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Non ST Elevation Acute Coronary Syndromes

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  • Compared to patients with new onset angina CCS III
  • CAD 2014 - NSTE ACS

    1. 1. Acute Coronary Syndromes Non STE ACS Salah Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA, USA
    2. 2. NSTE ACS • Definition • Spectrum (Pathology, Clinical Presentation) • Clinical Assessment – Careful History • Risk Stratification – History – Physical Examination – Investigations • Medical Therapy • When to consult/refer to Cardiology?
    3. 3. Acute Coronary Syndromes • Acute Myocardial Ischemia caused (usually) by coronary plaque rupture with superimposed intracoronary thrombosis & associated with increased risk of cardiac death • Non ST Elevation Myocardial Infarction is defined as elevation of cardiac enzymes in a patient with ACS without ST Elevation on the ECG Hurst’s the Heart, 12nd Edition
    4. 4. ACS Spectrum AHA.ACC 2004 STEMI guidelines
    5. 5. Netter’s Cardiology, 2nd Edition, 2010
    6. 6. Clinical Presentation • Rest Angina • New onset Angina – CCS III or IV at least • Angina of increasing severity, duration, or frequency Braunwald E. Unstable angina: a classification. Circulation 1989;80: 410–4.
    7. 7. Canadian Cardiovascular Society (CCS) Classification of Angina I Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina present with strenuous or rapid or prolonged exertion at work or recreation II Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or when under emotional stress or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions. III Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing more than one flight of stairs in normal conditions. IV Inability to carry on any physical activity without discomfort/anginal syndrome may be present at rest. Goldman L et al: Circulation 64:1227, 1981.
    8. 8. Importance of Clinical Assessment • NSTE ACS is a clinical diagnosis supported by ECG changes and elevation of cardiac enzymes • Risk factors are NOT to be used for diagnosis, but for risk stratification • Elevated Biomarkers alone should not be used to establish the diagnosis of NSTE ACS in the absence of the appropriate clinical setting
    9. 9. Ahmed • Ahmed is a 38 year old male who drives a rickshaw. He has no atherosclerotic risk factors apart from mild obesity • While driving his rickshaw last night, he felt pressure in the middle of his chest that lasted for 10 minutes, and spontaneously subsided; he was concerned so went home early • The same pain recurred and woke him from sleep that night • He comes to you for evaluation that am, and he is in a hurry because he wants to go back to work ASAP
    10. 10. Hamid • Haj Hamid is an 75 year old male, with diabetes, hypertension, and remote history of stroke. • He has been getting chest pain for several years, it lasts for several hours and occurs at rest • The pain does not stop him from doing the 5 prayers in the local mosque which is about 10 blocks from his house • His neighbor recently died of a heart attack and he is very concerned.
    11. 11. Problem 1 • Which patient has ACS Ahmed or Hamid or both?
    12. 12. Risk Stratification History – Higher Risk • Chest Pain – Prolonged, ongoing Chest pain at rest – Accelerating Symptoms • Risk Factors – Age, Prior MI, Atherosclerotic Risk Factors • Prior Aspirin Use
    13. 13. Risk Stratification Physical Examination– Higher Risk • Hemodynamic Instability – Hypotension – Tachycardia – Hypoxemia (Heart failure) • Signs of Heart Failure – JVP raised – S3 – Chest crackles – LE edema • New Mitral regurgitation murmur
    14. 14. Risk Stratification Investigations – Higher Risk • ECG – ST Changes (depression, transient elevation) – T wave Changes (depression, biphasic) – New Bundle Branch Block (right or left) – VT (sustained or non sustained) • Elevated Cardiac Biomarkers
    15. 15. Problem 2 • Mona is 56 year old female with DM & HTN • She had history of CAD, stable angina, and went to Jordan last year for check up; she had tests done that ended up with placing a coronary stent • She felt generally unwell with fatigue, headache for the last 2 days • She has no chest pain or shortness of breath or recurrence of her prior anginal symptoms
    16. 16. • Her medications include Aspirin, Plavix, metoprolol, atorvastatin & lisinopril • Clinical Examination is unremarkable, apart from BP 180/90 • Troponin 0.5 (upper normal limit is 0.05) • Rest of Labs are normal
    17. 17. What would you like to do next?
