Acute Coronary Syndrome...UA + - - NSTEMI + + - STEMI + + + Spectrum of disease •Unstable Angina...

Acute Coronary Syndrome

Sonny Achtchi, DO

Objectives

• Understand evidence based and practice based treatments for stabilization and initial management of ACS

• Become familiar with ACS risk stratification and its implications for treatment

ACC/AHA Guidelines, LOE

Anderson. JACC 2007; 50: 1-157

Features of ACS entities

Angina Biomarkers ST elevation

UA + - -

NSTEMI + + -

STEMI + + +

Spectrum of disease

•Unstable Angina •NSTEMI •STEMI

ACS Similar pathophysiology Similar management


AMI

Plaque Thrombosis

STEMI LM

LCx

LAD

Why ST elevations vs other ST segment deviations?

• Resting membrane potential higher in peri-infarct ischemic tissue

• “leaky” membranes generate potential

• Higher T-P segment in nontransmural b/c peri infarct areas generate current toward index electrodes ST depression

• Lower in transmural infarction ST elevation

http://www.cvphysiology.com/CAD/CAD012 ST segment changes.gif

http://www.cvphysiology.com/CAD/CAD012 ST segment changes.gif


Unstable Angina Definitions -AUC

Definition of AMI – Causes of myocardial damage

JACC. 2012 Oct 16;60(16):1581-98.

Definition of AMI - DDx

JACC. 2012 Oct 16;60(16):1581-98.

Definition of AMI

JACC. 2012 Oct 16;60(16):1581-98.

Definition of AMI and prior MI

Clinical Entities


Diagnostic Tools

• EKG

• Biomarkers

• Echocardiography

• Stress Testing

• Coronary angiography

– Catheter based (left heart cath)

• IVUS, OCT

– Computed Tomography

EKG – early risk stratification

• 12 lead ECG within 10 minutes of arrival

• If initial is not diagnostic and patient remains symptomatic, serial ECGs are recommended

B

I IIa IIb III

ECG patterns in ACS and mortality

Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999;281:707–13.

ST Depression & Elevation

ST Elevation

Twave inversion

ST Depression !

ACS risk stratification

STEMI?

YES NO

Cardiac Biomarkers

• Troponin

– Rises 4-8 hrs after injury

– Remain elevated for up to two weeks

– Prognostic information

– False positives

• CK-MB

– Rises 4-6 hours

– Remain elevated for 48-72 hours

– > 5% of total CPK or 2x ULN

– Can be predictive of mortality

– False positives

Cardiac biomarkers


Biomarker elevation and mortality

Acute Therapy

?

Acute Therapy

MONA? Prior to decision re: early invasive vs

conservative strategy

Aspirin/Antiplatelet Therapy

• Aspirin should be administered as soon as possible and continued indefinitely.

• Clopidogrel should be administered to patients who are unable to take ASA.

A

I IIa IIb III

A

I IIa IIb III

Proportional effects of antiplatelet therapy on vascular events (myocardial infarction, stroke,

or vascular death) in five main high risk categories.

British Medical Journal Publishing Group et al. BMJ

2002;324:71-86

©2002 by British Medical Journal Publishing Group

Morphine

• Reduces pain/anxiety, sympathetic tone, systemic vascular resistance and oxygen demand

• Can exacerbate hypotension or cause respiratory depression

• Use only after other treatments to address pathophysiology

B

I IIa IIb III

Class II Benefit >> Risk Procedure/ Treatment is RECOMMENDED to be administered or performed

Oxygen

• NC, 2-4 L per minute

• Thought to improve O2 delivery via higher O2 tension and Hgb saturation.

C

I IIa IIb III

Class II Benefit >> Risk Procedure/ Treatment is RECOMMENDED to be administered or performed

O2 – Benefit or risk?

Moradkhan, R. JACC. 2010 Sep 21;56(13):1013-6.

Nitroglycerin

• Dilates coronary vessels

• Reduces SVR (arterial) and preload (venous)

• Caution if hypotension or RV infarction

• Caution if PDE inhibitors within 24-48 hours (sildenafil, tadalafil)

C

I IIa IIb III

C

I IIa IIb III

Dual antiplatelet therapy - Clopidogrel

• Clopidogrel 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.

• Should be used regardless of LHC plans, but prior to LHC if invasive strategy

B

I IIa IIb III

CURE Trial: MI/Stroke/CV Death

The CURE Trial Investigators. N Engl J Med. 2001;345:494-502.

12,562 patients with ACS, only 21% with PCI

Beta Blockers

B

I IIa IIb III Oral beta-blocker therapy should be initiated within the first 24 hrs for patients without: 1) signs of HF 2) evidence of a low-output state 3) increased risk for cardiogenic shock 4) PR greater than 0.24 s 5) second or third degree heart block 6) active asthma

COMMIT Trial

Small reduction in reinfarction and ventricular fibrillation Increase in cardiogenic shock, occurred early (first day) and primarily in pts with HD compromise or at high risk for shock

Lancet 2005;366:1622–32.

ACE inhibitors

• An ACE inhibitor should be administered orally within the first 24 h to patients with pulmonary congestion or LV ejection fraction (LVEF) ≤ 40%.

A

I IIa IIb III

NSAIDS

• NSAIDS should not be administered during hospitalization because of the increased risks of mortality, reinfarction, hypertension, CHF, and myocardial rupture.

C

I IIa IIb III

Addition of UFH to ASA in ACS – Meta-analysis

• RR: 0.67 (0.44-1.02)

• * LMWH has equivalent benefit with regard to mortality, slight benefit with regard to MACE NNT= 107 (JAMA 2004;292(1)86-

89)

Oler, A. JAMA 1996;276:811-6

A

I IIa IIb III

Management Strategy

• Conservative

• Early Invasive (LHC in 24-48 hrs)

• How does one decide which?

Rehospitalization in UA – mean follow up 13 months

Bavry AA, et al. JACC. 2006; 48:1319-1325

Recurrent MI – mean f/u 2 years


Mortality– mean f/u 2 years


Who benefits?

European Heart Journal (2005) 26, 865–872

TIMI risk score

• Age >65

• Three or more risk factors for CAD

• Prior stents

• ST deviation on ECG

• At least 2 angina events in prior 24 hours

• ASA use in prior 7d

• Elevated biomarkers

Antman EM, et al. JAMA 2000;284:835–42.

Selecting a strategy Early Invasive Conservative

Recurrent angina/ischemia at rest with low-level activities despite intensive medical therapy + biomarkers New ST-segment depression Signs/symptoms of heart failure or new/worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG High risk score (e.g., TIMI, GRACE) Reduced left ventricular function (LVEF < 40%)

Low risk score (e.g., TIMI, GRACE) Absence of high-risk

Take home points

• All patients with ACS should get evidence based medical therapy – morbidity and mortality benefit

• Risk stratification is an important part of initial ACS management and dictates management strategy

• Involve your cardiology colleagues early

Questions?

Acute Coronary Syndrome...UA + - - NSTEMI + + - STEMI + + + Spectrum of disease •Unstable Angina...

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