Acute Coronary Syndrome (NSTEMI)

Acute Coronary SyndromeNon ST Elevation MI

Muhammad Asim RanaMBBS, MRCP, SF-CCM, EDIC, FCCP

Department of Critical Care MedicineKing Saud Medical City

Riyadh Saudi Arabia

Disclosures

We are not promotional speakers for any company but we do accept the breakfast in our presentations

(just for fun) A very special man is here to see U doctor!!

Session Objectives Utilize both clinical evaluation and risk

scoring in selecting the appropriate initial management strategy for patients with UA/NSTEMI

Identify potential updates to current UA/NSTEMI critical pathways based on the latest ACC/AHA UA/NSTEMI guidelines and recent UA/NSTEMI clinical trial results

Evaluate current approaches to discharge planning and follow-up, and modify them as necessary to promote adherence to medical and rehabilitative therapies

ACS48%

Stroke17%

Hypertension5%

others23%

CHF5%

0.5%

Atherosclerosis2%

0.5%

Deaths from ACS

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI† STEMI

1.24 million Admissions per year

.33 million Admissions per year

Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

Ischemic Heart Disease Evaluation

Based on the patient’s

• History / Physical exam• Electrocardiogram• Biochemical markers

Patients are categorized into 2 groups Non Cardiac Chest Pain Pain cardiac in origin USA/NSTEMI/STEMI

Spectrum of Coronary Syndromes

Endstage Heart Disease

Congestive Heart Failure

Ventricular Dilation

Remodeling

Arrhythmia & Loss of Muscle

Myocardial Infarction

Myocardial Ischemia

IHD/Angina Pectoris

Atherosclerosis

Endothelial Dysfunction

Risk Factors + Hypertension

Coronary ThrombosisChronicCoronarySyndromes

AcuteCoronarySyndromes

Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.

Acute Coronary Syndrome Definition The term ACS refers to a spectrum of

presentations caused by myocardial ischemia that includes Unstable Angina Non ST elevation myocardial infarction ST elevation myocardial infarction

Diagnosis Diagnosis requires a rise and/or fall in

serum levels (preferably troponin) together with:

Evidence of Myocardial Ischaemia

Defined clinically by patient history ECG (new ST-T wave changes, new left

bundle branch block or evolving pathological Q waves)

Imaging evidence of new regional wall motion abnormality.

Acute Coronary Syndromes Pathophysiology

The embracing term reflects the common pathophysiology ofPlaque disruption Intravascular thrombosis Impaired myocardial blood supply

STEMI Result of complete

epicardial occlusion following plaque disruption & leads to propagation of thrombus & epicardial vasoconstriction

NSTEMI Incomplete &

transient epicardial occlusion with platelet-rich & phasic distal embolisation

Pathophysiology

Summary of events & outcome

Acute ST Elevation MI

N Normal ECG

Acute Coronary SyndromeClinical Diagnosis

MONAMorphineOxygen

NTGAspirin

Blood Tests:Troponin at 12 hours after onset of pain, U&E, cholesterol, FBC, coagulationAdmission or subsequent ECG

High Risk ECG changes:(2 or more contiguous leads)ST depression > 1mmT inversion > 1mmTransient BBBMinor/ transient ST elevation

High Risk Clinical features:Ongoing rest pain.Haemodynamic instability.Arrythmias

Troponin Elevated?

NO

NOAble to exercise

?YES

ETT

NO

Considerinvestigations:Perfusion scanAngiographyCardiology Referral

ETT InconclusiveETT Normal

Low Risk Patient

Discharge

High Risk ECG changes:(2 or more contiguous leads)ST depression > 1mmT inversion > 1mmTransient BBBMinor/ transient ST elevation

High Risk Clinical features:Ongoing rest pain.Haemodynamic instability.Arrythmias

Troponin Elevated

High Risk1. LMWH2. Clopidogrel 300 stat, 75mg OD3. Aspirin 75 mg OD4. Beta Blockers: (metopr)25 mg

tds5. Hyperglycaemic control DIGAMI

protocol, if RBS > 10 mmol6. Morphine and / or IV nitrates if

continuing pain, titrate to pain and blood pressure.

