Intervention Procedure in Acute Coronary Syndrome Eka Ginanjar - W1.7 Intervensi pa… ·...
Transcript of Intervention Procedure in Acute Coronary Syndrome Eka Ginanjar - W1.7 Intervensi pa… ·...
Intervention Procedure in
Acute Coronary Syndrome
Dr. dr. Eka Ginanjar, Sp.PD-KKV, FINASIM, FACP, FICA
Division of Cardiology, Internal Medicine Departement, Faculty of Medicine Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia
Pelayanan Jantung Terpadu (PJT) RS Dr Cipto Mangunkusumo, Jakarta
CURRICULUM VITAE
Dr. dr. Eka Ginanjar, SpPD, K-KV, FINASIM, FACP, FICA Education:
Medical Doctor – FKUI 2003
Spesialis Penyakit Dalam (SpPD) – FKUI/RSCM 2009
Clinical and Interventional Cardiology – National Heart
Institute, Kuala Lumpur Malaysia 2012
Konsultan Kardiovaskular (KKV), FKUI/RSCM 2014
PhD in Medical Science – FKUI 2019
Fellow/membership: Instructor for American Heart Association (AHA) BLS-ACLS
2010
Fellow of Indonesian Society of Internal Medicine (FINASIM)
2012
Fellow of American College of Physician (FACP) 2014
Fellow of International College of Angiology (FICA) 2015
Member of European Society of Cardiology (ESC) 2013
Member of European Association of Percutaneous
Cardiovascular Interventions (EAPCI) 2013
Member of Acute Cardiovascular Care Association (ACCA)
2013
Position: Medical Staff and Lecturer at FKUI/RSCM
Clinical and Interventional Cardiologist at PJT-RSCM
Clinical and Interventional Cardiologist at RS MMC Jakarta
General Secretary of Indonesian Society of
Cardiocereberovascular
HEAD OF INTEGREATED HEART CENTRE (PJT) – RSCM
Secretary General of PAPDI
@Dr_EKG
Interest:Interventional CardiologyPeripheral & Endovascular InterventionEmergency MedicineAcute Cardiovascular CareHeart Failure and Stem CellPublic Health and Health EconomicsHospital Management
CASE
Tn. T 40 yo
Presented with typical chest pain since 4 hours
Referred from RS K
Smoker 1-2 packs per day
Fatigue, BP 120/80 mmHg, HR 60 bpm, RR 20 x/m
WHAT SHOULD WE DO….?
ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
( Dyslipidemia, BP, ,
Insulin Resistance,
Platelets, Fibrinogen, etc)Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
Arrhythmia and
Loss of Muscle
Remodeling
Ventricular
Dilatation
Congestive
Heart Failure
End-stage
Heart Disease
Primary prevention
Secondary prevention
Stroke
The Cardiovascular Continuum of Events
Spectrum of Pathology and Clinical IHD
Stable angina NSTEMI STEMI
IHD= Ischaemic heart diseaseNSTEMI= Non ST segment elevation myocardial infarctionSTEMI= ST segment elevation acute myocardial infarctionACS= Acute coronary syndrome
ACS
Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.
Ischemic Heart Disease
SUPPLY vs DEMAND
Initial Assessment for ACS patients
10 minutes10 minutes
No need to wait the result
No need to wait the result
REVASCULARIZATION
RISK Stratification on NSTEMI/UAP
Case 2 Mrs. S 45 YO
Chest pain since 12 hours, on and off
DM
Trop T Negatif
Component Time Delay
Improve Public
Awareness ACS Network
CODE STEMI
In Hospital and EMS
Diagnose capabilities
Importance for Early Reperfusion
Reperfusion is a key strategy in Acute STEMI care
and it time dependent
Shortening the time from symptom to reperfusion
and choosing the optimal reperfusion strategy for
STEMI patients are a great challenges in practice.
The infarction related artery (IRA) must be opened
early, consistently, and thoroughly in order to
effectively restore myocardial perfusion
1. Zhang et al. J Zhejiang Univ-Sci B (Biomed & Biotechnol). 2011; 12(8):629-632; 2. Ibanez B et al. Eur Heart J. 2017; 00: 1–66
TIME and Myocardial Salvage
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
Recommended /
indicated
Should be
considered
Not
recommended
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
Recommended /
indicated
Should be
considered
Not
recommended
A primary PCI strategy is
recommended over fibrinolysis
within indicated Timeframes
1 A
2017
CATHLAB
Percutaneus Coronary
Intervention
CASE 3
Tn. M 54 yo.
Chest pain since 2 hours
History of HT, DM, Smoking
Trop T Negatif
Danchin N. J Am Coll Cardiol Intv. 2009; 2: 901– 908.
The success of reperfusion in STEMI is dependent on
the time of administration
Time delays are central in the decision-making process
Registry data show that the 30-min DTN and 90-min
DTB time goals are extremely difficult to achieve
Analysis of the NRMI (National Registry of Myocardial
Infarction) 3/4 data demonstrated that only 4.2% of
patients undergoing PPCI achieve a DB time 90 min
Time delays are also crucial to determine the best
reperfusion strategy
Mortality benefit with fibrinolytics is
greatest with shortest delay to treatment
1. Boersma E et al. Lancet 1996;348:771–775;
P=0.001 vs
other
timepoints
0 0.5 1.0 40
Odds ratio
≥12–24
≥6–12
≥3–6
≥2–3
≥1–2
0–1
Proportional effect of fibrinolytic therapy on
35-day mortality according to treatment delay1
Benefit shown for treatment delays up to 12 hours
Control/placebo
better
Fibrinolytic
better
Time to
treatment (h)
22 trials were
reported between
1983 and 1993
and indexed in
the MEDLINE
information
system.
