ACS - acute coronary syndrome

I. V. SAMORODSKAYA,

Professor, Doctor of Medical Sciences

Acute coronary
syndrome

The multidisciplinary team decides

The use of modern methods of treatment in acute coronary syndrome (ACS)
- a term designating any group of clinical signs or symptoms,
Suspected acute myocardial infarction (MI) or unstable
Angina, allows you to hope for a significant reduction in hospital
Mortality and improved prognosis in the long-term.

Several years ago, research results and international trends were
Summarized by the All-Russian Scientific Society of Cardiologists in the Russian Diagnostic Guidelines
And treatment of patients with MI with ST segment elevation (2007), without ST segment elevation and unstable angina pectoris (2006). In 2010, the recommendations of the European
Society of Cardiologists (EOK) in choosing methods of myocardial revascularization, national guidelines for management of patients with ACS in Australia and
The results of the international
Consensus on the management of patients with ACS. In 2013
American Cardiology
Society (ACCF / AHA) has updated
Recommendations for the management of patients with ACS with
Rise of the ST segment.  

Decision on tactics
Patient management in ACS both with elevation so without ST segment elevation is not always unambiguously simple, often requires participation of a multidisciplinary
Team of specialists taking into account clinical recommendations, the course of the disease, the age of patients, conditions
Medical care. At the same time, all patients with suspicion of ACS
It is necessary to perform an ECG (in the absence of
Changes or questionable data, repeated entries with an interval of 15
-30 minutes depending on the clinical condition of the patient), and, if possible,
Cardiospecific enzymes, the use of aspirin is considered mandatory. In
All recommendations are given preference to x-ray endovascular methods
Revascularization of the myocardium in the presence of experienced skilled personnel.
Fibrinolytic therapy (as the first stage of assisting patients with ACS with an elevation of the ST segment) retains its significance for those situations,
When stenting can not be performed
Within 120 minutes from the moment
The emergence of pain syndrome (in the absence of contraindications and if from the moment of the painful syndrome no more than
12 hours). With ACS without ST segment elevation, fibrinolytic
Therapy is not prescribed.

If the risk of developing a heart attack and / or its
High complications

The participants
Creation of professional recommendations in Europe, the United States believes that implementation of
Coronary angiography within 2 hours from the moment of admission to hospital
It is recommended if a patient with an attack of angina pectoris on a background of medication
Treatment persists or recurses symptoms
Stenocardia, there are dynamic changes in the ST segment, indicating the development of damage
Or myocardial infarction; Hemodynamic
Instability, significant ventricular arrhythmias. Performing coronary angiography (with subsequent
Revascularization) within 24 hours from the moment of admission of the patient with ACS in a hospital is recommended in case of high
Risk of myocardial infarction, life-threatening
Complications and death. Similar terms for coronary angiography are recommended in
In cases where differential diagnosis of ACS is required with other
Urgent conditions (pulmonary embolism, exfoliating
Aneurysm of the aorta). In cases of ACS without ST-segment elevation with a low risk of life-threatening
Complications and deaths at the hospital stage
Treatment, but with persistent symptoms of angina and / or ischemia induced by
During a stress test, coronary angiography followed by revascularization
It is advisable to carry out the necessary and possible
Hospitalization within 72 hours of admission to hospital. In
Case, if the patient entered a medical facility, where there is no possibility
Perform coronarography, it is transferred to the appropriate hospital (for example,
Regional vascular center).

Common
Is considered a tactic of stenting (stent with a drug coating
Or without coverage) infarction of the dependent artery with thromboextraction (with
Necessary), with ACS with lifting
ST segment
Regardless of the performance and effect of fibrinolytic therapy (according to
ACC recommendations from 2013 after fibrinolytic therapy are recommended
CGF and stenting no earlier than
2-3 hours). If in ACS with ST segment elevation, in addition to the infarction-dependent artery, there are severe
Stenosis in other arteries, then their urgent stenting is performed only
In the presence of severe heart failure and / or cardiogenic shock. In others
Cases, delayed stenting is performed - the question of necessity and timing
Is resolved after performing stress tests before discharging the patient from
Hospital. According to the recommendations of US specialists from 2013 stents without
Coverage is preferable when the patient has
Diseases and conditions with a high risk of bleeding,
That the patient will not observe during the year a dual antiplatelet regimen
Therapy, and there is a likelihood of a subsequent surgical
Operation. In addition, the recommendations state that with ACS with ST-segment elevation, stenting after 24 hours from the moment of its
Development is not shown in cases of 1-2 vascular lesions in the absence
Signs of the preservation of myocardial ischemia. In the more rare cases (under certain conditions
Situations), angioplasty is performed.