High Risk Stable

Cardiac Cath.pre-morbid state and suitability for revasc.

High Risk UnStable Ongoing pain ECG changes GPIIbIIIa Urgent cath.pre-morbidity suitability for revasc.

What is UA/NSTEMI Patients Risk of inpatient Cardiac

Mortality and ischemic events?

• Age ≥ 65 years =1 point• At least 3 risk factors for CAD =1 point• Prior coronary stenosis of ≥ 50% =1 point• ST-segment deviation on ECG presentation =1

point• At least 2 anginal events in prior 24 hours =1

point• Use of aspirin in prior 7 days =1 point• Elevated serum cardiac biomarkers =1 point

Variables Used in the TIMI Risk Score

The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42.TIMI = Thrombolysis in Myocardial Infarction.

TIMI Risk Score

Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.TIMI = Thrombolysis in Myocardial Infarction.

TIMI Risk

Score

All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent

Revascularization Through 14 Days After Randomization %

0-1 4.72 8.33 13.24 19.95 26.2

6-7 40.9

GRACE Risk Score

The sum of scores is applied to a reference monogram to determine the corresponding all-cause mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRACE clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157.GRACE = Global Registry of Acute Coronary Events.

Variable Odds ratioOlder age 1.7 per 10 yKillip class 2.0 per classSystolic BP 1.4 per 20 mm

Hg ↑ST-segment deviation 2.4Cardiac arrest during presentation 4.3Serum creatinine level 1.2 per 1-mg/dL

↑Positive initial cardiac biomarkers 1.6Heart rate 1.3 per 30-

beat/min ↑

Why R U Confusing us?

UA/NSTEMI Hospital Care

Let’s Start with the Basics! Assuming the NSTEMI has been our diagnosis

ACC/AHA GuidelinesACS Treatment Overview: UA/NSTEMI

aIf possible, clopidogrel should be withheld for 5-7 days prior to the procedure.Anderson JL, et al. Circulation. 2007;116:803-877.

Initial invasive management

Initial conservative management

Diagnosis of UA or NSTEMI is likely or definite

Aspirin or clopidogrel (if patient is aspirin intolerant)

PCI or CABGa

Diagnostic angiograph

yMedical therapy

Long-term medical management:Clopidogrel, aspirin, β-blocker,

ACEI, statin

Evaluation of LV Function in pt with ischemia

Selection of Initial Treatment

Wright RS et al. Circ 2011;123;2022-2060.

Early TreatmentClass I Indications

Bed rest with continuous ECG Monitoring O2 therapy if saturation <90%, respiratory

distress, or other high-risk features for hypoxemia

SL NTG 0.4 mg q5min x3 then assessment of need for IV NTG

IV NTG indicated first 48 hours for treatment of persistent ischemia, CHF or HTN; should not preclude Rx with beta-blockers or ACE


Early TreatmentClass I Indications

Oral Beta-Blocker in first 24 hours for pt who do not have Signs of CHF Low out-put state Increased risk of cardiogenic shock Contraindication to Beta blockers/heart

block/COPD If Beta-Blockers are contraindicated a

nondihydropyridine calcium channel blocker may be used if no LV dysfunction


Early Treatment (Cont.) ACE inhibitor within 24 hours with pulmonary

congestion or LVEF < 40% in the absence of hypotension or contraindication

Because of the increased risk of mortality, reinfarction, HTN, CHF, and myocardial rupture NSAIDS except for ASA should be discontinued at presentation

Class II indications: It is reasonable to admin O2 to all UA/NSTEMI pts in

first 6 hours. IIa Morphine (1-5 mg IV) remains Class I for STEMI

although may increase adverse events in UA/NSTEMI (1,2) It is reasonable to administer morphine sulfate IV if

there is uncontrolled ischemic Chest Pain despite NTG. IIa1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.

