Acute Coronary Syndromes


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by Seema Nour in the Faculty of Medicine, University of Khartoum as part of SAMA's Visiting Faculty Program on April 4th 2011.

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  • changes greater than 0.5 mm Bundle-branch block, new T-wave changes Pathological Q waves or resting ST-depression less than 1 mm in multiple lead groups Normal or unchanged ECG
  • Score of more than 3 is high risk
  • Initial troponin is negative
  • Intravenous NTG may be initiated at a rate of 10 mcg per min and increased by 10 mcg per min every 3 to 5 min until relief of symptoms or blood pressure response is noted. A ceiling dose of 200 mcg per min is commonly used. Systolic blood pressure generally should not be reduced to less than 110 mm Hg in previously normotensive patients or to more than 25% below the starting mean arterial blood pressure if hypertension was present
  • Why have we moved towards considering these two strategies. Early study Vanquish showed harm with an early invasive strategy, Then came other trials which showed benefit. So in 2002 guidelines, all NST ACS patients should be treated with an invasive approach. Then came Most recently came ICTUS which showed no difference, so guidelines in 2007 were changed to say consider either strategy based on the risk of the patient. NOTE THAT ALL THE TRIALS THAT HAVE FAVORED AN INVASIVE APPROACH SHOW AN IMPROVEMENT IN REDUCTION IN ISCHEMIA. REDUCTION IN DEATH IS INCONSISTENT IN BETWEEN THE TRIALS, however some meta analaysis show some improvement in mortality
  • If patient has these low risk features they can be managed medically
  • If elected from start to take the early invasive approach
  • More bleeding in prasugrel arm but overall benefit outweigh the risk
  • Acute Coronary Syndromes

    1. 1. Seema Nour MBBCh Interventional Cardiologist Peninsula Regional Hospital
    2. 2. <ul><li>Definition </li></ul><ul><li>Incidence </li></ul><ul><li>NSTE-ACS </li></ul><ul><li>ST-ACS </li></ul><ul><li>Management </li></ul><ul><li>Conclusion </li></ul>
    3. 3. <ul><li>Refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia </li></ul><ul><li>Unstable Angina </li></ul><ul><li>Acute Non ST Elevation MI (NSTEMI) </li></ul><ul><li>Acute ST Elevation MI </li></ul>
    4. 4. <ul><li>UA </li></ul><ul><li>STEMI </li></ul>NSTEMI <ul><ul><li>Non occlusive </li></ul></ul><ul><ul><li>thrombus </li></ul></ul><ul><ul><li>Non specific </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Normal cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>Non-occlusive thrombus </li></ul></ul><ul><ul><li>sufficient to cause </li></ul></ul><ul><ul><li>tissue damage & mild </li></ul></ul><ul><ul><li>myocardial necrosis </li></ul></ul><ul><ul><li>ST depression +/- </li></ul></ul><ul><ul><li>T wave inversion on </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Elevated cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>Complete thrombus </li></ul></ul><ul><ul><li>occlusion </li></ul></ul><ul><ul><li>ST elevations on </li></ul></ul><ul><ul><li>ECG or new LBBB </li></ul></ul><ul><ul><li>Elevated cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>More severe </li></ul></ul><ul><ul><li>symptoms </li></ul></ul>
