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اكيد مافي احد ما سمع عن تصلب الشرايين؟ ?
او سمعت عن شخص جاه انسداد في شريان ودايما تساؤلات عن اكثر شي بنسمعه ايش هيا الدعامه ؟
علامات استفهام كبيره عن انقذوه بحبة تحت اللسان ⁉️
تعالو معانا نفهم عن كل مايخص
acute coronary syndrome ???‍⚕??‍⚕

-ماهو تعريف ال acute coronary syndrome ؟?
-ماهي اشهر المسببات وكيف يتكون المرض causes and Pathophysiology؟
-ماهي مضاعفات المرض (complications)؟
-طريقة تشخيص المرض والتقييم المبدئي للمرض(assessment and evaluation)✅

-كيف نتعامل مع المريض والتحكم بالمرض وايش اول شي يقدم له فالرعاية الصحية؟
-ماهي طريقة العلاج ?؟
-كيف تعالج المرأة الحامل ??؟

acute coronary syndromeماهو تعريف-
Acute coronary syndrome (ACS) includes all syndromes compatible with acute myocardial ischemia resulting from imbalance between myocardial oxygen demand and supply.
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عبارة عن مجموعة من الأعراض التي تنتج عن ضيق الشريان التاجي المسؤول عن تروية عضلة القلب بالغذاء والأكسجين وتنقسم الى نوعين اعتمادًا على قراءة جهاز ECG.
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-ما اشهر المسببات وكيف يتكون المرض causes - Pathophysiology؟
?endothelial dysfunction
طبقة الخلايا التي تكون السطح الداخلي للأعويه الدمويه .
?inflammation
?formation of fatty streak
ارتفاع نسبة الكولسترول بالدم
All these factors contribute to development of atherosclerosis

-complication of MI :?

-clinical presentation /deferential diagnosis:?

-(assessment and evaluation)????‍⚕
1- symptoms of ischemia
2- A 12-lead ECG should be performed and interpreted within 10 minutes of presentation.
3- Serial cardiac biomarkers
4-creatine kinase and cardiac troponins T and I

??? According to ECG reading :
a. new significant ST-segment–T-wave changes or new left bundle- branch block
b. Persistent ST-segment elevation should be treated according to the STEMI guidelines.

-??‍?Cardiac markers are proteins that leak out of injured myocardial cells into the bloodstream.
?the markers most widely used in detection of MI are (creatine kinase and cardiac troponins ) T and I as they are more specific for myocardial injury.

The cardiac troponins T and I are The most sensitive and specific test
for myocardial damage which are released within 3–6 hours of an attack of MI and remain elevated for up to 2 weeks .
??troponin I levels in heart attack is above 0.40 ng/ml
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?? تستخدم للتشخيص لحالات MI لتواجدها بالدم في خلال ساعات قليلة وتستمر ل ١٤ يوم حتى في تحسن الحاله

The CK-MB isoform of creatine kinase is expressed in heart muscle ; Since it has a short duration, it cannot be used for late diagnosis of acute MI but can be used to suggest infarct extension if levels rise again.
?This is usually back to normal within 2–3 days.??

??‍?? لسبب سرعة اختفائها من الدم فهي تستخدم لمتابعة MI اذا زادت عند المريض لان سبب وجودها مرتفع بعد ٣ ايام يدل على ان المريض مازال لديه MI ولم يتم معالجته بالصوره المطلوبه

- TIMI score Is useful in predicting mortality in NSTE-ACS
-GRACE risk model to predict mortality and MI(patient with high GRACE risk model can be identified for early invasive strategies)

?Lactate dehydrogenase (LDH) : is not as specific as troponin.
LDH-1 isozyme is normally found in the heart muscle . A high LDH-1 level suggest MI.

-Initial Anti-ischemia and Analgesic therapy in the management of ACS:
-تذكر دائماً هذا الأختصار وهو اسم MONA عند بدء بعلاج ACS?-

?early management for STEMI:

?? من بداية ظهور الأعراض يعطى المريض في سيارة الاسعاف MONA , ثم يحدد الدكتور الموجود اذا كان بإمكان المريض الوصول لغرفة العمليات لعمل primary PCI في خلال ٩٠ دقيقه من ظهور الاعراض .

?بعد ذلك يلزم على المريض اخذ نوعين من anti-platelet يكون واحد من هذه النوعين هو aspirin اذا لم يكن لدى المريض اي مانع للإستخدام وحيستمر عليهم لمدة ١٢ شهر
+ بالاضافة الى نوع واحد من anti-coagulant .

?اذا لمن يتمكن المريض من التواجد في غرفة العمليات خلال ١٢٠ دقيقه من ظهور الاعراض ، فعليه ان يأخذ من كلاس مذيبات الجلطه اذا لم يكن لديه اي موانع من استخدامها ( يشترط عليه خلال ٢٤ ساعه ان يقوم بعمل PCI ) .
- بعد ذلك عليه اخذ aspirin مع clopidogrel بالاضافه الى anticoagulant.