2. Meine T el al. Am Heart J 2005;149:1043- 9

Early Hospital Care2011 Focused update Antiplatelet therapy

ASA should be administered to USA/NSTEMI as soon as possible after hospital presentation and continued indefinitely (LOE A)

Clopidogrel (loading dose followed by maintenance dose) should be administered to USA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance (LOE B)

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Rx for all NSTEMI

Look who is sleeping

Hospital Care2011 Focused update Antiplatelet therapy

For USA/NSTEMI patients in whom an initial conservative strategy is selected clopidogrel (loading dose followed by maintenance dose) should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month and ideally up to 1 year


Conservative Rx

Hospital Care Initial Conservative Strategy:

Anticoagulant Therapy


Conservative Rx

Anticoagulant therapy should be added to antiplatelet therapy in UA/NSTEMI patients as soon as possible after presentation.

For patients in whom a conservative strategy is selected, regimens using either enoxaparin* or UFH (LOE A) or fondaparinux (LOE: B) have established efficacy.

In patients in whom a conservative strategy is selected and who have an increased risk of bleeding, fondaparinux is preferable.

*Limited data are available for the use of other low-molecular-weight heparins (LMWHs), e.g., dalteparin.

Time to use your grey matter

An 65 year-old woman presented to the ED at 6 AM with a history of intermittent chest pain x 1 week. She has long-standing hypertension and chronic kidney disease, and started hemodialysis recently. Her anti-hypertensive medications are: metoprolol, diltiazem, hydralazine, and lisinopril. She has been taking aspirin 325 mg daily since having a TIA one year ago.

Her blood pressure is 180/100. She has bibasilar rales and an S3 gallop. Her serum troponin is mildly elevated. Her CXR shows pulmonary congestion. The patient does not want to undergo invasive diagnostic studies. Which of the following therapies are not contraindicated:

a. Clopidogrel b. Prasugrel c. Enoxaparin d. Eptifibatide e. An intravenous fibrinolytic drug



Her blood pressure is 180/100. She has bibasilar rales and an S3 gallop. Her serum troponin is mildly elevated. Her CXR shows pulmonary congestion. The patient does not want to undergo invasive diagnostic studies. Which of the following therapies are most appropriate

a. ASA 325 mg daily b. ASA 325 mg daily and clopidogrel 75 mg daily c. Intravenous unfractionated heparin d. ASA 325 mg daily and Intravenous heparin e. ASA 325 mg OD & Clopidogrel 75mg OD & IV heparin



Her ECHO showed EF 30% & small pericardial effusion. Which of the following drugs should be discontinued? a. Metoprolol b. Diltiazem c. Hydralazine d. Lisinopril


Oral beta blockers should be initiated within first 24 hrs for those pts who do not have

1) Signs of heart failure 2) Evidence of low output state 3) Increased risk of cardiogenic shock 4) other contraindications to beta blockers

Risk Factors for Cardiogenic Shock Age > 70yrs BP <120 Heart rate >110 or < 60 Increased time since onset of symptoms



Her ECHO showed EF 30% & small pericardial effusion. Which of the following is indicated? a. Transe-esophageal echo b. Biventricular pacing c. Implantable cardioverter defibrillator d. Cardiac catheterization

Initial Conservative strategyAdditional Management considerations

Hospital Care2011 Focused update

For USA/NSTEMI patients in whom an initial conservative strategy is selected if recurrent symptoms/ischemia, CHF, or serious arrhythmias subsequently appear, then diagnostic angiography should be preformed


Conservative Rx


For patients with USA/NSTEMI treated conservatively without recurrent symptoms, CHF or arrhythmia a stress test should be performed

If the pt is not classified as low risk after the stress test then angiography should be performed


Conservative Rx


If at low risk Post Stress Test: Continue ASA Continue clopidogrel for at least 1

month and ideally up to 1 year Discontinue GP IIb/IIIa inhibitor if started Continue UFH for 48 hours or administer

enoxaparin or fondaparinux for the duration of hospitalization up to 8 days and then discontinue


Conservative Rx

Pharao gets prescription


An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine.

