Acute Coronary Syndromes. Case 1. Management Aims in ACS. Acute Coronary Syndromes. Ranil de Silva

Transcription

1 Acute Crnary Syndrmes Acute Crnary Syndrmes Ranil de Silva Senir Lecturer in Clinical Cardilgy Natinal Heart and Lung Institute, Imperial Cllege Lndn Cnsultant Cardilgist Ryal Brmptn and Harefield NHS Fundatin Trust ST elevatin ST depressin T wave inversin r nrmal ECG ESC NSTE-ACS Guidelines 2007 Management Aims in ACS Rapidly establish diagnsis Determine risks MACE (Death, nn-fatal MI, recurrent ischaemia, heart failure, arrhythmia, re-hspitalisatin, strke) Iatrgenic cmplicatins (bleeding) Chse and implement treatment strategy Timely Reduce risk f MACE Minimise risk f bleeding Treat mechanical cmplicatins Presenting ECG Case 1 79 Female 4 hrs chest burning Ex-smker, stpped 30 years ag Drugs warfarin, digxin 125 mcg, amldipine 5mg, frusemide 40mg, simvastatin 20mg Physical examinatin BP 180/90 mm Hg (R=L) HR 160 irreg RR 24/min, O2 sats 98% n rebreathe BM 9.6 mml/l Bibasal creps Blds tests Hb 10.8, K 4.1, Cr 126, INR 4.3, trpnin pending ECG Diagnsis Acute LAD syndrme (NSTEACS), rapid AF Acute psterir STEACS, rapid AF Acute inferir STEACS, rapid AF Acute infer-psterir STEACS, rapid AF Acute pericarditis, rapid AF

2 Clinical risk assessment Clinical Risk Scres Lw Medium High >75 y F >2h frm symptm nset Pulmnary edema (Killip 3) STEACS Warfarin Rx ( bleeding risk) Immediate Treatment Optins ASA 300mg, Clpidgrel 300mg, UFH, thrmblysis ASA 300mg, Clpidgrel 300mg, LMWH, thrmblysis ASA 300mg, Clpidgrel 300mg, fndaparinux, thrmblysis ASA 300mg, Clpidgrel 600mg, UFH, PPCI ± Gp IIbIIIa ASA 300mg, Clpidgrel 600mg, LMWH, PPCI ± Gp IIbIIIa ASA 300mg, Clpidgrel 600mg, bivalirudin, PPCI ± Gp IIbIIIa ASA 300mg, Clpidgrel 600mg, fndaparinux, PPCI ± Gp IIbIIIa ASA 300mg, Clpidgrel 600mg, LMWH, PPCI ± Gp IIbIIIa ASA 300mg, Clpidgrel 600mg, ½ dse abciximab blus + half dse lytic, transfer fr PCI I have n idea! Immediate Rx Lad with antiplatelets Aspirin 300 mg + Clpidgrel 600 mg Treat heart failure Mrphine 4 mg Fursemide 40mg iv GTN ivi Maintain K 4-5 mml/l Reslve the ischaemia! PPCI ACS Radial artery access Minimise bleeding risk, ~2/3 f majr bleeding in ACS patients are related t femral access Bivalirudin Thrmbus aspiratin Avid DES Triple therapy carries majr bleeding risk f 7% per yr Aspirin + clpidgrel carries 2-3% per yr risk f majr bleeding >75y PPCI Transfer <1h DTB <60 min Cardigenic shck CI t lysis Lysis Pre-hspital Pain t Rx <2h If transfer >2h: Lytic+GpIIbIIIa Fail t reperfuse Rescue PCI PCI within 24h High/Intermediate Risk Medical Rx Risk Stratificatin Angigraphy ± Revasc. within 96h Lw Risk Medical Rx ± Revasc.

3 STEACS Treatment Optins STEACS Immediate Drug Treatment PPCI (Keeley et al. Lancet 2005) Dr t balln <90 min Transfer time < 1h Thrmblysis ( PPCI if pain t Rx time <2h) Pre-hspital (CAPTIM, PRAGUE-2) In-hspital Rutine angigraphy within 24h pst-lysis (TRANSFER-AMI) Pharmacinvasive Transfer time >2h Half dse lytic + GpIIbIIIa (CARESS-AMI) PPCI Aspirin 300mg P2Y12 receptr antagnist Clpidgrel 600mg (CURRENT- OASIS7) Prasugrel 60mg (TRITON- TIMI38) Ticagrelr 180 mg (PLATO) Antithrmbin UFH Enxaparin (ATOLL) Bivalirudin (HORIZONS-AMI) Lysis Fibrin specific Tenecteplase Aspirin 300mg P2Y12 receptr antagnist Clpidgrel 300mg (CLARITY-TIMI28) Antithrmbin UFH Enxaparin (EXTRACT- TIMI25) Fndaparinux (OASIS-6) PPCI fr STEMI PPCI v Fibrinlysis Keeley et al Lancet 2003;361:13 Keeley et al. Lancet Asian female Case 2 Physical findings Admitted with septic arthritis f L knee Chest pain and hyptensin pst-peratively PMHx IHD PCI t LAD (DES) 3 mnths previusly T2D Hyperlipidaemia Pale, cl peripheries, sweaty HR 80 irregular BP 80/60 mmhg O 2 sats 90% n rebreathe O 2