Timing and logistical factors influence choice
of reperfusion strategy
1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation2013;127:e362–e425; 3. Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation2004;110:1909–1915; 6. Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142
• PCI vs non-PCI capable hospitals1–3
• Dependence on operator
expertise/volume3
• Availability of a 24/7 service1,3*
• Availability of a pre-hospital system for
diagnosis and treatment3,4,5
*Patients treated during non-working hours (6 PM to 8 AM) have a greater delay to therapy, twice the failure rate of PPCI, and a >2-fold increased 30-day mortality rate3,6
• Patient ability to recognize
symptoms1,2
• Mode of transportation to the
hospital
(self-presentation vs EMS)1,2
• Inter-hospital transfer challenges
(distance, traffic patterns, climatic
conditions etc)2,3
Time to reperfusion Healthcare resource
Contraindications to fibrinolytic therapy1–3
1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042; Accessed November 6, 2017; 2. O’Gara PT et al. Circulation2013;127:e362–e425; 3. Morse MA et al. Drugs 009;69:1945–1966
• Previous intracranial hemorrhage or stroke of
unknown origin at any time
• Ischemic stroke in the preceding 6 months
• Central nervous system damage or neoplasms or
arteriovenous malformation
• Recent major trauma/surgery/head injury (within
the preceding 3 weeks)
• Gastrointestinal bleeding within the past mo
• Known bleeding disorder (excluding menses)
• Aortic dissection
• Non-compressible punctures in the past 24 h (e.g.
liver biopsy, lumbar puncture)
• Ischemic stroke more than 6 months ago
ABSOLUTE
• Transient ischemic attack in the preceding 6
month
• Oral anticoagulant therapy
• Pregnancy or within 1 week postpartum
• Refractory hypertension
• Advanced liver disease
• Infective endocarditis
• Active peptic ulcer
• Prolonged or traumatic resuscitation
RELATIVE
Fibrinolytic Therapy
Drugs Dosage & AdministrationSpecific
Contraindication
Streptokinase 1.5 Million units over 30-60 min i.v. Previous treatment
with streptokinase
or anistreplase
Alteplase 15 mg i.v. bolus
0.75 mg/kg i.v. over 30 min (up to 50 mg)
Then 0.5 mg/kg i.v. over 60 min (up to 35 mg)
Reteplase 10 units + 10 units i.v. bolus given 30 min apart
Tenecteplase
(TNK-tPA)
Single i.v. bolus:
30 mg (6000 IU) if <60 kg
35 mg (7000 IU) if <70 kg
40 mg (8000 IU) if <80 kg
45 mg (9000 IU) if <90 kg
50 mg (10000 IU) if ≥90 kg
It is recommended to reduce to half-dose in
patients ≥75 years old ESC Guideline. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042
Fibrinolytic Complication and it’s
management Hypotention Allergic reaction Bleeding Arythmia
• Patient position –
supine
• Reduce or stop
streptokinase
drops
• Provide Ringer
Lactate / NaCL
100 ml (10
minutes)
• Stop vasodilator
drug (eg. Nitrate)
• Streptokinase
drop continue if
systolic pressure
> 90 mmHg
Mild allergic
Antihistamin injection
(difenhidramin 10 mg
i.v)
Severe allergic
Dexamethasone
injection 5 mg
Minor Bleeding
Pressure to bleeding
area
Major Bleeding – eg
ICH
Stop streptokinase
and refer patient for
further bleeding
management
• Refer to ACLS
guidelines
• Reperfusion sign
• Premature
Ventricular
Contraction
• Idiophatic
Ventricular Rhytm
Parameter Successful Fibrinolytic Therapy
1. Reduction of chest pain
2. Decrease ST elevation > 50%
3. Arrhythmia reperfusion Reference : iSTEMI Indonesia Video
Early Reperfusion Strategy in STEMI
Rescue PCI
If Failed Thrombolytic
(60 -90 min after start
thrombolytic)
Routine Angiography
± PCISuccessful Thrombolytic
Within 2-24 Hours
Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6,
2017.
Symptom
Onset
Primary PCI Fibrinolytic
0 – 3 hours
3 – 12 hours
> 12 hours
Presented to PCI
HospitalWire crossing 60 minutes
Presented to Non
PCI HospitalWire crossing 90 minutes
Maximum
target
time from
diagnosis
Summary
Primary Management in every spectrum of CAD is very important from risk factor management to primary management of acute space.
Risk Stratification is very important step for NSTEMI/UAP
Reperfusion is a key strategy in Acute STEMI care and it time dependent
PPCI is preferred options for reperfusion strategy for STEMI patients
Fibrinolytic therapy is an important reperfusion alternative when onset chest pain < 3 hours or when primary PCI cannot be offered in a timely manner
Important to know capabilities of each hospital before referring STEMI patients to prevent delay
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