Clinical Case. Management of ACS Based on ACC/AHA & ESC Guidelines. Clinical Case 4/22/12. UA/NSTEMI: Definition

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1 Clinical Case Management of ACS Based on ACC/AHA & ESC Guidelines Dr Badri Paudel Mr M 75M Poorly controlled diabetic Smoker Presented on Sat 7pm Intense burning in the retrosternal area Clinical Case Admission Working diagnosis Chest Pain Suspicion of Acute Coronary Syndrome Mr M 75M Poorly controlled diabetic Smoker Presented on Sat 7pm Intense burning in the retrosternal area 96bpm 110/70 Clear chest No S 3 or murmur ECG Biochemistry Risk Stratification Diagnosis Persistent ST ST or T Normal ECG Trop +ve Trop -ve High Risk Low Risk N USA Treatment Reperfusion Invasive Non-invasive ESC guidelines 2007 UA/N: Definition ST or prominent T on ECG and/or Positive biomarkers in absence of ST elevation in an appropriate clinical setting 1

2 Trends in ACS Mortality trends N 10.8 Incidence (per 100,000) Q Wave Non-Q Wave In-hospital year Furman JACC 2001 Source: ESC guidelines Implications of Statistics Principal Presentations NSTE-ACS commoner than ACS patients tend to be Older More diabetes More renal failure Other co-morbidities Overall, similar 1-yr mortality 1. Rest angina 2. New-onset angina 3. Increasing angina Pre-hospital Management Aspirin Pre-hospital Management Sublingual Nitrate Chest pain pts to have mg aspirin as early as possible No response Call Ambulance And reach ER Chewable/soluble aspirin preferred over enteric coated Single dose NTG Partial relief (only for CSA pts) Two more doses, But reach ER if Any pain persists 2

3 ECG Time Goals 1.0 Initial ECG performed & interpreted Within 10 min of arrival Survival 0.85 No ST dep 1mm dep Initial ECG non-diagnostic Serial ECGs 15-60min apart 2mm dep Follow-up in days Admission Working diagnosis Chest Pain Suspicion of Acute Coronary Syndrome Cardiac Enzymes ECG Persistent ST ST or T Normal ECG Biochemistry Trop +ve Trop -ve Risk Stratification High Risk Low Risk Diagnosis N USA Treatment Reperfusion Invasive Non-invasive Clinical case Cardiac Troponins in ACS M, 75M DM, Smoker Rest pain Clinically stable ECG change Troponin T 0.7ng/mL N Engl J Med

4 Troponins for Rx decisions Role of Echo in Risk Assessment RWMA LV dysfunction Associated valvular abnormalities Differential diagnosis Clinical case Admission Working diagnosis Chest Pain Suspicion of Acute Coronary Syndrome M, 75M DM, Smoker Rest pain Clinically stable ECG changes Positive Trop-T Echo: Hypokinetic Ant wall. EF 50% ECG Biochemistry Risk Stratification Persistent ST ST or T Normal ECG Trop +ve Trop -ve High Risk Low Risk Diagnosis N USA Treatment Reperfusion Invasive Non-invasive Risk Stratification - Purpose TIMI Risk Score for USA/N Elements of TIMI Score for risk stratification in USA 1. Likelihood of obstructive CAD 2. Risk of adverse outcomes Age 65 years 3 traditional CAD risks Prior coronary lesion 50% ST-segment deviation on admission ECG anginal episodes in last 24 hrs Prior aspirin use Elevated cardiac enzymes Presence of each element is assigned 1 point 4

5 14-day event risk with TIMI Score Clinical case TIMI Score 0 or /7 Event rates 4.7% 8.3% 13.2% 19.9% 26.2% 40.9% With increasing risk score there is progressively greater benefit from therapies like LMWH, platelet gpiib/iiia inhibitors & invasive strategy M, 75M DM, Smoker Rest pain Clinically stable Admission ECG Trop-T Positive RWMA, EF 50% TIMI risk 4 points Rx Benefit of Risk Scoring Antman et al JAMA 2000 Other Markers of Risk - BNP NEJM