    5. 5. <ul><li>Despite improvements in primary prevention ACS admissions continue to rise </li></ul><ul><li>Estimated 1.6 million admissions for ACS annually </li></ul><ul><li>70% of these cases are due to NST-ACS </li></ul><ul><li>Estimated that 1 person dies of a heart attack every minute </li></ul>
    6. 7. <ul><li>Occurs due to reduced myocardial perfusion secondary to coronary artery narrowing caused by a thrombus </li></ul><ul><li>Thrombus is usually nonocclusive and develops on a disrupted atherosclerotic plaque </li></ul><ul><li>Other less common causes is dynamic obstruction due to intense focal epicardial coronary artery spasm or coronary dissection </li></ul>
    7. 8. <ul><li>A 67 yr old obese woman with diabetes presents with chest pain at rest </li></ul><ul><li>Pain resolved on admission with ASA/NTG </li></ul><ul><li>Patient had a pacemaker placed for sick sinus syndrome </li></ul><ul><li>Medications: metformin </li></ul><ul><li>Exam showed a carotid bruit </li></ul><ul><li>Cardiac markers negative </li></ul>
    8. 10. <ul><li>In ER patients presenting with chest pain/SOB should be triaged urgently </li></ul><ul><li>System were an ECG is obtained within 10mins </li></ul><ul><li>Cardiac biomarkers obtained </li></ul><ul><li>Troponin is the preferred one </li></ul><ul><li>If normal repeat between 8-12hrs </li></ul>
    9. 11. <ul><li>Trauma (including contusion; ablation; pacing; ICD firings, endomyocardial biopsy, cardiac surgery, after-interventional closure of ASDs) </li></ul><ul><li>Congestive heart failure (acute and chronic) </li></ul><ul><li>Aortic valve disease and HOCM with significant LVH </li></ul><ul><li>Hypertension </li></ul><ul><li>Hypotension, often with arrhythmias </li></ul><ul><li>Noncardiac surgery </li></ul><ul><li>Renal failure </li></ul><ul><li>Critically ill patients, especially with diabetes, respiratory failure </li></ul><ul><li>Drug toxicity (eg, adriamycin, 5 FU, herceptin, snake venoms) </li></ul><ul><li>Hypothyroidism </li></ul><ul><li>Coronary vasospasm, including apical ballooning syndrome </li></ul><ul><li>Inflammatory diseases (eg, myocarditis, Kawasaki disease, smallpox vaccination, </li></ul><ul><li>Post-PCI </li></ul><ul><li>Pulmonary embolism, severe pulmonary hypertension </li></ul><ul><li>Sepsis </li></ul><ul><li>Burns, especially if TBSA greater than 30% </li></ul><ul><li>Infiltrative diseases: amyloidosis, hemachromatosis, sarcoidosis, and scleroderma </li></ul><ul><li>Acute neurologic disease, including CVA, subarachnoid bleeds </li></ul><ul><li>Rhabdomyolysis with cardiac injury </li></ul><ul><li>Transplant vasculopathy </li></ul>Modified from Apple FS, et al Heart J. 2002;144:981-986.
    10. 12. <ul><li>How would you risk stratify her? </li></ul>
    11. 13. High Risk Intermediate Risk Low Risk History Known CAD Prior MI Patient presenting with typical symptoms Chest/left arm pain Age >70yrs Diabetes Male Recent cocaine use Physical Exam Pulmonary Edema Hypotension, MR Arrythmias Manifestation of extra-cardiac vascular disease Pain reproducible on exam ECG New transient ST segment depression >1mm T wave inversions in multiple leads New T-wave changes Pathological Q waves St depression 0.5-1mm Normal or unchanged Cardiac Markers Elevated cardiac enzymes Slightly elevated Normal
    12. 14. <ul><li>Age >65yrs </li></ul><ul><li>>3 or more cardiac risk factors </li></ul><ul><li>Known CAD stenosis (over 50%) </li></ul><ul><li>Aspirin use in the last week </li></ul><ul><li>Recent (<24hrs) of severe angina </li></ul><ul><li>Elevated cardiac markers </li></ul><ul><li>ST deviation >0.5mm </li></ul>
