M/39 CC D. => peak CKMB (12 hr later) ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl #

Transcription

1 Acute Coronary Syndrome - Case Review - Young-Guk Ko, MD Yonsei Cardiovascular Center Yonsei University College of Medicine

2 Case 1

3 M/39 # CC D : Severe squeezing chest pain : 4 hours, aggravated since 1 hr ago Risk factors : HTN (-),( DM (-)( Smoking - 30 PYs P/Ex : BP 150/65 mmhg, PR 71/min Lab : initial CKMB 3.04 ng/ml, Troponin-T T <0.01 ng/ml => peak CKMB (12 hr later) ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl

4 EKG : Initial in ER

5 Chest AP

6 Management in ER Aspirin 250 mg p.o. Clopidogrel 300 mg p.o. Nasal O 2 Heparin i.v IU Morphin 3 mg => Cath room

7 Coronary Angiography

8 PCI with protection device Cypher 3.0 x 18 mm

9 Aspirate from culprit coronary artery

10 EKG : 90 min after PCI

11 EKG : at discharge HD #4

12 Echocardiography LVEF 55%

13 Heart MRI

14 Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 120 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1

15 Stone GW et al. JACC 2002 Post Procedure Angiography 173 pts with AMI treated with PTCA < 24 h

16 Survival in Patients with TIMI-3 3 Flow Months Stone GW et al. JACC 2002

17 Protection Devices

18 Frequency (%) FilterWire TM System - Case-matched controlled study, Single center, Pisa - p= TIMI 3 Flow Grade 3 Myocardial Blush n=47 (FW group) Distal Protection (n=53) PCI Alone (n=53) 66 p= p= Complete (>70%) ST Resolution Change in LVEF (%) at 30D FW p <0.02 Control Limbruno U, et al. Circulation 2003;108:171-6.

19 EMERALD (1) n=501, STEMI 6 hr, 2mm ST or LBBB, No cardiogenic shock Myocardial Blush (% Patient) p=ns GuardWire Control ST-Segment Resolution at 30min p=ns GuardWire (n=233) Control (n=216) / Final 0 Absent ( < 30%) Partial (30-70%) Complete ( > 70%) Stone GW. JAMA. 2005;293:

20 EMERALD (2) n=501, STEMI 6 hr, 2mm ST or LBBB, No cardiogenic shock Infarct Size by 99m Tc-SPECT p=ns GuardWire Control Days MACE (% Patient) p=ns GuardWire (n=243) Control (n=244) All (n=427) LAD (n=171) RCA/LCx (n=256) 0 Death MACE Stone GW. JAMA. 2005;293:

21 YUMC data

22 infarcted mass/lv mass (%) P = 0.03 Initial MRI Follow up MRI YUMC data

23 Delayed hyperenhancement at MRI in patients with AMI Kim et al. NEJM 2000;343:

24 MRI hyperenhancement thickness & (%) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% contractile function reserve 94/98(95.9%) 40/80(50.0%) N=32, pts with primary PCI, Initial MRI, 6M after Exercise echo 24/113(21.2%) < 25% 26-50% 51-75% % Percent of segments with functional improvement 12/119(10.1%) Transmural extent of hyperenhancement(%) ACC abstract, YUMC data

25 Case 2

26 F/66 # CC : Epigastric pain with nausea D : 1½1 hours Risk factors : HTN (-),( DM (-)( P/Ex : BP 95/55, PR 29/min Lab : initial CKMB 3.06 ng/ml TnT <0.01 ng/ml => peak CKMB ng/ml T.chol/TG/HDL/LDL 187/34/46/134 mg/dl

27 EKG : Initial in ER

28 Management in ER Aspirin 250 mg p.o. Clopidogrel 300 mg p.o. Nasal O 2 Heparin 4000 IU i.v. Tenecplase (TNK) 30 mg i.v.. bolus => Cath room

29 EKG : 10 min after TNK injection

30 Coronary Angiography

31 PCI Cypher 3.5 x 23 mm

32 EKG : 90 min after PCI

33

34 Case 3

35 M/50 # CC : Sudden substernal chest pain at rest D : 30 min PI : intermittent effort chest pain for 1 year Risk factors : HTN (+) for 6 months, on med DM (+) for 2 years, on oral med Smoking (+) 30 PYs P/Ex : BP 130/80, PR 60/min Lab : Initial CKMB 3.04 ng/ml, Troponin-T T <0.01 ng/ml => peak CKMB ng/ml AC Glucose 182 mg/dl, HbA1c 7.2% T.chol/TG/HDL/LDL 180/150/48/102 mg/dl

36 EKG : Initial in ER

37 Chest AP

38 Management in ER Aspirin 250 mg p.o. Clopidogrel 300 mg p.o. Nasal O 2 Heparin 4000 IU i.v. Tenecplase (TNK) 40 mg i.v.. bolus => Cath room

39 Coronary Angiography

40 PCI with protection device Cypher 3.5 x 18 mm

41 EKG : 90 min after PCI

42 EKG : at discharge

43 Echocardiography

44 Heart MRI

45 Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 120 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1 Glimepiride 2mg #1

