Acute Coronary syndrome - medkorat.in.th · Acute Coronary syndrome Pearl & Pitfall Outline...

21/05/56

1

W. Wiwatworapan MD. Cardiologist, Maharat Nakorn Ratchasima Hospital

Acute Coronary syndrome Pearl & Pitfall

Outline

• STEMI ACC guideline 2013

– Management algorithm

– Pitfall in STEMI

• NSTE-ACS

– Management algorithm

– Pitfall in NSTE-ACS

21/05/56

2

STEMI

21/05/56

3

Symptom Recognition

Call to Medical System

ED Cath Lab PreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied

Management Guideline

21/05/56

4

Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion

In PCI-capable center

In non-PCI-capable center

Primary PCI FMC-device time

≤ 90 min

Transfer for primary PCI if FMC-device time ≤ 120 min

Fibrinolytic within 30 minutes if FMC-device time > 120 min

Urgent transfer for PCI

If fail reperfusion or reocclusion

Transfer for CAG within 3-24 hr

(pharmacoinvasive strategy)

PCI or CABG

or Medication

DIDO ≤ 30 minutes

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction



21/05/56

5





≤ 90 min

PCI or CABG

or Medication





DIDO ≤ 30 minutes


PCI or CABG

or Medication

21/05/56

6





DIDO ≤ 30 minutes

Except • Posterior wall MI • Suspected acute Left

main stenosis

Fibrinolytic Agents

• Anaphylaxis • Should repeat dose

within 6 months

• Need adjunctive anticoagulant

• Higher patency rate • More complication

21/05/56

7

Fibrinolytic Agents - Contraindications

Adjunctive Antiplatelet to Support Reperfusion With Fibrinolytic Therapy

!

21/05/56

8

Adjunctive Anticoagulant to Support Reperfusion With Fibrinolytic Therapy









PCI or CABG

or Medication

DIDO ≤ 30 minutes

21/05/56

9






≤ 90 min







PCI or CABG

or Medication

DIDO ≤ 30 minutes

• < 12-24 hr • Cardiogenic shock • Contraindication for

fibrinolytic • Inconclusive

Loading 2 antiplatelet Loading 2

antiplatelet

Loading 2 antiplatelet

anticoagulant

Pitfall in STEMI

21/05/56

10

Female 50 y, chest pain 1 h

A. Repeat ECG B. Refer for primary PCI C. Fibrinolytic agent D. Work up other cause of chest pain

F/U ECG 10 min later

A. Repeat ECG B. Refer for primary PCI C. Fibrinolytic agent D. Work up other cause of chest pain

21/05/56

11

Post SK 30 min

Post SK 60 min

At ER

21/05/56

12

Post SK 70 min

A. Urgency refer for PCI B. Refer for CAG in 3-24 hr C. Optimize medication &

refer next few days D. Medication only

Pearl & Pitfall

• In inconclusive ECG • Look for reciprocal change

• Serial ECG

• Or.. Echocardiogram if you can

21/05/56

13


After given fibrinolytic agent, patient developed hypotension & cannot palpate left brachial pulse

Calcium sign

21/05/56

14

Pearl & Pitfall

• In Acute inferior wall MI (esp. RV infarct) • Carefully exam pulse 4 extremities

• Consider CXR – Wide mediastinum

– Calcium sign

Female 50 y, chest pain 1 h A. Repeat ECG in 10 minutes B. Repeat ECG with V3R, V4R C. Repeat ECG with V7-V9 D. Rx as UA/NSTEMI

21/05/56

15

Pearl & Pitfall

• In ACS with suspected Posterior wall MI • Tall R in V1-2 with ST depression

• ECG V7-9

EKG ที่รพช.

Male 70 y, chest pain 1 h

A. Prinzmetal’s angina B. Acute RV infarct C. Tako tsubo cardiomyopathy D. Left main stenosis

21/05/56

16

EKG 2 เดือนก่อน

ST elevation in aVR

• ST elevation greater ≥ 0.5 mm in aVR in NSTEMI with often very significant ST depression in many leads (≥8) favors the diagnosis of occlusion of left main trunk.

