Acute Coronary Syndrome (2019) ANEK KANOKSILP Central Chest Institute of Thailand

Transcription

1 Acute Coronary Syndrome (2019) ANEK KANOKSILP Central Chest Institute of Thailand

2 โรคหลอดเล อดแดงแข ง (Atherosclerosis)

3 ป จจ ยเส 4 ยงท 4ทา ให เก ดโรคหลอดเล อดแดงแข ง (Atherosclerosis) ปร บเปล ( ยนได เบาหวาน ความด นโลห ตส ง ไขม นในเล อดส ง ส บบ หร : ไขม นทรานส ภาวะอ วนลงพ ง อาหารสไตล ตะว นตก ภาวะด Bอต อ อ นซ ล น ปร บเปล ( ยนไม ได ส งอาย เพศชาย ประว ต โรคหลอดเล อดแดงแข งใน ครอบคร ว พ นธ กรรม

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6 EGAT score Developed Thai CV risk score OUTCOMES WHO ACC/AHA ESC EGAT Heart Score Thai ASCVD Score Fatal CHD Nonfatal CHD Fatal stroke Nonfatal stroke PAD Revascularization

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8 Primary prevention for CAD Score < 10% = Low Risk Score % = Intermediate Risk Score 20- <30 % = High Risk Evaluate for statin treatment Score 30 % = VeryHigh Risk

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10 Pathology of Acute coronary syndrome Dissection 10

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14 Spectrum of myocardial injury, ranging from no injury to myocardial infarction

15 Reasons for the elevation of cardiac troponin values because of myocardial injury

16 Clinical classification of myocardial infarction 1 Myocardial infarction type 1 2 Myocardial infarction type 2 3 Myocardial infarction type 3 4 Coronary procedure-related myocardial injury a. MI associated with PCI (type 4a MI) b. Stent/scaffold thrombosis associated with PCI (type 4b MI) c. Restenosis associated with PCI (type 4c MI) 5 MI associated with CABG (type 5 MI)

17 Myocardial infarction type 1

18 Myocardial infarction type 1 Criteria for type 1 MI Detection of a rise and/or fall of ctn values with at least one value above the 99th percentile URL and with at least one of the following: Symptoms of acute myocardial ischaemia; New ischaemic ECG changes; Development of pathological Q waves; Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology; Identification of a coronary thrombus by angiography including intracoronary imaging or by autopsy. a

19 Myocardial infarction type 2

20 Myocardial infarction type 2 Criteria for type 2 MI Detection of a rise and/or fall of ctn values with at least one value above the 99th percentile URL, and evidence of an imbalance between myocardial oxygen supply and demand unrelated to acute coronary athero-thrombosis, requiring at least one of the following: Symptoms of acute myocardial ischaemia; New ischaemic ECG changes; Development of pathological Q waves; Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology.

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23 Myocardial infarction type 3 Criteria for type 3 MI Patients who suffer cardiac death, with symptoms suggestive of myocardial ischaemia accompanied by presumed new ischaemic ECG changes or ventricular fibrillation, but die before blood samples for biomarkers can be obtained, or before increases in cardiac biomarkers can be identified, or MI is detected by autopsy examination.

24 Clinical classification of myocardial infarction 1 Myocardial infarction type 1 2 Myocardial infarction type 2 3 Myocardial infarction type 3 4 Coronary procedure-related myocardial injury a. MI associated with PCI (type 4a MI) b. Stent/scaffold thrombosis associated with PCI (type 4b MI) c. Restenosis associated with PCI (type 4c MI) 5 MI associated with CABG (type 5 MI)

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26 The spectrum of ACS.

27 Initial assessment of patients with suspected acute coronary syndromes

28 Vulnerable plaque =plaque not only prone to thrombosis/rupture but also at risk for rapid progression 70% of ACS culprit lesions 30% of ACS culprit lesions Naghavi M, Libby P, Circulation. 2003;108:

29 Acute coronary syndromes: Pathogenesis

30 Heart Attack : Warning Signs Chest pain or discomfort, which may involve pressure, tightness or fullness Pain or discomfort in one or both arms, the jaw, neck, back or stomach Shortness of breath Feeling dizzy or lightheaded Nausea Sweating

31 Heart Attack : ECG

32 การร กษาผ ป วย STEMI โดยการเป ดหลอดเล อดห วใจเร วท :ส ด ภายใน 2 ชม.แรกหล งจากเร :มม อาการเจ บหน าอกผลการร กษาด ท :ส ด

33 Effects of Total Ischemic Time on Infarct Size and Clinical Outcomes JACC: CARDIOVASCULAR INTERVENTIONS, VOL. 4, NO. 6, 2011 JUNE 2011:

