Percutaneus coronary intervention in Non ST elevation myocardial infarction

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Unstable angina (UA), acute non-ST elevation myocardial infarction (NSTEMI), and acute ST elevation myocardial infarction (STEMI) are the three presentations of acute coronary syndromes (ACS). The first step in the management of patients with ACS is prompt recognition, since the beneficial effects of therapy are greatest when performed soon after hospital presentation. For patients presenting to the emergency department with chest pain suspicious for an ACS, the diagnosis of myocardial infarction can be confirmed by the electrocardiogram (ECG) and serum cardiac biomarker elevation; the history is relied upon heavily to make the diagnosis of unstable angina

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  • King SB, III, Kosinski A, Guyton RA, Lembo NJ, Weintraub WS.Eight year mortality in the Emory Angioplasty vs Surgery Trial (EAST). J Am Coll Cardiol. 2000;35:1116 –21
  • Percutaneus coronary intervention in Non ST elevation myocardial infarction

    1. 1. Dedicated to AHA /ACC/SCAI 2012- guidelines PCI IN NSTEMI Dr R Barik/Prof A.N Patnaik/Dr N Lalita NIMS,Hyderabad PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    2. 2. NSTEMI:An ACS  Chest pain of at crescendo/at rest/worsening for at least 30 minutes and <48-72 hrs  ECG: ST-depression of >0.1 mV in at least 2 or transient ST-segment elevation >0.1 mV in at least 2 leads for less than 30 minutes) and/or T-wave changes (inversion of >0.15 mV in at least two contiguous leads)  Biomarker: cardiac troponin T >0.01 μg/L PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    3. 3. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    4. 4. Bird’s eye view…………..Hamm Lancet 358:1533,2001 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    5. 5. Fibrinolysis: Red vs. White thrombus STEMI The GUSTO investigators. N Engl J Med 1993; 329:673. GUSTO- J Am Coll Cardiol 1995; 25:10S. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994; 343:311. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348:771. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA 1993; 270:1211 18-30 DEATH REDUCTION FOR EACH 1000 TLT GIVEN NSTEMI TIMI IIIB, ISIS-2, and GISSI 1 trials. A meta-analysis of fibrinolytic therapy in UA/NSTEMI patients showed no benefit NO of fibrinolysis versus standard therapy (FTT Collaborative-1994). Fibrinolytic agents had no significant beneficial effect and actually increased the risk of MI. Committee to Revise the 1999 Guidelines for the PCI IN NSTEMI-INCOMPLETE WHITE Management of patients with acute myocardial infarction). J Am Coll Cardiol. THROMBUS
    6. 6. White= platelet plug±lilttle red thrombus LEAST respond to fibrinolytic therapy Jang IK et al. Differential sensitivity of erythrocyte-rich and platelet-rich arterial thrombi to lysis with recombinant tissue-type plasminogen activator. A possible explanation for resistance to coronary thrombolysis. Circulation 1989 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    7. 7. ACC/AHA guidelines , 1999/2002/2004/2007...Contd PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    8. 8. Two issues better clarified  Definitions of UA and NSTEMI Definitions of early invasive and early conservative strategies PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    9. 9. A perfect SANDWITCH
    10. 10. IMISCABLE PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    11. 11. Causes are many PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    12. 12. Phenotype of deception • •     Two thirds of ACS of are USA/NSTEMI F>M ,F= 30% to 45% NSTEMI=25% to 30% AND STEMI =20% of Older>YOUNGER Prior MI/CSA/DM/Revasc/CVA/PAD/CKD 80% of patients with UA/NSTEMI have HX of CAD-higher syntax score  IRA is not occluded in 60 to 85 percent cases  9 to 14 % of NSTEMI : normal vessels or no vessel with ≥50 to 60 percent stenosis (CRUSADE registry)
    13. 13. Contd... • Risk is highest at presentation fades but at 6 months cumulative mortality >STEMI • Early mortality risk is: 3% and 5%=STEMI • F/U is worse than STEMI • Recurrence/older age • CAD/ prior MI/DM/ diabetes/CKD/CVA/PAD+ • 50% higher risk with comorbities • >Killip's II mortality = STEMI PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    14. 14. PROGNOSIS: Fire under ash  Similar to that with an STEMI  Worse than USA  70% Non occlusive benefit is diluted by >50% TVD  recurrent ischemia> STEMI (35 versus 23 percent at one year in (GUSTO-IIb)  Significant amount of myocardium often remains at risk  AW ischemia is dangerous (SPRINT registry) Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    15. 15. A big fall(patient) for Small rise(Tn) Small rise in biomarkers most of the reveals a big damage related to the likelihood of severe TVD, an unstable plaque with thrombus and downstream microembolization, and impairment of coronary flow; these factors are all associated with an increased risk for reinfarction and death 1.FRISC II and TACTICS-TIMI 18 2. Ricciardi MJ, Wu E, Davidson CJ, et al. Visualization of discrete microinfarction after percutaneous coronary intervention associated with mild creatine kinase-MB elevation. Circulation 2001 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    16. 16. NTEMI Paradox? High sensitive TnT increases NSTEMI incidences but better care reduces fatality
