Ranil de Silva
Consultant Cardiologist
Senior Lecturer in Clinical Cardiology
Goals of the initial clinical evaluation
Is this an ACS?
What is the prognosis?
Clinical diagnosis of ACS
Acute Coronary Syndromes
ST depression T wave inversionST elevation
ESC NSTE-ACS Guidelines 2007
or normal ECG
Cardiac Enzyme Changes in ACS
ESC NSTE-ACS Guidelines 2007
Cardiac Magnetic Resonance Imaging
Prognostication in ACS
 Clinical
 12 lead ECG
 Biomarkers
Clinical prognostication in ACS
Troponin and Prognosis
Lindahl et al NEJM 2000
Risk scores for prognosis in ACS
Risk of death after ACS (GRACE)
In-hospital 6 months post-discharge
 High (score >140)
 >3%
 Intermediate (score 109-14...
Who can be discharged?
 Low clinical probability of ACS
 Atypical features of pain
 Few risk factors
 No previous card...
ACS – What are we trying to reduce?
 Death
 Recurrent MI
 Recurrent ischaemia
 Stroke
 Iatrogenic
 Bleeding
 MATCH ...
Aims of Pharmacologic Management in ACS
 Symptom relief
 Stabilise ruptured plaque
 Facilitate mechanical reperfusion
...
Antiplatelets
 Aspirin
 P2Y12 Receptor
Antagonists
 Ticlopidine
 Clopidogrel
 Prasugrel
 Cangrelor
 AZD6140
 Gp II...
Anticoagulants
 Indirect thrombin inhibitors
 Unfractionated heparin
 Low molecular weight heparin
 Direct thrombin in...
MIRACL
0
3
6
9
0 4 8 12 16
Time since randomisation (weeks)
Cumulativeincidence(%)
Relative risk = 0.74
(0.57-0.95), p=0.0...
Interventional Treatment in ACS
 Mechanical reperfusion/haemodynamic support
 PCI
 CABG
 IABP/Impella/Tandem heart
Timing of angiography?
 Immediate
 ST elevation or new LBBB (PPCI)
 Clinical features of heart failure/shock/arrhythmia...
NSTE-ACS: Benefits of early intervention
ESC NSTE-ACS Guidelines 2007
Evaluation of the Patient with Chest Pain
ESC NSTE-ACS Guidelines 2007
Post-Discharge Management
 Cardiac rehabilitation + education
 Smoking cessation
 Risk factors - treating to target
 C...
Case 1
 74 Asian female
 Admitted with septic arthritis of L knee
 Develops chest pain and hypotension, post-op
 PMHx
...
Physical findings
 Pale, cool peripheries, sweaty
 HR 80 irregular
 BP 80/60 mmHg
 O2 sats 90% on rebreathe O2
12 lead ECG
What’s happened?
 Clopidogrel stopped by admitting surgical team
 STENT THROMBOSIS
 ACUTE LAD INFARCT + MOBITZ II AV BL...
Immediate Management
 Clopidogrel 600 mg stat
 Atropine + TPW
 Intubate + ventilate
 Consider inotropes
 dopamine/dob...
Stent Thrombosis
Risk Factors for Stent Thrombosis with DES
CASE FATALITY RATE
45% !!
Iakovou et al. JAMA 2005;293:2126-2130
Risks of Stopping Clopidogrel
Ho et al. JAMA 2008
Case 2
 85F retired GP receptionist
 Dizziness + palpitation +
presyncope
 PMHx
 Hypertension
 Hypercholesterolaemia
...
Investigations
 Troponin 0.22
 Echo: Moderate-severe LV impairment(inferior
hypokinesis)
 Coronary angiogram
PCI (Genous stent)
ICD Implant
Case 3
 57M
 Troponin +ve ACS
 Previous CABG and PCI to SVG to D1
 Known thrombophilia (on chronic warfarin Rx)
 Coro...
PCI to SVG to D1
Take home messages
 Use risk scores (it’s more than troponin!!)
 Tailor treatment to patient’s risk of
 Recurrent ischa...
Acute Coronary Syndromes Who needs the cath lab at 3am?
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Acute Coronary Syndromes Who needs the cath lab at 3am?

  1. 1. Ranil de Silva Consultant Cardiologist Senior Lecturer in Clinical Cardiology
  2. 2. Goals of the initial clinical evaluation Is this an ACS? What is the prognosis?