    13. 17. <ul><li>A 67 yr old obese woman with diabetes presents with chest pain at rest </li></ul><ul><li>Pain resolved on admission with ASA/NTG </li></ul><ul><li>Patient had a pacemaker placed for sick sinus syndrome </li></ul><ul><li>Medications: metformin </li></ul><ul><li>Exam showed a carotid bruit </li></ul><ul><li>Cardiac markers negative </li></ul>
    14. 18. <ul><li>Admit </li></ul><ul><li>Send home with close follow up </li></ul><ul><li>Reassure the patient and discharge with follow up in 4 weeks </li></ul>
    15. 19. <ul><li>Bedrest and telemetry </li></ul><ul><li>Oxygen therapy </li></ul><ul><li>Nitrates- SL/Oral/Topical, use IV in those with refractory angina </li></ul><ul><li>Beta Blockers in first 24 hrs-ORAL!! </li></ul><ul><li>ACEI-in first 24hrs in those with heart failure or EF <40% </li></ul><ul><li>ARB in those with ACEI intolerance </li></ul><ul><li>Statin regardless of LDL level </li></ul>
    16. 20. <ul><ul><li>Nitrates if BP<90 mmHg or RV infarction </li></ul></ul><ul><ul><li>Nitrates within 24-hrs of Sildenafil or 48 hrs of Tadalafil </li></ul></ul><ul><ul><li>Immediate release dihydropyradine Ca-blockers in the absence of B-Blocker therapy </li></ul></ul><ul><ul><li>IV ACE-inhibitors </li></ul></ul><ul><ul><li>IV B -blockers in patients with acute HF, Low output state or cardiogenic shock, PR interval >0.24 sec, 2 nd or 3 rd degree heart block, active asthma, or reactive airway disease </li></ul></ul><ul><ul><li>NSAIDS and Cox-2 inhibitors </li></ul></ul>
    17. 23. TIMI IIIB (94) Conservative Strategy Favored N=920 Invasive Strategy Favored N=7,018 VANQWISH (98) MATE FRISC II (99) TACTICS- TIMI 18 (01) VINO RITA-3 (02) TRUCS ISAR- COOL ICTUS (05) No difference N=2,874 Weight of the evidence
    18. 24. <ul><li>Low risk score (e.g., TIMI, GRACE) </li></ul><ul><li>Patient or physician preference in the absence of high-risk features </li></ul>
    19. 25. <ul><li>Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy </li></ul><ul><li>Elevated cardiac biomarkers </li></ul><ul><li>New or presumably new ST-segment depression </li></ul><ul><li>Signs or symptoms of HF or new or worsening mitral regurgitation </li></ul><ul><li>High-risk findings from noninvasive testing </li></ul><ul><li>Hemodynamic instability </li></ul><ul><li>Sustained ventricular tachycardia </li></ul><ul><li>PCI within 6 months or prior CABG </li></ul><ul><li>High risk score (e.g., TIMI, GRACE) </li></ul><ul><li>Reduced left ventricular function (LVEF less than 40%) </li></ul>
    20. 27. <ul><li>Hemodynamic instability </li></ul><ul><li>Elecrical instability </li></ul><ul><li>Refractory angina </li></ul><ul><li>PCI in past 6 months </li></ul><ul><li>CABG </li></ul><ul><li>EF <40% </li></ul>Definitive/Possible ACS Initiate ASA, BB, Nitrates, Anticoagulants, Telemetry <ul><li>Early Invasive Strategy </li></ul><ul><li>TIMI Risk Score > 3 </li></ul><ul><li>New ST segment </li></ul><ul><li>deviation </li></ul><ul><li>Positive biomarkers </li></ul><ul><li>Conservative Strategy </li></ul><ul><li>TIMI Risk Score <3 (Esp. Women) </li></ul><ul><li>No ST segment deviation </li></ul><ul><li>Negative Biomarkers </li></ul>Coronary angiography (24-48 hours) Recurrent Signs/Symptoms Heart failure Arrhythmias Remains Stable ↓ Assess EF and/or Stress Testing ↓ EF<40% OR Positive stress Go to Angiography