The decision on the method of revascularization in patients with ACS without ST segment elevation, as well as in ACS with ST segment elevation, but in the absence of
Coronary angiography of local narrowing of the coronary bed, uniquely "guilty" in
ACS, or there is a multivessel lesion, in which performance
Stenting is technically impossible or the risk of
Benefit, is accepted by several specialists (cardiovascular surgeon,
Cardiologist, specialist in the field of
X-ray endovascular methods of diagnosis and treatment), taking into account
Clinical, angiographic data, assessment of the fractional reserve of blood flow,
The estimated long-term prognosis.

Medication support
Be sure

With ACS with ST segment elevation Many experts believe that modern tactics of managing patients in
Depends on the capacity of the country's health system
(Region) to perform primary x-ray-endovascular interventions (without previous
Thrombolysis) within 2 hours of the development of the patient's clinical symptoms.

If it is expected that the time from the moment of the patient's first contact with
Medical staff before the time of coronary angiography will be more than 2
Hours, then patients
(In the absence of contraindications) it is necessary to perform thrombolysis with
Subsequent delivery to the clinic for coronary angiography and revascularization
Myocardium for 3-24 hours. In those cases, if against a background of thrombolysis
Elevation of the ST segment is retained for more than 50% of the baseline level and / or
Pain, the patient is shown an emergency coronary angiography. In cases of successful
Thrombolysis, coronary angiography and revascularization (in the presence of indications) may
Be carried out within 24 hours. The recommendations note that
Revascularization of the myocardium can improve the prognosis and when it is performed 24-60
Hours from the onset of clinical symptoms, but only in cases where
There are recurrences of angina and / or myocardial ischemia
Instrumental research.

Outside
Depending on the type of ACS and the method of revascularization is mandatory
Medicamentous support, which includes antiplatelet,
Antiplatelet therapy, beta-blocker therapy, angiotensin-converting inhibitors
Enzyme, statins. Drug therapy is adjusted individually in
Depending on the form of ACS, the severity of the course, the presence of associated pathology. AT
This publication will focus only on antiplatelet therapy,
Accompanying methods of myocardial revascularization.

ACS without lifting segment S T

AT
Similar cases with x-rayendovascular methods of myocardial revascularization
"Double" disaggregant therapy is prescribed, which includes oral
Reception of acetylsalicylic acid (ASA) and clopidogrel (or prasugrel or
Ticagrelor). ACA is administered at the first dose of 150-300 mg (or 250-500 mg in the form of
IV bolus), followed by a dosage of 75-100 mg / day, loading dose
Clopidogrel is 600 mg (as early as possible) followed by admission 75
Mg / day for 9-12 months, prasugrel - a loading dose of 60 mg, followed by
With a dose of 10 mg / day, or ticagrelor - a loading dose of 180 mg, followed by
Taking 90 mg 2 times a day. Indications for additional use
GPIIb-IIIa inhibitors consider a high risk of intracoronary thrombosis in patients undergoing angioplasty and / or stenting
Coronary arteries.

AT
Recommendations of NICE (UK) noted that
Patients with a high risk of cardiovascular events (projected 6-month
Mortality rate above 3%) and undergoing coronary angiography and revascularization in
96 hours from the time of admission to the hospital, a routine
The use of eptifibatide or tirofiban. Abciximab is prescribed as a therapy,
Accompanying X-ray-endovascular revascularization in the event that there is no
The ability to prescribe other GPIIb-IIIa inhibitors. It should be noted that in
Differences from the recommendations of NICE (UK) in the recommendations
European Society of Cardiology "preference" is given to abciximab (class
Indications I), at the same time for eptifibatida
Or tirofiban indicated class IIa.

Choice and dosage
Anticoagulants before angiography
Revascularization in patients with ACS without
The rise of the ST segment is determined on the basis of
Stratification of the risk of thrombotic, ischemic and hemorrhagic complications. At very high risk
Ischemic events (for example, with unstable hemodynamics, refractory life-threatening arrhythmias), the patient
Delivered directly to the X-ray and assigned to him
Unfractionated heparin (UFH) in the form of IV bolus 60 units / kg followed by its
Infusion during the implementation of revascularization in combination with a double
Antiplatelet therapy. With a high risk of bleeding, you can apply
Monotherapy with bivalirudin in the form of a bolus of 0.75 mg / kg followed by an infusion of 1.75
Mg / kg / hour. For patients with an average risk of ischemic events (for example,
Stable hemodynamics, but positive troponin test, recurrent
Angina, dynamic changes in the ST segment), which are planned to be invasively intervened within 24-48
Hours, there are the following treatment options before the start of coronary angiography with
Planned x-rayendovascular myocardial revascularization:

• For patients <75 years old

UFG 60 units / kg in the form of IV bolus,
Then infusion under the control of activated partial thromboplastin time
(APTT) or Enoxaparin 1 mg / kg subcutaneously x 2 per day or Fondaparinux 2.5 mg / day
Subcutaneously or Bivalirudin 0.1 mg / kg as an IV bolus followed by infusion
0.25 mg / kg / hour

• For patients ≥75 years old

UFG 60 units / kg in the form of IV bolus,
Then infusion under the control of APTTV

Or Enoxaparin 0.75 mg / kg x 2 in
Day or Fondaparinux 2.5 mg / day subcutaneously or Bivalirudin 0.1 mg / kg in the form of
IV bolus with subsequent infusion of 0.25 mg / kg / hour.