?The goal of therapy in STEMI is minimize the infarct size by restore infarct related artery , prevention of complications and control the symptoms.

fibrinolytic agent ?:
is indicated in patients with STEMI who present within 12 hours of the onset of
chest discomfort to a hospital not capable of primary PCI within 120 minutes of medical contact and have no absolute contraindications to fibrinolytic therapy .

A fibrin-specific agent (alteplase, reteplase, or tenecteplase) is preferred over the non–fibrin specific agent streptokinase.
?Intracranial hemorrhage (ICH) and major bleeding are the most serious side effects of fibrinolytics.

?contraindications to fibrinolytic Therapy:

?early management for NSTE-ACS:

?The goal of therapy in NSTE-ACS is to prevent total occlusion of the related artery and to control chest pain and associated symptoms.

?عند تشخيص المريض ب NSTE-ACS فإنه يتم علاجه اعتمادًا على حساب TIMI , GRACE (score) وينقسم العلاج على حسب الاسكور الى العلاج الدوائي فقط او العلاج بوضع PCI or CABG .

Pharmacotherapy for these medications with details :
الادويه التي يتم استخدامها في المستشفى بالتفصيل بعد حالة Acs نتعرف عليها ??‍⚕
Aspirin
- An irreversible cyclooxygenase-1 inhibitor blocking the formation of thromboxane A2– and thromboxane A2_ mediated platelet activation⬇️

- Established first-line therapy in ACS; reduces the incidence of recurrent MI and death
- Aspirin is given indefinitely
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ii. P2Y12 inhibitors
(a) Inhibit the effect of adenosine diphosphate on the platelet, a key mediator resulting in amplification of platelet activation
(b) P2Y12 inhibitor therapy is given to all patients
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(1) should not be administered to patients with a history of stroke or transient ischemic attack
(2) The efficacy or ticagrelor is decreased in patients treated with higher doses of aspirin (greater than 300 mg daily) compared with lower doses (less than 100 mg daily)
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ii. GP IIb/IIIa inhibitors:?
Benefit from adding GP IIb/IIIa inhibitors to aspirin therapy is greatest among those with highest-risk features (elevated biomarkers, diabetes, undergoing revascularization)⬇️يتبع

and in those not receiving adequate pretreatment with clopidogrel or ticagrelor .
-?It is reasonable (class IIa, 2014 NSTE-ACS guideline) to give GP IIb/IIIa inhibitors to high
risk patients with NSTE-ACS treated with UFH and adequately pretreated with clopidogrel or ticagrelor.

⛔⛔Anticoagulant recommendations
An anticoagulant should be administered to all patients with ACS in addition to antiplatelet therapy to reduce the risk of intracoronary and catheter thrombus formation ⛔⛔
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i. UFH:(a) Exerts its effects as an indirect thrombin inhibitor on fibrin-bound clots
(b) Given as intravenous bolus with or without infusion and adjusted according to (aPTT) or (ACT) to
maintain therapeutic anticoagulation
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⛔usually continued for 48 hours or until PCI is performed⛔
(c) Risks include bleeding, thrombocytopenia, and HIT with or without thrombosis.

(d) Monitoring includes aPTT or ACT, Hgb/Hct, and platelets.
(e) Unlike other anticoagulants, UFH is not renally cleared and can be used safely in those with renal impairment..
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ii. Enoxaparin
(a) Low Molecular weight Heparin with balanced anti-factor Xa (anti-Xa) and anti-IIa activity. b) Given as subcutaneous injection
(c) Does not require routine anti-Xa monitoring; SCr to calculate CrCl for dosing; monitor Hgb, Hct, platelets
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(d) Risks include bleeding, injection site hematomas, spinal or epidural hematomas, retroper- itoneal hematoma/bleeding, thrombocytopenia including HIT with or without thrombosis, mechanical prosthetic valve thrombosis (in pregnancy)
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iii. Fondaparinux
(a) Selective inhibitor of activated factor X
(b) Longest half-life of anticoagulants (17 hours)
(c) Given as subcutaneous injection
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?Does not require routine anti-Xa monitoring; requires SCr to calculate CrCl to assess for contraindication; monitor Hgb, Hct, platelets
(e) Risks include bleeding, thrombocytopenia, and spinal or epidural hematomas.
(f) No increased risk of H
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iv. Bivalirudin
(a) A direct thrombin inhibitor; directly inhibits thrombin in both circulating and bound clots and inhibits thrombin-mediated platelet aggregation
(b) Given as an intravenous bolus with or without infusion fixed rate and usually continued until the end of PCI ⬇️

with or without delay after infusion in some high-risk patients⛔
(d) Can be given in patient with history of or suspected HIT undergoing PCI

بعد علاج الحاله وخروجه من المستشفى لابد من التوصيات باستمراره الادويه
??
?General point: For all ACS patients, treat and control modifiable risk factors such as:
o hypertension, dyslipidemia, obesity, smoking, and diabetes mellitus (DM).

?all patient should receive indefinite treatment with the following medications (in
the absence of contraindications?