  3. 3. Clinical diagnosis of ACS
  4. 4. Acute Coronary Syndromes ST depression T wave inversionST elevation ESC NSTE-ACS Guidelines 2007 or normal ECG
  5. 5. Cardiac Enzyme Changes in ACS ESC NSTE-ACS Guidelines 2007
  6. 6. Cardiac Magnetic Resonance Imaging
  7. 7. Prognostication in ACS  Clinical  12 lead ECG  Biomarkers
  8. 8. Clinical prognostication in ACS
  9. 9. Troponin and Prognosis Lindahl et al NEJM 2000
  10. 10. Risk scores for prognosis in ACS
  11. 11. Risk of death after ACS (GRACE) In-hospital 6 months post-discharge  High (score >140)  >3%  Intermediate (score 109-140)  1-3%  Low (score ≤108)  <1%  High (score >118)  >8%  Intermediate (score 89-118)  3-8%  Low (score ≤88)  <3%
  12. 12. Who can be discharged?  Low clinical probability of ACS  Atypical features of pain  Few risk factors  No previous cardiac history  Normal ECG/No ST segment shift  12 hr troponin negative  Other important differential diagnoses excluded  Outpatient functional test and cardiology clinic follow-up
  13. 13. ACS – What are we trying to reduce?  Death  Recurrent MI  Recurrent ischaemia  Stroke  Iatrogenic  Bleeding  MATCH TREATMENT STRATEGY TO RISK OF ADVERSE EVENTS
  14. 14. Aims of Pharmacologic Management in ACS  Symptom relief  Stabilise ruptured plaque  Facilitate mechanical reperfusion  Reduce ischaemic complications  Improve prognosis
  15. 15. Antiplatelets  Aspirin  P2Y12 Receptor Antagonists  Ticlopidine  Clopidogrel  Prasugrel  Cangrelor  AZD6140  Gp IIb IIIa antagonists  Abciximab  Tirofiban  Eptifibatide
  16. 16. Anticoagulants  Indirect thrombin inhibitors  Unfractionated heparin  Low molecular weight heparin  Direct thrombin inhibitors  Bivalirudin  Dabigatran (RE-DEEM)  Factor Xa inhibitors  Fondaparinux  Apixaban  Rivaroxoban
  17. 17. MIRACL 0 3 6 9 0 4 8 12 16 Time since randomisation (weeks) Cumulativeincidence(%) Relative risk = 0.74 (0.57-0.95), p=0.02 Atorvastatin Placebo 8.4% 6.2% Cannon et al NEJM 2004
  18. 18. Interventional Treatment in ACS  Mechanical reperfusion/haemodynamic support  PCI  CABG  IABP/Impella/Tandem heart
  19. 19. Timing of angiography?  Immediate  ST elevation or new LBBB (PPCI)  Clinical features of heart failure/shock/arrhythmia  Continuing symptoms of chest pain/dynamic ECG changes  Within 48 hrs  Troponin positive  Abnormal presenting ECG  Previous coronary revascularisation  Diabetes mellitus
  20. 20. NSTE-ACS: Benefits of early intervention ESC NSTE-ACS Guidelines 2007
  21. 21. Evaluation of the Patient with Chest Pain ESC NSTE-ACS Guidelines 2007
  22. 22. Post-Discharge Management  Cardiac rehabilitation + education  Smoking cessation  Risk factors - treating to target  Clinical surveillance for symptom recurrence
  23. 23. Case 1  74 Asian female  Admitted with septic arthritis of L knee  Develops chest pain and hypotension, post-op  PMHx  IHD – PCI to LAD (DES) 3 months previously  T2D  Hyperlipidaemia
  24. 24. Physical findings  Pale, cool peripheries, sweaty  HR 80 irregular  BP 80/60 mmHg  O2 sats 90% on rebreathe O2
  25. 25. 12 lead ECG
  26. 26. What’s happened?  Clopidogrel stopped by admitting surgical team  STENT THROMBOSIS  ACUTE LAD INFARCT + MOBITZ II AV BLOCK  CARDIOGENIC SHOCK
  27. 27. Immediate Management  Clopidogrel 600 mg stat  Atropine + TPW  Intubate + ventilate  Consider inotropes  dopamine/dobutamine  norepinephrine  Frusemide iv infusion  Immediate transfer to PCI capable facility  Reperfusion  Mechanical haemodyamic support
  28. 28. Stent Thrombosis
  29. 29. Risk Factors for Stent Thrombosis with DES CASE FATALITY RATE 45% !! Iakovou et al. JAMA 2005;293:2126-2130
  30. 30. Risks of Stopping Clopidogrel Ho et al. JAMA 2008
  31. 31. Case 2  85F retired GP receptionist  Dizziness + palpitation + presyncope  PMHx  Hypertension  Hypercholesterolaemia  RA  Rx:  Prednisolone 5mg  Folic acid 5mg  Ranitidine 150 mg  Calcichew D3  Methotrexate 15mg  Adalimumab  Flucloxacillin
  32. 32. Investigations  Troponin 0.22  Echo: Moderate-severe LV impairment(inferior hypokinesis)  Coronary angiogram
  33. 33. PCI (Genous stent)
  34. 34. ICD Implant
  35. 35. Case 3  57M  Troponin +ve ACS  Previous CABG and PCI to SVG to D1  Known thrombophilia (on chronic warfarin Rx)  Coronary angiogram – subtotal thrombotic occlusion of SVG to D1
  36. 36. PCI to SVG to D1
  37. 37. Take home messages  Use risk scores (it’s more than troponin!!)  Tailor treatment to patient’s risk of  Recurrent ischaemic events  Bleeding  Low risk patients  Exclude non-coronary differentials  Early outpatient functional testing for reversible ischaemia and cardiology follow-up  Do not stop clopidogrel without discussion with a cardiologist, unless lifethreatening bleeding

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