    17. 17. How frequently you Dx NSTEMI  SHOCK: 20% of all cardiogenic shock  The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO)-II and PURSUIT:5% but > 60% mortality  PURSUIT, TIMI IIIB Investigators,PRISM,PRISM-PLUS>10%
    18. 18. Risk scores for NSTEMI/USA PCI vs. Medical Rx PCI vs. CABG Bleeding risk Thrombolysis In Myocardial Infarction (TIMI)  Global Registry of Acute Coronary Events (GRACE) Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT SYNTAX TIMI Mehran R et al.2007 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    19. 19. Basis of risk score for PCI PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    20. 20. TIMI RISK cut off for PCI TRIALS PCI INDICATION±IIB-IIIA inhibitors TACTICS-TIMI 18 score ≥3 PRISM-PLUS score ≥4 TIMI 11B and ESSENCE score ≥4 and 5 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    21. 21. Grace risk for PCI PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    22. 22. Right person to talk right way PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    23. 23. Syntax after CAG......Ya!Ya! STEPS ANTIPLATLETS IIB-IIIA inhibitor ANTICOGULATION ICCU ASA to all No to Abciximab LMW/Fondaparin aux/Bivaluridin No to Abciximab -do- PREPARATION ON +1 antiplatlets for PCI but No Prasugrel CAG DONE,PCI ON CAG +CABG Now you can give Abciximab is Prasugrel if congratulated patient is on only aspirin But Ticagrelor is best No antiplatlets No AB except Aspirin PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS -do- but bivaluridin is prefered Heparin
    24. 24. With rising risk LMWH :ESSENCE: Efficacy and Safety of SC Enoxaparin in USA & Non-Q-Wave MI, TIMI 11B:TLT in MI  GP IIb/IIIa inhibition (TIMI Risk Score for UA/NSTEMI in PRISM-PLUS) Invasive strategy: Comparaison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879–87) are found more beneficial PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    25. 25. Supporting trial PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    26. 26. PCI is HARMFUL Timelines Trials Old (TIMI IIB and Harmful in VANQWISH) comparison to CABG PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS Comments
    27. 27. Early angioplasty TIMINGS TRIALS REUSLTS EARLY VS LATE Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-COOL) 2003 Results of PTCA/Angio is better than done later(4days) TIMACS  GRACE risk score>140 (Timing Compared early (median = 14 hours after of Intervention in randomization) with later (median = 50 hours) reduction of the primary endpoint Acute-Coronary (death, MI, and stroke) in the group as a Syndromes )-2009 whole but a significant reduction in the primary endpoint in patients with 28% reduction of the secondary endpoint of PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS MI, and refractory ischemia with death,
    28. 28. EARLIER (but <STEMI) is better 6 to 24 h is better than 48 to 96 h interervals ESAR-COOL: Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA. 2003;290:1593–9 FRISC II  TACTICS-TIMI 18 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    29. 29. But ......... Significant renal dysfunction is Poison Szummer K et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-system for enhancement and development of evidence based care in Heart Disease evaluated According to recommended therapies (SWEDEHEART). Circulation 2009;120:851-8 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    30. 30. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    31. 31. ANTIPLATLETS CONSERVATIVE INVASIVE TICA>>>CLOPI>>>>PRASU High risk:IIB-IIIA Inhibitor,avoid abciximab TICA>>>>PRASU>>>CLOPI No IIB-IIIA Inhibitor with Bivalurudin High risk:IIB-IIIA Inhibitor add Abciximab prefered >eftifibatibe>tirofiban PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    32. 32. ANTICOAGULANTS AHA ESC 1. invasive strategy : 1. invasive strategy : enoxaparin, unfractionated enoxaparin, unfractionated heparin (UFH), or heparin (UFH), or bivalirudin bivalirudin(prefered with 2. persistent angina, bleeding risk) hemodynamic instability, or 2. Urgent (immediate refractory arrhythmias, for angiography), bivalirudin or whom UFH or bivalirudin is UFH is preferred preferred 3. Conservative:enoxaparin, 3. Conservative: fondaparinux fondaparinux, or UFH,1and 1 prefred over LMW prefered PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    33. 