Pharmacotherapy ?✅:
ACEI: stroke, or recurrent
- benefit: reduce mortality, decrease reinfarction, and prevent heart failure. (HOPE study and LANCET study)
- they are considered for all patient with IHD particularly those with (HTN, DM, CKD, and LVSD with EF less than 40)

- they are given orally.
- if patient cannot tolerate ACEI due to dry cough, consider switching to
ARBs
- contraindications ⛔️include,
- SBP less than 100
- Bilateral renal artery stenosis  AKI
- Pregnancy??

dose aspirin?
- The recommended dose is 75mg
- In case of aspirin allergy, consider using clopidogrel 75mg daily.
In case of history of GI bleeding:
- You can give clopidogrel (more cost)
- You can give PPI + aspirin (proven to be as effective as
clopidogrel and less costly)

Contraindication⛔️:
active bleeding (both aspirin and clopidogrel are CI)
High intensity statin:
- Recommended regardless of the lipid level due to their pleotropic effect.
- Moderate intensity statin is recommended for patient ≥75 years old or in case patient is not tolerating

high intensity statin:
- High intensity statin?
are Rosuvastatin (Crestor), 20 to 40 mg and Atorvastatin (Lipitor), 40 to 80 mg

Beta Blocker?:
-Benefit: decrease mortality, the re infraction, and the arrhythmias.
-BB associated with mortality reduction in clinical trial include:
carvedilol, metoprolol succinate, propranolol, and bisoprolol.
-Given at least for 3 years or indefinitely
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-If the patient has HF it must be given indefinitely
-Contraindications include:
-A-V block (2nd or 3rd degree)
-Heart rate less than 60
-SBP less than 90
-Acute HF
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-Severe reactive airway disease
-Severe depression
- Avoid BB with intra sympathomimetic activity (ISA) ,such as,
acebutolol and pindolol .

Calcium channel blocker (DHP)?:
-They are only considered in the following situation
-They replace BB in case of severe reactive airway disease
-Secondary prevention when the patient in already on ACEI and
BB and still the BP is not controlled.
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-Ongoing ischemia and the patient is taking BB and nitrate
-DHP CCB: amlodipine or felodipine
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Aldosterone antagonist?:
- Given for patient who are already on ACEI and BB + LVEF ≤40% + (Patient has either DM or HF)
- In the above case they should be given within the first 7 days and are used indefinitely.
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They include:
eplerenone or spironolactone
- Contraindications include
- Spironolactone: eCrCL less than 50
- Eplerenone: eCrCL less than 30
- Serum K more than 5
- Hypotension
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طبعا بعد ماستقرت حالة المريض وتم صرف الادويه المناسبه له لابد من متابعة حالة المريض بنتعرف سوا كيف تتم المتابعه??‍⚕?
-✅ follow up for patient:
1⃣ Relife of ischemic discomfort.
2⃣ Return ECG changes to baseline.
3⃣ Absence or resolution of HF sign & symptomes.

4⃣ Monitring parameters of adverse effects are dependent on the indiviual drugs used.
“In general the most common adverse effects from ACS include hypotension & bleeding

وبعدها راح نتكلم عن المراه الحامل وهنا بتكون : وراح ننتبه على بعض الادويه سواء كان يصح باستخدامه او تسبب ضرر او ننصح بتعامل مع الادويه بكل دقه??
Low dose aspirin
P2Y12 receptor blocker -clopidogrel, prasugrel or ticagrelor. The safety of these medications has not been established

- The combination of a P2Y12 receptor blocker and aspirin might increase bleeding at the time of delivery.
- For patients receiving clopidogrel it is
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?recommended to hold clopidogrel for seven days before a scheduled delivery.
Fibrinolytic therapy: relatively contraindicated o Anticoagulation: heparin can be used ✅
-heparin should be discontinued before or during labor to minimize maternal bleeding complications.
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Nitrates: Intravenous, transdermal, and oral nitrates can be used in pregnancy ✅
Statin: contraindicated in pregnancy o Beta blocker: generally safe ✅
The preferred agent in pregnancy is labetalol o ACEI: contraindicated in pregnancy

وبكذا نكون خلصنا acute coronary syndrome?? وبالنهاية من لايشكر الناس لا يشكر الله شكر خاص لكتابة المحتوى بقيادة:
د.مروج
@morooj_3
وأعضائها :
أروى فلاته
@chocolatah1997
مي محمد الأدريسي
@mayidrissi

فريق دار تجهيز الثريد :
نوره
@aishamylife_0
رحاب العمري
@Ra7ob19
وبإشراف على الثريد :
د.رنا كلاّب @rana_alshlagy

وشكر خاص لفريق التصميم بقيادة: ???:
فيصل القزلان @Sniicckers
واعضائه :
نوره الشمراني @nourra16__
غنى الفوزان @gnweshah

بكذا انتهينا من
“acute coronary syndrome “
و تعرفنا عليه بشكل مختصر وجميل? ?، نتمنى انكم استفدتوا✨
ونلقاكم بثريد الاثنين القادم 2 ديسمبر
وراح يكون موضوعنا عن:
Arrhythmia ?
?سبحانك اللهم وبحمدك أشهد أن لا إله إلا أنت أستغفرك وأتوب أليك?

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