6 Quick Re-Cap NSTE-ACS as important as Risk stratification aims at CAD diagnosis & estimating risks to help Rx decisions Newer Markers are emerging, but risk scores are currently the best way to predict outcomes Hospital Management History, examination, ECG & initial biomarkers should help classify chest pain patients into: Possible ACS Definite ACS Chronic stable angina Non cardiac diagnosis Hospital Management Possible ACS Normal ECG Observe, serial ECGs, Serial enzymes If negative, discharge after stress test* Abnormal ECG (or follow-up ECGs/enzymes turn positive) Treat as definite ACS Hospital Management Definite ACS Admit to CCU or step-down unit Continuous ECG ± SpO 2 monitoring Supplemental oxygen to pts with low SpO 2, respiratory distress, basal creps * Or schedule stress test on OP basis Anti-ischemic Therapy Rest / Oxygen Nitrates (sublingual/oral/topical, IV for ongoing pain) Morphine IV (pain, CHF) β-blocker (oral, IV for ongoing pain) Non-dihydropyridine Ca 2+ blocker (verapamil /diltiazem) ACE Inhibitors Anti-Ischemic Therapy Contraindications for nitrates Nitrates contraindicated in: SBP < 90mmHg or 30mmHg below baseline Severe bradycardia (< 50 bpm) Tachycardia (>100 bpm) RVMI Pts with ED who took sildenafil in last 24h or tadalafil in last 48h 6

7 Anti-Ischemic Therapy Beta-blockers Anti-Ischemic Therapy Calcium channel blockers Start β-blocker within first 24h for patients who do not have: signs of HF low-output state high risk for cardiogenic shock AV block, asthma Verapamil or diltiazem: initial therapy if LV function is normal & if β# cannot be given Immediate-release dihydropyridine Ca- antagonists not to be used unless combined with a β-blocker Anti-Ischemic Therapy ACEI/ARB Anti-coagulants ACEI for pulmonary congestion or LVEF 40% Contraindicated if hypotension (SBP <100 mmhg or <30 mmhg below baseline) or other known contraindications ARB may be used in pts intolerant of ACEI UFH Enoxaparin Fonduparinux LD: 60 U/ kg (max 4000 U) Infusion: 12 U/kg/ h (max 1000 U/ h) Maintain aptt times control LD: 30 mg IV bolus MD: 1 mg/ kg SC q12h 2.5 mg SC once daily Platelet GP IIb/IIIa Receptor Antagonists Clinical case 1. In all patients managed with invasive Rx 2. Patients who continue to have ischemia despite ASA+CLOP+heparin 3. Patients in the high risk group M, 75M DM, Smoker Rest pain Clinically stable Admission ECG Trop-T Positive RWMA, EF 50% Pain persists Same ECG Eptifibatide bolus followed By infusion started 7

8 Choice of GpIIbIIIa blocker IV eptifibatide or tirofiban is the preferred choice Abciximab is indicated only if PCI is likely without appreciable delay Select Management Strategy: Initial Invasive Versus Initial Conservative Strategy 1. First contact INITIAL EVALUATION 2. diagnosis/risk assessment VALIDATION 3. Invasive strategy 1. First contact INITIAL EVALUATION 2. diagnosis/risk assessment VALIDATION 3. Invasive strategy URGENT Persistent angina Persistent ECGs CHF/instability VT/VF URGENT Persistent angina Persistent ECGs CHF/instability VT/VF Chest pain type Physical Risk factors ECG ACS Troponins Biochem Special markers Serial ECGs Assess risk score EARLY troponins Dynamic ECGs DM/Renal dysfunction LV dysfunction Post MI angina Prior MI/PCI/CABG High risk scores Chest pain type Physical Risk factors ECG ACS Troponins Biochem Special markers Serial ECGs Assess risk score EARLY troponins Dynamic ECGs DM/Renal dysfunction LV dysfunction Post MI angina Prior MI/PCI/CABG High risk scores ESC 2007 ACS unlikely NO or ELECTIVE No CP recurrence No CHF No ECG/Trop change ESC 2007 ACS unlikely NO or ELECTIVE No CP recurrence No CHF No ECG/Trop change 1. First contact INITIAL EVALUATION 2. diagnosis/risk assessment VALIDATION 3. Invasive strategy Chest pain type Physical Risk factors ECG ACS Troponins Biochem Special markers Serial ECGs Assess risk score EARLY URGENT Persistent angina Persistent ECGs CHF/instability VT/VF troponins Dynamic ECGs DM/Renal dysfunction LV dysfunction Post MI angina Prior MI/PCI/CABG High risk scores Evidence for Early Invasive Rx ESC 2007 ACS unlikely NO or ELECTIVE No CP recurrence No CHF No ECG/Trop change 8