33. Coronary angiogram analysis AMI DISEASE PATTERN CORONARY AND EXTRA CARDIACS NSTEMI Eccentric/fissure/erosion/Collaterals/calfic TVD : >50% stenosis is 34% DVD:28% SVD: 26% Mild CAD: <50% stenois is 13%(excellent prognosis on short term) LMCA: 10% ( >50%)  Women :less extensive  NSTEMI :extensive disease >NSTEMI High SYNTAX More carotid/RAS/PAD STEMI Single culprit TACTICS–TIMI 18 trial/Other 16 registries PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    34. 34. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    35. 35. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    36. 36. Femoral Vs. Radial Approach RIVAL: non superior ACUITY: Radial is superior PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    37. 37. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    38. 38. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    39. 39. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    40. 40. Thrombus Aspiration During PCI in NSTEMI STEMI TAPAS –Class I NSTEMI Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Non-ST-elevation Myocardial Infarction Study (TAPAS II) Phase IV results of 580 patient waited PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    41. 41. Drug-eluting stents are better  Kandzari DE et al. Frequency, predictors, and outcomes of drug-eluting stent utilization in patients with high-risk in NSTEMI. Am J Cardiol 2005; 96:750. Mauri L, Silbaugh TS, Garg P, et al. Drugeluting or bare-metal stents for acute myocardial infarction. N Engl J Med 2008; 359:1330. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    42. 42. Culprit vs. +by critical stander(s) Decision lies with operator 1.ACUITY(Acute Catheterization and Urgent Intervention Triage Strategy ) trial:favours 2. Shishehbor MH, Lauer MS, Singh IM, et al. In unstable angina or non-STsegment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol 2007; 49:849. 3. ESC Guidelines for NSTEMI 2011-advise to improve decision using FFR/IVUS 4.PRAMI(Preventive Angioplasty in Myocardial Infarction) invstigator for STEMI PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    43. 43. CABG vs.PCI:TVD/LMCA/LAD/LVD PRE DES ERA DES era/SYNTAX era ERACI II ,AWESOME favour CABG SYNTAX favours CABG is better PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    44. 44. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    45. 45. Major bleeding PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    46. 46. Diabetes a close friend • • • • • • 20%-30% of NSTEMI Independent predictor of CVE at 1 year Ulcerated plaque/more thrombus/diffuse PCI is not welcomed# unless SVD DES+Abciximab better(EAST) PCI<<<<<<CABG benifit(BARI)/EAST/NHLBI registry #Kip KE et al.Coronary angioplasty in diabetic patients: the National Heart, Lung,and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Circulation. 1996;94:1818 –25 . PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    47. 47. DM/PCI • PCI is reasonable with SVD and inducible ischemia(Level of Evidence: IB) • BETER use insulin (DIGAMI) Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879–87 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    48. 48. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    49. 49. Elderly and PCI:Go ahead EVIDENCE RESULTS (FRISC-II, TACTICS, RITA-3, VINO, and MATE – Meta analysis before 1996 Older UA/NSTEMI patients face increased early procedural risks with revascularization relative to younger patients, yet the overall benefits from invasive strategies are equal to or perhaps greater in older adults and are FRISC II recommended. (Level of Evidence: IB) TACTIS TIMI 18 Cleveland clinic review(contemporary review) Predictors of operative death (LV dysfunction, previous CABG, peripheral vascular disease, and diabetes) were similar to those in younger patients PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    50. 50. Renal dysfunction and NSTEMI Benefit of early invasive Rx is lost if proper timing and precaution is not opted Szummer K, Lundman P, Jacobson SH, et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART).Circulation. 2009;120:851– 8 PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    51. 51. TIMING OF DISCHARGE • Not well defined • early angiography/revascularization/stent facilities earlier discharge • Antithrombotic/anticoagulation delays • Radial access helps go early • Easy trial: Proves same day discharge by TRA PCI of 1000 patient with bolus dose of abcixmab only is noninferior to overnight stay with 12 infusion PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    52. 52. NSTEMI PCI-2012 Guide PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS
    53. 53. PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS

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