34 Reperfusion therapy for STEMI Salvage myocardium Improve both early and late clinical outcomes The highest number of lives saved is within the first hour after symptom onset: the golden hour

35 Reperfusion Strategies in STEMI 1 Fibrinolysis 2 Percutaneous coronary intervention - Primary PCI - Delayed PCI 3 CABG

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37 Fibrinolytic therapy =>the gold standard of reperfusion therapy since the 1980s But successful in restoring full early patency in about 50% Significant risk of severe side effects

38 Comparison of Reperfusion Strategies at 90 min > Net efficacy 20 None SK tpa PCI % %

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41 Contraindications for fibrinolytic use in STEMI Absolute Contraindications Any prior intracranial hemorrhage Known structural cerebral vascular lesion (eg, arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head trauma or facial trauma within 3 months ACC/AHA 2007 Focused Update*

42 Relative Contraindications History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) History of prior ischemic stroke >3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged (>10 minutes) CPR or major surgery (< 3 weeks) Recent (within 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (>5 days ago) or prior allergic reaction to these agents Pregnancy Contraindications for fibrinolytic use in STEMI Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding ACC/AHA 2007 Focused Update*

43 Point of Entry Protocol : GOAL Less than 90 minutes

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45 Major component of time delay

46 Factors Associated with Delays in Mechanical Reperfusion Tx FMC-PPCI Door-Balloon Symptoms onset and identification Call EMS Pre-hospital phase ER Cath Lab Increasing Loss of Myocytes

47 Primary PCI: Does Door-Balloon time affect mortality rate? Patient delay D-B Cath LAB Transportation delay A D-B =30 min B D-B = 60 min C D-B = 100 min

48 Primary PCI: Does Door-Balloon time affect mortality rate? Patient delay Transportation delay D-B Cath LAB A D-B =30 min B Total ischemic time D-B = 60 min C D-B = 100 min FMC - PPCI

49 Components of delay in STEMI and ideal time intervals for intervention. ESC Guideline 2012

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53 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

54 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

55 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

56 Defining PCI in STEMI 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

57 What is new in 2017 Guidelines on AMI-STEMI 2017 NEW / REVISED CONCEPTS

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60 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

61 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

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63 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

64 A C A => B = 101 Km A => C = 44 Km C => B = 67 Km Logistics B

65 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

66 Chest pain and ST segment resolution in STEMI Spontaneous Reperfusion Complete Infarction?? Adequate Collateral network Fibrinolytic therapy Mechanical reperfusion (PCI )

67 ST segment resolution score (STR) in a patient treated by fibrinolysis

68 STREAM Study

69 MONA Morphine Oxygen Nitrate X Aspirin

70 Acute coronary syndromes:pathogenesis

71 NSTE-ACS Fibrinolysis is not appropriate and may even be harmful Anti-ischemic therapy consisting of nitroglycerin and β-blockade Current medical therapy of non-stemi besides anti-ischemic drugs includes aspirin,p2y12 inhibitors, (low molecular) heparin, statins and ACEinhibitors

72 Decision-making algorithm in ACS

73 Rapid rule-out of ACS with high-sensitivity troponin

74 0h/3h rule-out algorithm of NSTEMI ACS using highsensitivity cardiac troponin assays 2015 NSTEMI ESC guidelines

75 Non ACS -Troponin elevation

76 Spectrum of myocardial injury, ranging from no injury to myocardial infarction

77 GRACE risk calculator

78 Mortality in hospital and at 6 months according to the GRACE risk score

79 Risk criteria mandating invasive strategy in NSTE-ACS Very-high-risk criteria Haemodynamic instability or cardiogenic shock Recurrent or ongoing chest pain refractory to medical treatment Life-threatening arrhythmias or cardiac arrest Mechanical complications of MI Acute heart failure Recurrent dynamic ST-T wave changes, particularly with intermittent ST-elevation High-risk criteria Rise or fall in cardiac troponin compatible with MI Dynamic ST- or T-wave changes (symptomatic or silent) GRACE score >140 Intermediate-risk criteria Diabetes mellitus Renal Insufficiency (egfr < 60 ml/min/1.73m 2 ) LVEF <40% or congestive heart failure Early post-infarction angina Prior PCI Prior CABG GRACE risk score >109 and <140 Low-risk criteria Any characteristics not mentioned above 2015 NSTEMI ESC guidelines

80 Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification 2015 NSTEMI ESC guidelines

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82 Heart Attack : ECG

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88 THANK YOU FOR ATTENTION