    21. 29. <ul><li>Women </li></ul><ul><li>Intermediate Risk </li></ul><ul><li>Normal enzymes </li></ul><ul><li>EKG not diagnostic as it is paced </li></ul><ul><li>Can go either way-Invasive therapy </li></ul>
    22. 30. <ul><li>Aspirin (162-325mg), non enteric coated </li></ul><ul><li>Clopidogrel for those with aspirin intolerance </li></ul><ul><li>Enoxaparin/UFH until serial enzymes negative </li></ul><ul><li>No GBIIb/IIIa inhibitor as no high risk features </li></ul><ul><li>We proceeded with stress testing </li></ul>
    23. 31. <ul><li>Exercise treadmill test (ETT) </li></ul><ul><li>ETT with nuclear imaging </li></ul><ul><li>Adenosine nuclear stress test </li></ul><ul><li>Stress Echo </li></ul>
    24. 33. <ul><li>Low risk features (<1%/yr mortality) </li></ul><ul><li>Ejection Fraction >40% </li></ul><ul><li>Low risk treadmill score >5 (Duke score) </li></ul><ul><li>Normal or small perfusion defect </li></ul>
    25. 34. <ul><li>The stress test was negative for ischemia but showed an EF of 35% </li></ul><ul><li>Now what would you do? </li></ul>
    26. 38. <ul><li>Cardiac cath showed 80% mid RCA lesion which was stented with a drug eluting stent </li></ul>
    27. 39. <ul><li>What medications would you send this </li></ul><ul><li>patient home on? </li></ul>
    28. 40. <ul><li>Aspirin </li></ul><ul><li>Clopidogrel </li></ul><ul><li>Beta-blockers: (all pts, slow titration with moderate to severe failure </li></ul><ul><li>ACE-Inhibitors: CHF, EF<40%, HTN, DM </li></ul><ul><li>(All pts-Class IIa) ARB when intolerant to ACE. (Class IIa as alternative to ACEI) </li></ul><ul><li>Aldosterone blockade: An ACEI, CHF with either EF<40% or DM and if CrCl>30 ml/min and K < 5.0 mEq/L </li></ul><ul><li>Statins </li></ul>
    29. 42. <ul><li>BP goal<130/80mmHg </li></ul><ul><li>Lipid profile-LDL goal<70mg/dl </li></ul><ul><li>Weight loss </li></ul><ul><li>Exercise </li></ul><ul><li>Revaluate EF with an echo after maximizing medical therapy </li></ul>
    30. 44. <ul><li>Aspirin-old drug but very effective </li></ul><ul><li>1 month f/u 20% reduction in deaths </li></ul>BMJ 2002
    31. 45. NEJM 2001
    32. 46. <ul><li>Conducted in centers without routine use of early invasive strategy </li></ul><ul><li>Less than 50% had a cardiac cath during the index hospitalization </li></ul><ul><li>Increased level in major bleeding in those undergoing CABG in <5 days </li></ul>
    33. 47. NEJM 2007
    34. 49. <ul><li>Contraindicated in patients with a prior TIA/stroke </li></ul><ul><li>Not recommended in patients over 75 yrs of age </li></ul><ul><li>Not to be used in those <40kg </li></ul><ul><li>Has not been tested in patients with kidney disease </li></ul>
    35. 50. <ul><li>Multiple trials showing benefit </li></ul><ul><li>Most benefit in those undergoing PCI </li></ul><ul><li>Also mortality benefit in diabetics </li></ul><ul><li>Must tailor use to patient, as increased risk of bleeding if on aspirin, plavix, and anticoagulant </li></ul>
    36. 51. <ul><li>Class I </li></ul><ul><ul><li>Unfractionated Heparin </li></ul></ul><ul><ul><li>Enoxaparin </li></ul></ul><ul><ul><li>Bivalarudin </li></ul></ul><ul><ul><li>Fondaparinux </li></ul></ul><ul><ul><li>Relative choice depends on invasive vs conservative strategy and bleeding risk </li></ul></ul>
