STEMI Presentation and Case Discussion. Case #1

Transcription

1 STEMI Presentation and Case Discussion Scott M Lilly MD PhD, Interventional Cardiology The Ohio State University Contemporary Multidisciplinary Cardiovascular Conference Orlando, Florida September 17 th, 2016 Case #1 37 year old male Hypertension, tobacco use Works as a roofer Typical work day, returned home, experienced sudden onset chest pain Presented to local hospital Symptom onset to presentation: 30 minutes ECG obtained Aspirin, ticagrelor, heparin bolus Transferred Estimated Transfer Time: 45 minutes 1

2 Case #1 2

3 9/17/2016 3

4 Pathophysiology and Therapy Lilly et al Lilly and Wilensky, Curr Pharm Ther

5 ACS Management: Drug Therapy Address Pathophysiology Anti platelet Aspirin ADP Receptor Inhibitor Clopidogrel Prasugrel Ticagrelor Minimize Consequences Beta receptor antagonists ACE inhibitors Statins Anti coagulation Aspirin in ACS Multiple trials 30 50% RR in death, myocardial infarction O Gara et al ACC/AHA STEMI Guideline. O Gara et al., STEMI Guidelines; The RISC Group. Lancet

6 CURE: Clopidogrel for UA/NSTEMI CV Death, MI, Stroke Cumulative Hazard Rate Placebo + Aspirin (n=6303) Clopidogrel + Aspirin (n=6259) Months of Follow-up 20% Relative Risk Reduction P<0.001 n=12,562 Yusuf S et al. N Engl J Med. 2001;345:494. ADP Receptor Inhibitors CLOPIDOGREL PRASUGREL TICAGRELOR CANGRELOR Plt inhibition 40 60% 70% 80 90% % Pharmacology Irreversible, prodrug Irreversible, prodrug Reversible, active drug Reversible, active drug Onset 2 4h h 30 min 30 min 2 min Duration 3 10 d 5 10 d 3 4 d min Trials CURE TRTON TIMI 38 PLATO Outcomes Standard CV Mort, MI, CVA CV Mort, MI, CVA** CHAMPION PHOENIX MI, ST Dose/Cost QD/+ QD/++ BID/+++ IV/++++ 6

7 Balancing Risks Ischemic risk Bleeding risk PRASUGREL TICAGRELOR CANGRELOR Ischemia/MACE Reduced Reduced Reduced Bleeding Increased No increase Increased Mortality No change Reduced No change Exclusions Platelet Inhibition CVA/TIA, < 60 kg, > 75 yo ICH ICH Case Conclusion and Take Home Points First medical contact to balloon: 82 minutes Drug eluting stent to left anterior descending artery Pre discharge ejection fraction 25 30% Discharge medications included aspirin 81 mg daily, ticagrelor 90 mg twice daily, metoprolol XL 50 daily, and lisinopril 10 mg daily 7

8 Case #2 73 year old male No past medical history Awoke with chest pain and diaphoresis Progressed, included nausea and emesis Presented to local hospital Symptom onset to presentation: ~ 25 minutes ECG obtained Aspirin, clopidogrel, heparin bolus Transferred Estimated Transfer Time: 45 minutes Case #2 8

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11 Clinical Course Drug eluting stent to the right coronary artery First contact to balloon 90 minutes Post PCI ejection fraction 60 65% with mild inferior wall hypokinesis. Experienced dyspnea on ticagrelor transitioned to clopidogrel Transition between ADP Receptor Antagonists ADP Receptor antagonists have different pharmacodynamics. These differences are incredibly relevant when transitioning between agents in the vulnerable perimyocardial infarction period. ACC.16; Min et al., submitted 11

12 Transition between ADP Receptor Antagonists Maintained Clopidogrel Ticagrelor to Clopidogrel P Value n = 2857 (94%) n = 182 (6%) Composite Endpoint 66 (2.31) 4 (2.20) Myocardial infarction 27 (0.95) 2 (1.10) In hospital mortality 0 (0.00) 0 (0.00) Cerebrovascular events 3 (0.11) 0 (0.00) Bleeding event within 72 hrs 36 (1.26) 2 (1.10) ACC.16; Min et al., submitted Case Conclusion and Take Home Points Drug eluting stent to the right coronary artery Transitioned from ticagrelor to clopidogrel due to dyspnea Pre discharge ejection fraction 60 65% with mild inferior wall hypokinesis. Large observational series or randomized trials are needed to establish an optimal algorithm for transition between ADP receptor antagonists. 12

13 Case #3 60 year old male, hypertension, hyperlipidemia Acute substernal chest pain, nausea and emesis Called EMS, and to arrived at non PCI hospital within an hour of symptom onset Inclement weather with anticipated transfer delay of 2.5 hours 25 Case #3 60 year old male with inferior STEMI Tenecteplase administered, along with aspirin, clopidogrel and heparin Transferred to Ross Heart Hospital Hemodynamically stable, but with ongoing chest pain 26 13

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15 Thrombolysis: Clinical Efficacy 22 randomized trials , n = 50,246 Thrombolysis v placebo in STEMI Mortality benefit if < 2 hours from symptoms Stroke rate 1-2% Boersma et al Lancet 348:

16 Thrombolysis: Why Now? New PCI Centers, PCI in new PCI centers ppci access increased from 79% to 79.9% PCI in 2008 No PCI in 1997 Horowitz et al. Lancet 2013; 128: Pinto, ACC.13 Pharmacotherapy if delay to reperfusion Case Conclusion and Take Home Points Rescue PCI, drug eluting stent to the distal right coronary artery Pre discharge ejection fraction 55% with mild inferior wall hypokinesis. In STEMI, thrombolysis is indicated if first medical contact to primary PCI time is judged to be > 2 hrs Transfer to PCI capable hospital, evaluate for angiography on arrival 16