The 12 lead ECG in ST elevation myocardial infarction : a practical approach for clinicians

21/05/56

17


A. Anterior wall MI B. Inferior wall MI C. Lateral wall MI D. Not MI

Pearl & Pitfall

• In other causes of ST elevation (Not MI) • No Dynamic change

• No progression to Q wave

• Involve > 1 coronary territories

21/05/56

18

NSTE-ACS

What should you know about NSTE-ACS

• Assessment of “Likelihood of ACS”

• Early Hospital care

• Early Risk Stratification

• Invasive vs. Conservative Strategy

• Pharmacotherapy

• Long-term secondary prevention

21/05/56

19

Likelihood of ACS

ACC/AHA UA/NSTEMI Guideline 2007

High Intermediate Low

Symptoms Chest or left arm discomfort reproducing prior documented angina

Chest or left arm discomfort

Symptom in absence of any intermediate likelihood character

History Know history of CAD > 70 years Male, DM

Recent Cocaine use

Physical Examination

Transient MR Hypotension Rales

Manifestation of extracardiac vascular disease

Chest pain reproduced by palpation

ECG ST deviation ≥ 1 mm T wave inversion in multiple lead

Q wave ST depression 0.5 – 1 mm

Normal

Cardiac Biomarkers Positive Normal Normal

Early Hospital Care

Class I

• Bed rest & Telemetry

• Oxygen (maintain saturation > 90%)

• Nitrate

• Oral Beta-blockers in 1st 24-hours if no contraindications (IV Beta-blockers class IIa)

• ACE-I in 1st 24-hours for heart failure of LVEF < 40% (Class IIa for all other patients)

• Statin

21/05/56

20

Early Hospital Care

Class III

• Nitrates if SBP < 90 mmHg or RV infarction

• Nitrates within 24-hrs of Sildenafil or 48-hrs of Tadalafil use

• IR-CCB in absence of Beta-blockers

• NSAIDs & COX-2 inhibitors

Early Risk Stratification

• Rapid clinical determination

• Troponin is the preferred biomarker

• If normal, repeat biomarker at 6-12 hours after onset of symptoms

21/05/56

21

Antman EM, et al. N Engl J Med. 1996;335:1342-1349.

TIMI III B Trial N=1,404

Troponin I Levels to Predict the Risk of Mortality in ACS

4.7 8.3

13.2

19.9 26.2

40.9

0

10

20

30

40

50

0/1 2 3 4 5 6/7 Number of Risk Factors

14-d Death, MI, or Urgent Revascularization (%) 10 times

Antman EM, et al. JAMA. 2000;284:835-842.

TIMI risk score

Age ≥ 65 years ≥ 3 risk factors for CAD Prior stenosis > 50% ST-segment deviation ≥ 2 anginal in 24 hours Use of aspirin in 7 days cardiac biomarkers

21/05/56

22

JAMA 2004;291:2727-33

Management Strategies for Non ST elevation ACS

Definite/Possible ACS Initiate ASA, Beta-blockers, Nitrates, ECG monitor

Early Invasive Strategy TIMI Risk Score ≥ 3 New ST segment deviation Positive biomarkers Hemodynamic instability Refractory angina PCI in past 6 months CABG LVEF < 40%

Conservative TIMI Risk Score < 3 No ST segment deviation Negative biomarkers

Recurrent symptoms Heart failure

Serious arrhythmia

Stable

Assessment of EF Stress Test

Coronary angiography LVEF < 40%

Stress test +ve

21/05/56

23

Antithrombotic in ACS

At least 2 Antiplatelet

1 Anticoagulant

Antiplatelet (At least 2)