Physical exam is normal , ECG is below

What would you recommend? a. A resting sistamibi scan b. A nuclear stress test c. Intravenous fibrinolytic drug d. Cardiac Cath

Selection of Initial Treatment




Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal,

CTn 2.9 Which of the following therapies are most appropriate? a. ASA 325 mg daily b. ASA 325 mg daily and clopidogrel 75 mg daily c. ASA 325 mg daily and prasugrel 10 mg OD e. Clopidogrel 75mg OD & IV eptifabatide


Pt with definite USA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual-antiplatelet therapy on presentation (LOE A) ASA on presentation The second should be given before PCI

as follows…..


Medium to High Risk patients…..


Before PCI: Clopidogrel (LOE B) An IV GP IIb/IIIa inhibitor (LOE A)

eptifibatide or tirofiban are the preferred agents

At the time of PCI: Clopidogrel if not started before PCI (LOE

A) Prasugrel (LOE B) An IV GP IIb/IIIa inhibitor (LOE A)Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Medium to High Risk patients…..



Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal,

CTn 2.9 Which of the following therapies are not appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin

Initial Invasive StrategyAnticoagulation

Continue Smiling



Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, Creatinin clearance is

<30 ml/min, CTn 2.9 Which of the following therapies are not appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin



Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin normal

but there is history of heparin induced thrombocytopenia Which of the following therapies is appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin


For patients with USA/NSTEMI in whom CABG is selected post angiography Continue ASA Discontinue IV GP IIb/IIIa inhibitor 4 hours

before CABG Continue UFH Discontinue enoxaparin 12-24 hours before

CABG and dose with UFH per institution practice

Discontinue fondaparinux 24 hours before CABG and dose with UFH per institution practice

Discontinue bivalirudin 3 hours before CABG and dose with UFH per institution practiceWright RS et al. J Am Coll Cardio 2011; 57;e215-e367


In patients taking thienopyridine in whom CABG is planned and can be delayed…

Discontinue clopidogrel for at least 5 days

Discontinue prasugrel for at least 7 days

Unless the need for revascularization and or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding… (LOE C)


ACC/AHA Guidelines update 2011UA/NSTEMI: Long-Term Medical Management

UA or NSTEMI at hospital discharge

Inhospital management with medical therapy

(without stenting)

Inhospital therapy with bare-metal stent

implantation

Inhospital therapy with drug-eluting stent

implantation

Aspirina 75-162 mg/d indefinitely plus

clopidogrelb 75 mg/d for at least 1 mo, ideally up

to 1 yr

Aspirina 162-325 mg/d for at least 1 mo, then

75-162 mg/d indefinitely plus

clopidogrelb 75 mg/d or prasugrel 10 mg/d for at

least12 months*

Aspirina 162-325 mg/d for at least 3 mo with Sirolimus and 6 mo

paclitaxel, then 75-162 mg/d indefinitely

plusclopidogrelb 75 mg/d or

prasugrel 10 mg/d for at least 12 mo

Is an indication for anticoagulation present?

If yes: add warfarinc,d

If no: continue dual antiplatelet

therapy

aIf patient is allergicto aspirin, useclopidogrel alone (indefinitely) or try aspirin desensitization.

cContinue aspirin indefinitely and warfarin long term, if indicated for specific conditions.dIf warfarin is added to aspirin and clopidogrel, the recommended INR is 2.0-2.5.

bIf patient is allergic to clopidogrel, use ticlodipine 250 mg PO bid.Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Dear Doctor!

Evaluating Recurrent RiskSecondary Prevention

StrategiesBroad Goals during Hospital discharge

phase Prepare the patient for normal

activities Use the acute event as an

opportunity to reevaluate the plan of care - lifestyle and risk factor modification

Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Can U Revise

Take all these pills daily until a new clinical trial is published

Evidence based medicine

Questions?No questions?

Good!Then let’s go home

& try some herbal Rx

Acute Coronary Syndrome (NSTEMI)

Education

Transcript of Acute Coronary Syndrome (NSTEMI)