Have
Patients with a low risk of cardiovascular events (without increasing the level of
Troponin and ST segment changes), more conservative
Treatment and is appointed fondaparinux (2.5 mg / day subcutaneously), or enoxaparin (1
Mg / kg subcutaneously 2 times a day, in patients ≥75 years - 0.75 mg), or UFH (60 U / kg in
Type IV bolus, then infusion under the control of APTT).

STS with ST segment elevation  

In this
Clinical situation is assigned to "double" disaggregant therapy of ASA (150-300 mg orally or
250-500 mg in the form of IV bolus followed by 75-100 mg / day) and prasugrel
(Loading dose of 60 mg followed by 10 mg / day), or ticagrelor (loading dose 180 mg s
Subsequent administration of 90 mg 2 times a day) or clopidogrel (loading dose 600
With the subsequent reception
75 mg / day). The recommendations of the European Society of Cardiology indicate that
Prasugrel and ticagrelor are more effective than clopidogrel in terms of reduction
Frequency of combined ischemic end points and stent thrombosis in patients
IM with ST elevation, and does not increase the risk
Heavy bleeding. According to the recommendations of ACC 2013, prasugrel is not
Recommended for patients with
Presence in the history of ONMK or TIA. In the event that, before entering the
Medical institution for coronary angiography and stenting to the patient
Fibrinolysis was performed and was less than 24 hours and during the same period were not used
Clopidogrel (prasugrel), then the dose of clopidogrel loading is 300 mg,
And prasugrel remains 60 mg.

At high risk
Intracoronary thrombosis simultaneously with dual antiplatelet therapy
It is recommended the administration of GPIIb-IIIa inhibitors (abciximab v / bolus 0.25 mg / kg, followed by infusion of 0.125 mg / kg / min to
The maximum level of 10 mg / min for 12 hours). Currently there is no
Convincing evidence of greater efficacy of GPIIb-IIIa inhibitors when used on
Pre-hospital or before the catheterization.

As
Anticoagulant therapy is used UFH (IV bolus 60 U / kg in combination with GPIIb-IIIa inhibitor or IV bolus 100 U / kg without
Inhibitor GPIIb-IIIa). Bivalirudin as monotherapy in place of UFH in combination with the GPIIb-IIIa inhibitor according to the recommendations of ACC 2013
Is recommended for patients with a high risk of dangerous bleeding (bolus 0.75 mg / kg followed by infusion 1.75
Mg / kg / hour); At the same time, fondaparin is not recommended because of the high risk
Catheter thrombosis.

After an extract from
A double antiplatelet therapy is applied for at least 12 months.

Particular attention should be paid to the combination of
Clopidogrel and proton pump inhibitors, often used for prevention
Gastrointestinal bleeding. According to the consensus of the working group on thrombotic prophylaxis
And hemorrhagic complications ICSI combined use of drugs for patients from
Groups of low risk of bleeding is not indicated, their simultaneous use should be individualized on the basis of
Accounting for use and risk. Only
A drug from the IPP group - pantoprazole - is not a "competitor" to clopidoglue
For the isoenzyme CYP2C19. On the other hand
There are no qualitative clinical trials evaluating the effect of
Application of pantoprazole and clopidogrel
To simultaneously reduce the risk of cardiovascular and hemorrhagic
Complications. As an alternative to PPI, it is possible to use blockers H2 receptors - famotidine, ranitidine.

Routine pharmacological
therapy

Beta-blockers are prescribed in the first 24 hours after the development of ACS to all patients
In the absence of heart failure with a syndrome of low cardiac output,
Cardiogenic shock and standard contraindications to the appointment of this group of drugs.
Reception of beta-blockers continues during the entire period of hospitalization and after
Extracts.
ACE inhibitors are prescribed
All patients with anterior MI, ejection fraction less than 40% in the absence
Contraindications. In the presence of contraindications to inhibitors of ACE use blockers
Receptors of angiotensin II. Antagonists
Aldosterone is indicated in patients with symptomatic heart failure
And / or the presence of diabetes mellitus. Long-term use of statins is shown to all
Patients with ACS (in the absence of contraindications).