    37. 55. <ul><li>In patients recently hospitalized within 10 days for an acute coronary syndrome: </li></ul><ul><ul><li>“ Intensive” high-dose LDL-C lowering (median LDL-C 62 mg/dL) compared to “moderate” standard-dose lipid-lowering therapy (median LDL-C 95 mg/dL) reduced the risk of all cause mortality or major cardiac events by 16% (p=0.005) </li></ul></ul><ul><ul><li>Benefits emerged within 30 days post ACS with continued benefit observed throughout the 2.5 years of follow-up </li></ul></ul><ul><ul><li>Benefits were consistent across all cardiovascular endpoints, except stroke, and most clinical subgroups </li></ul></ul>
    38. 58. <ul><li>Only 70% of eligible patients for reperfusion therapy receive therapy </li></ul><ul><li>Regardless of PCI or lytics </li></ul><ul><li>Door to needle times >30minutes </li></ul><ul><li>Door to balloon times >115mins </li></ul><ul><li>Average delay to ED is 120mins </li></ul>
    39. 59. Most benefit in the first 3 hours whether with lysis or PCI, and after 3 hrs with PCI
    40. 61. <ul><li>Class 1 recommendations </li></ul><ul><li>ST elevation >0.1 in 2 or more contiguous leads </li></ul><ul><li>Less than 12 hrs of onset symptoms </li></ul><ul><li>NO need to have persistent symptoms </li></ul>
    41. 63. <ul><li>Class 3 recommendations </li></ul><ul><li>ST elevation for over 24hrs, pain resolved </li></ul><ul><li>ST depression only </li></ul><ul><li>Contraindication to lytic therapy </li></ul>
    42. 65. Careful assessment of risk benefit
    43. 66. <ul><li>Diabetic retinopathy </li></ul><ul><li>Menses </li></ul><ul><li>NOT CONTRAINDICATIONS </li></ul>
    44. 67. <ul><li>Elderly </li></ul><ul><li><70kg </li></ul><ul><li>Uncontrolled hypertension </li></ul><ul><li>TNK with LMWH >75yr old </li></ul><ul><li>Lowest risk with streptokinase </li></ul>
    45. 68. <ul><li>Still use CLOPIDOGREL </li></ul><ul><li>Evidence-Commit and Clarity trials </li></ul><ul><li>Improved patency </li></ul><ul><li>Decreased reinfarction </li></ul><ul><li>Improved survival </li></ul><ul><li>No excess bleeding </li></ul><ul><li>Careful in patients >75yrs </li></ul><ul><li>(Commit did not enroll patients over 75 and clarity did not have a loading dose) </li></ul>
    46. 70. <ul><li>Pulmonary embolus </li></ul><ul><li>Aortic dissection </li></ul>
    47. 73. <ul><li>Thank you </li></ul>
    48. 74. <ul><li>An 80 yr old woman transferred from an outside hospital </li></ul><ul><li>The patient presented earlier that day with an </li></ul><ul><li>anterior MI </li></ul><ul><li>The patients chest pain had started 3 days prior to admission </li></ul><ul><li>Prior to transfer the patient became confused, oliguric and hypotensive </li></ul>
    49. 75. <ul><li>What is the differential diagnosis? </li></ul>
    50. 76. <ul><li>Cardiogenic shock </li></ul><ul><li>Right ventricular Infarction </li></ul><ul><li>Papillary muscle rupture </li></ul><ul><li>Ventricular septal rupture </li></ul><ul><li>Free wall rupture </li></ul><ul><li>Conduction abnormalities </li></ul>
    51. 77. <ul><li>Risk stratify patients with non ST elevation ACS presenting to the Emergency Room </li></ul><ul><li>Recognize the role of medical treatment in management of ACS </li></ul><ul><li>Recognize the difference between conservative and invasive management of non ST elevation ACS </li></ul><ul><li>Recognize the role of reperfusion therapy in patient with ST Elevation ACS </li></ul>