Clopidogrel Prasugrel Ticagrelor

Conservative X

PCI

Thrombolytic X X

Dose OD OD b.i.d

Variability of Response

++ + +

Risk of Bleeding + ++ +

Genotyping CYP 2C19 Not establish Not establish

Transition to elective Sx

5 d 7 d 3-5 d

Antiplatelet effect Slowwer Faster Faster

ASA +

21/05/56

24

Anticoagulant (Indirect) Heparin LMWH Fondaparinux

Molecular Wt 15,000 5,000 1,728

Target Xa and IIa Xa > IIa Xa

Bioavailability 30% 90% 100%

(hr) 1 4 17

Renal excretion No Yes Yes

Antidote Complete Partial No

HIT <5% <1% Very rare

Initial Conservative Strategy

ASA (I A)

Clopidogrel if ASA intolerant (I B)

Initiate Anticoagulant (I A)

• UFH (I A)

• Enoxaparin (I A)

• Fondaparinux (I B)

Clopidrogrel (I B)

Ticagrelor (I B)

IV GP IIb/IIIa inh (Eptifibatide or Tirofiban) (IIb)

Mortality Antiplatelet trialist

Less bleeding Contra. If CrCl < 30

Death/MI/RI compare with UFH

Prefer Enoxaparin or Fondaparinux (IIa)

GP IIb/IIIa inh for recurrent ischemia (IIa)

No evidence of Prasugrel

21/05/56

25

Early Invasive Strategy

Initiate Anticoagulant (I A)

• UFH (I A)

• Enoxaparin (I A)

• Bivalirudin (I B)

• Fondaparinux* (I B)

• Clopidrogrel (I A)

• Prasugrel (I B)

• Ticagrelor (I B)

• IV GP IIb/IIIa inh (I A)

ASA (I A)

Clopidogrel if ASA intolerant (I B)

UFH if CAG

Bleeding ? Should not switch from

UFH

Clopidogrel + GP IIb/IIIa inh (IIa) : Favor if – • Delay CAG • High risk feature

MACE Bleeding

Use in PCI case only

NSTE-ACS

ASA intolerant Clopidogrel 75 mg OD

Indefinite Therapy (IIa B) ASA 75-162 mg OD

Indefinite Therapy (I A)

Medication

Clopidogrel 75 mg OD (I A) or Ticagrelor 90 mg BID (I B) At least 1 mo (I A) & up to 12 mo in the absence of risk of bleeding (I B)

PCI

Clopidogrel 75 mg OD (I A) or Ticagrelor 90 mg BID (I B) for 12 mo Continuation > 12 months may be considered in pt with a high risk of thrombosis and a low risk of bleeding (IIb C)

Prasugrel 10 mg daily may be Considered (12 mo) in the absence of : Increased bleeding risk Likely to undergo CABG within 7 days History of stroke or TIA Age > 75 years Weight < 60 kg (Class IIa, Level B) (I B for ACC)

Risk of stent thrombosis

Canadian Journal of Cardiology 27 (2011) S1–S59

ASA 162-325 mg LD (I A)

Clopidogrel 300-600 mg LD before or at time of PCI

(I B)

Plasugrel at time of PCI (I B)

21/05/56

26

Secondary Prevention Class I Indications

• Aspirin

• Beta-blockers

• ACE-I : CHF, LVEF <40%, HT, DM

(All patients- Class Iia)

• ARB : ACE-I intolerant & CHF with LVEF <40%

• Aldosterone antagonist – On ACE-I, CHF with LVEF < 40%

• Standard Risk Factor Management

Secondary Prevention Class III

• Hormone Replacement Therapy

• Anti-oxidant (Vit C, Vit E)

• Folic acid

21/05/56

27

Likelihood of ACS

2 antiplatelet + 1 anticoagulant + Other medication

Reperfusion

Risk stratification Revascularization

1

2

3

4

5

W. Wiwatworapan MD. Cardiologist, Maharat Nakorn Ratchasima Hospital

Acute Coronary syndrome Pearl & Pitfall

Acute Coronary syndrome - medkorat.in.th · Acute Coronary syndrome Pearl & Pitfall Outline...

Documents

Transcript of Acute Coronary syndrome - medkorat.in.th · Acute Coronary syndrome Pearl & Pitfall Outline...