    18. 18. CT Head • Showed intracranial hemorrhage
    19. 19. TIMI Risk Score • age 65 y or older; • at least 3 risk factors for CAD; • prior coronary stenosis of 50% or more; • ST-segment deviation on ECG presentation; • at least 2 anginal events in prior 24 h; • use of aspirin in prior 7 d; • elevated serum cardiac biomarkers
    20. 20. Problem 3 • It is 11pm in the Emergency Room in a major Chicago Hospital; the nursing supervisor had already called you to tell you that there are having a bed shortage • You are evaluating a 58 year old male with history of one episode of chest pain at rest that lasted for 30 minutes • He has no risk factors • Physical Examination is unremarkable apart from BP 150/90 • First Troponin is negative • Admit overnight or Discharge with follow up in 2 days?
    21. 21. • You decide to admit the patient for monitoring overnight • His second troponin comes back at 2.4 • He is chest pain free since admission • What medications would you like to prescribe?
    22. 22. Medical Therapy - Principles • Relief of Angina • Dual Antiplatelet Therapy • Anticoagulation • ACEI/ARB for Acute MI (especially with LV dysfunction) • Aldosterone Blockers for Acute MI with LV dysfunction • Risk Factor Modification – Lipid Control – BP Control
    23. 23. Dual Antiplatelet Therapy • Aspirin – once daily (lifelong) – 300 or 325mg as initial dose – 81mg as maintenance dose • Clopidogrel – 300 or 600mg (depending on timing of PCI) – Continue for one year (regardless of whether PCI/CABG is performed)
    24. 24. Newer Antiplatelet Agents • Higher Efficacy, More reliable antiplatelet activity • Prasugrel – Thienopyridine – P2Y12 blocker recently approved – For administration at the time of PCI • Ticagrelor – Non thienopyridine – P2Y12 blocker recently approved – Approved for ACS
    25. 25. Anticoagulation – Unfractionated Heparin • IV loading dose at 60 u/kg (maximum of dose of 4000 u) • Maintenance dose of 12u/kg/hr (maximum of 1000 u/hr) • Target APTT 1.5x to 2x upper limit of normal • Continue for minimum of 48 hrs or till PCI is performed
    26. 26. Anticoagulation – Enoxaparin • 1mg/kg SQ q12 hours • Every 24hours if Cr Cl < 30 • Continue for minimum of 48 hrs or till PCI is performed
    27. 27. Anticoagulation – Fondaparinux No PCI planned/conservative strategy • 2.5mg SQ every 24 hours • Avoid if Cr Cl < 30 • Should Not be given if PCI is contemplated
    28. 28. Problem - continued • You admit the patient to telemetry unit • You start – Aspirin 325mg – Clopidogrel 600mg loading dose – Heparin drip – Atorvastatin 80mg – Metoprolol 25mg q12 hours – NTG prn as needed for chest pain
    29. 29. 2am • The nurse calls you that the patient is now having chest pain again. • She administers NTG sublingual and performs the vital signs and repeats the ECG • You come to evaluate the patient • He is sweaty, and having ongoing chest pain • HR 90/min, BP 160/80 • His PTT is in the target range
    30. 30. What would you like to do next?
    31. 31. • You order 1mg of IV morphine and start the patient on nitroglycerin drip • His chest pain improves and he says he feels better, but he still continues to have mild chest pain, and looks ill • You call the Interventional Cardiologist oncall who decides to activate the Cath Lab
    32. 32. • Coronary Angiography reveals a 99% stenosis in the mid LAD artery with ulcerated appearance • A drug eluting stent is placed in the mid LAD artery • The patient is transferred back to the telemetry unit because the CCU is full • His heparin drip is stopped in the Cath Lab
    33. 33. • The patient is monitored for another 24 hours • Echocardiogram is performed and shows LVEF 60%, normal valves • Fasting glucose is 110mg/dl • LDL 100mg/dl • Rest of labs are within normal limits
    34. 34. • Today is Day 3 since his admission • HR 60/min, BP 145/80 • Chest clear • His right femoral artery site looks good
    35. 35. • His current medications are – Aspirin 325mg once daily – Clopidogrel 75mg once daily – Atorvastatin 80mg once daily – Metoprolol 25mg twice daily • The patient is ready for discharge • Would you like to make any changes to this medication list?