46 Time is myocardium Door-to to-balloon time < 90 min But, US NRMI data 111 min for all, 198 min for transfer Importance of complete restoration of flow TIMI 3 after thrombolysis 50~60% Pharmacoinvasive recanalization! Dauerman and Sobel.. J Am Coll Cardiol 2003;42:646

47 Dauerman Dauerman and and Sobel Sobel. J Am. J Am Coll Coll Cardiol Cardiol 2003;42: ;42:646

48 GUSTO-V V investigators. Lancet 2001;357:1905 GUSTO-V Reteplase + Abciximab 16,588 pts with AMI < 6h Full dose r-pa r vs half dose r-pa + abciximab

49 ASSENT-3 3 investigators. Lancet 2001;358:605 ASSENT-3 Tenecteplase + LMWH / Abciximab / Heparin 6,095 pts with AMI < 6h Probability (%) Tenecteplase + Heparin Tenecteplase + Enoxaparin Tenecteplase + Heparin + Abciximab log-rank p= Days to death, remi,, refractory ischemia Primary endpoints Death Recurrent MI Refractory ischemia Bleeding (non-cerebral) Abciximab 39.7 % Enoxaparin 25.6 % Heparin 21.1 %

50 Case 4

51 M/60 # C.C : Chest pain at rest D : for 2 hr PHx : HiBP(-), DM (-), Smoking (-) Hypercholesterolemia (+) => no med P/Ex : BP 150/100 mmhg PR 87/min Lab : CKMB : initial 20.5 ng/ml=> peak ng/ml Tn-T ng/ml, hscrp mg/l T.chol/TG/HDL/LDL 153/219/32/101 mg/dl

52 EKG : Initial in ER

53 Chest PA

54 Management in ER Aspirin Clopidogrel 250 mg 300 mg Nasal O 2 Enoxaparin 60 mg s.q.. bid Tirofiban (Agrastat)) 0.4 µg/kg/min i.v.. bolus => 0.1 g/kg/min i.v. for 48 hr

55 EKG : 8 hours later

56 Echocardiography Normal sized cardiac chambers No regional wall motion abnormality LVEF = 73%

57 Coronary Angiography HD #3

58 PTCA with Stenting Cypher 2.75 x 33 mm

59 PTCA with Stenting Pre Post stenting

60 Heart MRI

61 Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 60 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1

62 Placebo GP IIb/IIIa antagonist 30 day mortality & MI 20% 16% 12% 8% 4% P=0.015 P= % 15.7% 14.2% 4.7% *at 6 month : 17.9% vs 13.7%, p=0.027 *P=NS 11.7% 10.6% P=NS 7.1% 5.8% P=NS 8.0% 8.2% 0% PRISM-PLUS PURSUIT PARAGON PRISM GUSTOIV-ACS n=1915 n=10,948 n=2282 n=3232 n=7800 Tirofiban + heparin Eptifibatide + heparin Lamifiban ± heparin Tirofiban only Abxicimab +heparin

63 30-Day Death or MI N All PCI Trials All ACS Trials ACS Troponin (+) 1368 ACS PCI 2311 ACS no PCI ACS Troponin (-) RRR Placebo IIb/IIIa % 5.6% % 11.4% % 6.9% % 9.6% % 13.3% % 6.5% IIb/IIIa better Placebo Better Chew & Moliterno JACC 2000; 36:2028

64 Recurrent ischemia / ST seg.. shift / deep T inversion / cardiac markers Early invasive strategy Monitoring (rhythm and ischemia) β blocker/nitrate/heparin GP IIb/IIIa inhibitor Early conservative strategy Immediate angiography hour angiography Recurrent ischemia, HF or serious arrhythmia stabilized LV function EF<40% EF>40% Stress Test Not low risk Low risk 2002 ACC/AHA UA/NSTEMI Guidelines Medical Rx

65 Case 5

66 F/77 # CC D : Severe chest pain developed during sleep : 3 hours Risk factors : HTN (+) for 10yrs, on med DM (-)( PHx : Bronchial asthma for 5 yrs P/Ex : BP 145/77, PR 68/min Lab : Initial CKMB ng/ml, Troponin-T T ng/ml => peak CKMB ng/ml T.chol/TG/HDL/LDL 169/83/63/129 mg/dl

67 Chest AP

68 EKG : Initial in ER

69 Management in ER Aspirin 250 mg p.o. Clopidogrel 300 mg p.o. Nasal O 2 Heparin 5000 IU i.v. Tirofiban (Agrastat )) 0.4ug/kg i.v.. loading => 0.1ug/kg/min for maintenance

70 EKG : 12 hours later

71 Coronary Angiography

72 PTCA with Stenting Vision 3.5 x 15 mm

73 PTCA with Stenting

74 Aspirate from culprit coronary artery

75 EKG : after PCI

76 Echocardiography

77 Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Diltiazem 90 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1

78 EKG : at discharge

79 EKG : 4 months later