4 12 lead ECG ECG Diagnsis Acute inferir NSTEACS, SR Acute inferir NSTEACS, Mbitz I AV blck Acute inferir NSTEACS, Mbitz II AV blck Acute anterir STEACS, SR Acute anterir STEACS, Mbitz I AV blck Acute anterir STEACS, Mbitz II AV blck Risk assessment What s happened? Lw Medium High Clpidgrel stpped by admitting surgical team STENT THROMBOSIS ACUTE LAD STEACS + MOBITZ II AV BLOCK CARDIOGENIC SHOCK Immediate Management Clpidgrel 600 mg stat Atrpine + TPW Intubate + ventilate Cnsider intrpes dpamine/dbutamine nrepinephrine Frusemide iv infusin Stent Thrmbsis Immediate transfer t PCI capable facility Reperfusin Mechanical haemdyamic supprt

5 Management f Cardigenic Shck Risk Factrs fr Stent Thrmbsis with DES Early reperfusin imprves shrt and lng term mrtality Mechanical supprt (IABP, Impella, Tandem Heart) imprves utcmes Mrtality (%) 70% 60% 50% 40% 30% 20% 47% 56% 50% 63% 53% 66% ERV IMS CASE FATALITY RATE 45%!! 10% 0% 30 days (n=302) 6 mnths (n=301) 12 mnths (n=299) Hchman et al. NEJM 1999 Hchman et al. JAMA 2000 Iakvu et al. JAMA 2005;293: Learning pints Anterir STEACS + AV blck has pr prgnsis, indicating prximal LAD cclusin Cardigenic shck is an indicatin fr urgent revascularisatin + haemdynamic supprt Acute stent thrmbsis carries ~50% mrtality rate D nt stp clpidgrel within 1 year f DES implantatin withut specific cnsultatin with a cardilgist Case 3 68M Inf MI, Rx d with tenecteplase R arm weakness CT shws small L frntal intracerebral haemrrhage Recurrent chest pain 12 lead ECG: 5mm ST II, III, avf Optins Transfer fr rescue PCI Repeat thrmblysis Cnservative Phne a friend! Interventinal Cardilgist N mrtality benefit frm Rx ing uncmplicated inferir MI Prgnsis frm cmpleted inf MI better than extending ICH frm further anti-thrmbin and anti-platelet Rx Neurlgist Discntinue aspirin and clpidgrel

6 In the thrmblysed patient Failure t reperfuse 20% f arteries remain ccluded Nrmal crnary flw in ~65% at 90 min Reduced tissue perfusin in ~75% Increased majr bleeding risk (ICH %) ~15% risk f recurrent ischaemia/re-infarctin Pst-thrmblysis <50% reductin in ST at 60 min after fibrinlysis Lk carefully at the pst-fibrinlysis ECGs! Onging symptms (beware masking effect f analgesics), arrhythmia, haemdynamic instability Gershlick et al. NEJM 2005;353:2758 Optins (REACT) Case 4 Cnservative Repeat fibrinlysis Rescue PCI ( 6 mnth death, rec MI, severe HF, CV event) 78F Jaw and thrat discmfrt Rapidly wrsening exercise tlerance PMHx Hypertensin Hyperlipidaemia Drugs Aspirin 75mg OD Amldipine 5mg OD Simvastatin 40mg ON HR 70 BP 140/70 mm Hg Nrmal physical examinatin 12 lead ECG Initial management Nn-cardiac, discharge Stable angina pectris, utpatient cardiac investigatin Unstable angina, treat fr NSTEACS 12 hr trpnin I <0.04

