Acute Coronary Syndrome. Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine

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1 Acute Coronary Syndrome Cindy Baker, MD FACC Director Peripheral Vascular Interventions Division of Cardiovascular Medicine

2 Topics Timing is everything So many drugs to choose from What s a MINOCA? 2

3 Acute Coronary Syndrome Clinical syndrome with acute myocardial ischemia and/or infarction due to an abrupt reduction in coronary blood flow. UA STEMI NSTEMI 3

4 Libby P. Inflammation in Atherosclerosis. Nature 420;

5 Acute Coronary Syndromes Presentation Ischemic Discomfort ACS Working Dx ECG No ST Elevation NSTE-ACS ST Elevation Cardiac Biomarker UA NSTEMI* STEMI* Final Dx Unstable Angina Myocardial Infarction NQMI QwMI Noncardiac Etiologies

6 Reperfusion Therapy for Patients with STEMI *Patients with cardiogenic shock or severe heart failure initially seen at a non PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy ACC/AHA Guideline for the Management of STEMI

7 Primary PCI in STEMI IIb 2013 ACC/AHA Guideline for the Management of STEMI

8 NSTEMI/UA Early Invasive Strategy Ischemia Driven Strategy 8

9 TIMI Risk Score* for NSTE-ACS TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 d After Randomization, % *The TIMI risk score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables: 65 y of age; 3 risk factors for CAD; prior coronary stenosis 50%; ST deviation on ECG; 2 anginal events in prior 24 h; use of aspirin in prior 7 d; and elevated cardiac biomarkers.

10 GRACE Risk Model Nomogram To convert serum creatinine level to micromoles per liter, multiply by 88.4.

11 Factors Associated With Appropriate Selection of Early Invasive Immediate Invasive (within 2 hrs) Signs or symptoms of HF or worsening MR Hemodynamic instability Recurrent angina or ischemia at rest or with low level activites despite intensive medical therapy Sustained VT or VF Early Invasive (within 24 hrs) None of the above but GRACE score > 140 Temporal change in Tn New or presumably new ST depression Delayed invasive (within 24-72hrs) None of the above but diabetes mellitus Renal insufficiency (GFR < 60 ml/min.1.73m2) Reduced LV systolic function (EF <0.40) Early post-infarct angina PCI within 6 months Prior CABG GRACE risk score ; TIMI score >/=2 11

12 Factors Associated With Appropriate Selection of Ischemia- Guided Strategy Ischemia-guided stategy Low-risk score (TIMI 0 or 1), GRACE <109 Low-risk Tn negative female patient Patient or clinician preference in the absence of high-risk features 12

13 Antiplatelet Therapy in Acute Coronary Syndrome Deepak L. Bhatt et al. Circ Res. 2014;114: Copyright American Heart Association, Inc. All rights reserved.

14 Adjunctive Antiplatelet Therapy to Support Reperfusion With Primary PCI *The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily ACC/AHA Guideline for the Management of STEMI

15 Steg PG, et al. Circulation. 2010;122: Plato Trial

16 NSTEMI/UA Treated With an Initial Invasive or Ischemia-Guided Strategy Recommendations COR LOE A P2Y 12 inhibitor (either clopidogrel or ticagrelor) in addition to aspirin should be administered for up to 12 months to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy. Options include: I B Clopidogrel: 300-mg or 600-mg loading dose, then 75 mg daily Ticagrelor : 180-mg loading dose, then 90 mg twice daily B The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

17 Treated With an Initial Invasive or Ischemia-Guided Strategy Recommendations COR LOE It is reasonable to use ticagrelor in preference to clopidogrel for P2Y 12 treatment in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strategy. IIa B In patients with NSTE-ACS treated with an early invasive strategy and dual antiplatelet therapy (DAPT) with intermediate/high-risk features (e.g., positive troponin), a GP IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. Preferred options are eptifibatide or tirofiban. IIb B

18 Cangrelor H N S 4Na + N N O O O P Cl Cl O P O O O P O O O N N S C F 3 H O O H Intravenous P2Y 12 inhibitor ADP analogue Plasma half-life: 3-6 minutes Full recovery of platelet function within 60 minutes

19 Bhatt DL et al. N Engl J Med 2013;368: Champion Phoenix Trial

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21 21 Yeh RW, Secemsky EA, Kereiakes DJ, et al, DAPT Study Investigators. JAMA. 2016;315:

22 MINOCA -Definition A positive cardiac biomarker Clinical evidence of ischemia (symptoms, ST-T wave changes, development of pathologic Q waves, imaging evidence of new loss of viable myocardium or new wall motion abnormality Non-obstructive coronary arteries on angiography (less than 50%) Eur Heart J 2016

23 MINOCA -Incidence Estimated 54, ,000 cases/year in US Up to 5% one-year death rate AHA statistics 2016; Pasupathy et al Circulation. 2015; 131:

24 24 Non-Obstructive CAD- Common in All Forms of ACS

25 25 MINOCA is Caused By a Variety of Underlying Etiologies

26 26 MINOCA is Caused By a Variety of Underlying Etiologies

27 Plaque Rupture 27 Images taken from Light Lab Imaging/SJM

28 28 Cardiac MRI Can Be Helpful to Identify Cause of MI

29 Women s Heart Attack Program (HARP) Clinical Imaging Study: OCT and MRI in women with MINOCA Population Stress Study: Randomized trial of stress management intervention in women with MI Basic Platelet Study: Comprehensive assessment of thrombotic and platelet-mediated pathways in women with MINOCA 29 funded by the AHA Go Red for Women Network

30 30 THANK YOU!