualised medicine
One Size Does Not Fit All
Precision medicine ( Personalized medicine )
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Factors for physicians to consider in determining the optimal duration of DAPT after DES implantation for individual patients
Eisen, A. & Bhatt, D. L. (2015) Defining the optimal duration of DAPT after PCI with DES Nat. Rev. Cardiol. doi:10.1038/nrcardio.2015.87
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