7 ACS Adjunctive Pharmaclgy in NSTEACS Analgesia O 2 PPCI Transfer <1h DTB <60 min Cardigenic shck CI t lysis Lysis Pre-hspital Pain t Rx <2h If transfer >2h: Lytic+GpIIbIIIa Fail t reperfuse Rescue PCI PCI within 24h High/Intermediate Risk Medical Rx Risk Stratificatin Angigraphy ± Revasc. within 96h Lw Risk Medical Rx ± Revasc. Oral antiplatelet Aspirin + Clpidgrel/Prasugrel/Ticagrelr Antithrmbin/Xa antagnists UFH/LMWH Bivalirudin Fndaparinux Apixaban/Rivarxaban Intravenus antiplatelet Abciximab/Tirfiban/Eptifibatide Initial Treatment Clpidgrel 300mg lad, 75 mg OD Bisprll 2.5 mg OD Atrvastatin 80 mg ncte Enxaparin 1 mg/kg sc BD NSTEACS Immediate Drug Treatment Aspirin 300mg P2Y12 receptr antagnist Clpidgrel 300mg (CURE) 75 mg OD fr 1 year Clpidgrel 600mg (CURRENT-OASIS7) 150mg OD fr 7d and 75mg OD fr 1 year Prasugrel 60mg (TRITON-TIMI38) 10mg OD fr 1 year (5mg OD in special cases) Ticagrelr 180 mg (PLATO) 90 mg BD fr 1 year Antithrmbin/Xa antagnist UFH LMWH (ESSENCE, FRISC) Bivalirudin (ACUITY) Fndaparinux (OASIS-5) Des the statin matter? Next day Cumulative incidence (%) Cannn et al NEJM 2004 Placeb 8.4% Atrvastatin Relative risk = 0.74 ( ), p= Time since randmisatin (weeks) 6.2% Wivitt et al. Circulatin 2006 Clinical prgress Further jaw discmfrt at rest N ECG changes N trpnin rise HR 68 BP 130/70 Chest clear Wuld yu? Increase medical therapy Bisprll 5mg OD Perindpril 2mg OD ISMN MR 30mg OD Refer fr crnary angigraphy Bth f the abve

8 NSTEACS Timing f Angigraphy Recmmended within 96h (NICE) Crnary Angigram Mehta et al. JAMA 2005;293:2908 TIMACS NEJM 2009 Rutinely within 24h f admissin is preferable EHJ 2011;32:32 Rutine immediate angigraphy ± PCI prvides n additinal benefit v within 24h ABOARD JAMA 2010 Immediately if nging symptms, dynamic ECG changes, haemdynamic instability, arrhythmia Crnary Angigram Which is the culprit lesin? LAD Intermediate RCA Can t tell Desn t matter PCI t all What next? IVUS IVUS-VH OCT FFR Stress ech MPS CMR Any f the abve CMR Nrmal LV dimensin Nrmal LV systlic functin N reginal wall mtin abnrmalities

9 CMR Nvel Diagnstics in NSTEACS T2w STIR Oedema/Area at Risk Late Gadlinium Enhancement - Infarctin Plaque characterisatin IVUS OCT Culprit lesin: intermediate artery N inducible stress perfusin defect Stne et al. NEJM 2011 High Sensitivity Cardiac Trpnin Assays >100-fld mre sensitive MI defined as >99 th centile f nrmal ppulatin Earlier diagnsis specificity Clinical status Asymptmatic Mbile n ward N ECG changes Prgress What wuld yu d? PCI t intermediate Cntinue medical Rx Keller et al NEJM 2009 Reichlin et al NEJM 2009 Treatment n discharge Pst ACS Lng Term Treatment Treatment Aspirin 75mg OD Clpidgrel 75mg OD Bisprll 10mg OD ISMN MR 30mg OD Perindpril 4mg OD Atrvastatin 80mg OD Omeprazle 20mg OD Targets HR <60 bpm LDL <2mml/L BP <130/80 mm Hg Beta blcker (COMMIT) High dse statin (MIRACL, PROVE-IT TIMI22) Eplerenne if assciated HF (EPHESUS) Omacr (GISSI Prevenzine) ACEI (AIRE) LDL <2mml/L; BP<130/80 Cardiac rehabilitatin PROVE-IT TIMI22 Circulatin 2010

10 Key Learning Pints ACS Incidence f STEACS is falling and NSTEACS is increasing PPCI within an established netwrk t ensure timely prvisin f interventin is preferred ptin fr Rx f STEACS Early but nt immediate angigraphy ± PCI is indicated fr NSTEACS Use risk scres t assess risk-benefit Individualised treatment t reduce MACE and avid bleeding ptimised net clinical benefit Risk scres fr prgnsis in ACS Risk f death after ACS (GRACE) Bleeding (CRUSADE) In-hspital High (scre >140) >3% Intermediate (scre ) 1-3% Lw (scre 108) <1% 6 mnths pst-discharge High (scre >118) >8% Intermediate (scre ) 3-8% Lw (scre 88) <3% Determinants f risk Age Baseline Hb egfr HR Female gender Signs f heart failure Prir vascular disease DM SBP <110 r >180 mm Hg CRUSADE Bleeding Scre p<0.001 fr trend; Derivatin: C=0.71 Validatin: C