9 Invasive strategy in non-st elevation ACS Is there reduction in death or non-fatal MI? Invasive strategy in non-st elevation ACS Is there a mortality benefit? Trial FU months FRISC2 60 TRUCS 12 TACTICS 6 RITA 3 60 VINO 6 ISAR COOL 1 ICTUS 32 TOTAL 37 OR 0.85 (95% CI ) NNT 43 Odds Ratio (95%CI) Inv Con 19.9% 24.5% 7.9% 16.7% 7.3% 9.5% 15.9% 19.5% 6.3% 22.4% 5.8% 11.8% 23.0% 15.3% 14.8% 17.1% Trial FU months FRISC2 60 TRUCS 12 TACTICS 6 RITA 3 60 VINO 6 ISAR COOL 1 ICTUS 32 TOTAL 38 OR 0.85 (95% CI ) NNT 83 Odds Ratio (95%CI) Inv Con 9.6% 10.0% 3.9% 12.5% 3.3% 3.5% 11.4% 14.4% 3.1% 13.4% 0.0% 1.4% 7.5% 6.7% 7.3% 8.5% N=8114 P= Invasive better Conservative better N=8375 P= Invasive better Conservative better Routine vs Selective Invasive Strategies in ACS To Cath or Not to Cath That Is No Longer the Question How Soon should we cath? ISAR-COOL: Major results at 30 days End point Cooling off (%) Death/MI Death Nonfatal MI Q-wave MI Early intervention(%) Significant reduction in primary endpoint (p=0.04) Neumann FJ. AHA Scientific Sessions 2002 TIMACS trial Timing of intervention in patients with acute coronary syndromes CAG<24 h v/s >36h Early Secondary endpoints Delayed Early Delayed Clinical Case Death/MI/Revasc Death/refractory isch/stroke Shamir Mehta. AHA scientific sessions

10 Cardiac cath CAD Yes No Revascularization Strategy in UA/N Discharge from protocol Post-Discharge care Drugs required in the hospital to control ischemia should be continued after hospital discharge Left main disease Yes CABG No Education about symptoms of AMI & how to seek help ASA 75 to 325 mg/d 1- or 2- Vessel Disease Medial Therapy, PCI or CABG 3- or 2-vessel disease with proximal LAD involvement LV dysfunction or treated diabetes* No PCI or CABG Yes CABG *There is conflicting information about these patients. Most consider CABG to be preferable to PCI. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1 e157, Figure 20. Clopidogrel 75 mg/d β-blockers if no contraindications Lipid-lowering agents & diet ACEI if CHF, LVEF<0.40, HT or diabetes Long-Term Antithrombotic Therapy at Hospital Discharge after UA/N Medical Therapy without Stent UA/N Patient Groups at Discharge Bare Metal Stent Group Drug Eluting Stent Group Special Subsets Diabetes Mellitus Aggressive Rx approach just like nondiabetics ASA 75 to 162 mg/d indefinitely & Clopidogrel 75 mg/d at least 1 month & up to 1 year ASA 162 to 325 mg/d for 1 month, then 75 to 162 mg/d indefinitely & Clopidogrel 75 mg/d for at least 1 month and up to 1 year ASA 162 to 325 mg/d for 3-6 months, then 75 to 162 mg/d indefinitely & Clopidogrel 75 mg/d for at least 1 year Focus on good glycemic control Yes Indication for Anticoagulation? No Prefer CABG if multivessel disease suitable for both Rx modes Add: Warfarin (INR 2.0 to 2.5) Continue with dual antiplatelet therapy as above Anderson JL, et al. J Am Coll Cardiol 2007;50:e1 e157, Figure 11. INR = international normalized ratio; LOE = level of evidence. Special Subsets Older Patients Management intent similar to the young Include functional status & comorbidities in decision making Dosage adjustments Special Subsets Women No difference in medical Rx Recommendations for invasive strategy: similar to those of men In women with low-risk features: conservative strategy similar to men 10

11 Thank You 11