What is a myocardial infarction and how do we treat it? Paul Das Consultant Cardiologist North Wales Cardiac Centre Glan Clwyd Hospital

Transcription

1 What is a myocardial infarction and how do we treat it? Paul Das Consultant Cardiologist North Wales Cardiac Centre Glan Clwyd Hospital

2 What is a myocardial infarction?

3 THEY AINT WHAT THEY USED TO BE

4 Case 1 79 yo F Intermittent chest pain 6 days HS Trop T 782, 1909 ng/l

5 Case 2 76 yo M AF 30 mins chest pain at rest Trop I 540, 4215 ng/l

6 Case 3 65 yo man On holiday Hypertension 2 days exertional chest pain HS Trop T 179, 180, 190 ng/l

7 Case 4 56 yo M Smoker 2 hours acute chest pain HS Trop T 23, 2303 ng/l

8 3 rd Universal definition of acute myocardial infarction (2012): Myocardial cell death due to prolonged ischaemia Evidence of myocardial necrosis within a clinical setting consistent with acute myocardial ischaemia Detection of a rise +/- fall in cardiac biomarker values above 99 th centile URL plus at least one of: Symptoms of ischaemia Significant ST changes or new Left Bundle Branch Block Imaging evidence of wall motion abnormality or loss of myocardial viability Development of pathological Q waves Intracoronary thrombus seen at angiography or autopsy

9 High Sensitivity Cardiac Troponin T Values from ng/l 99 th centile = 14 ng/l Rule out MI if two readings <14 in 6 hours Doubling plus one reading >14 suggests acute MI Change (delta) of % may be due to chronic event Delta <20% suggests not an acute evenet

10 PRIMARY CORONARY ARTERY DISEASE -Plaque rupture -Thrombus INJURY UNRELATED TO ISCHAEMIA -Trauma -Cardiotoxins IMBALANCE OF MYOCARDIAL O2 SUPPLY & DEMAND -Dysrhythmias -Coronary spasm -LV hypertrophy -Anaemia -Aortic dissection etc INDIRECT MYOCARDIAL INJURY -PE -Sepsis -Renal failure etc

11 Classification of MI (2012) Type 1 Spontaneous MI Type 2 Myocardial injury due to ischaemic imbalance Type 3 Cardiac death with symptoms but no biomarkers Type 4a MI related to PCI Type 4b In-stent thrombosis Type 5 MI related to CABG

12 Mechanisms of Type 1 vs Type 2 MI

13 NICE guidance for assessment of acute chest pain Initial assessment and referral to hospital Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering: -the history of the chest pain -the presence of cardiovascular risk factors -history of ischaemic heart disease and any previous treatment previous investigations for chest pain Initially assess people for any of the following symptoms, which may indicate an ACS: -pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes -chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these -chest pain associated with haemodynamic instability -new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes Do not use people's response to glyceryl trinitrate (GTN) to make a diagnosis Do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant feature

14 NICE guidance for assessment of acute chest pain Resting 12-lead ECG Take a resting 12-lead ECG as soon as possible. When people are referred, send the results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital Follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor (see recommendation ) Follow Unstable angina and NSTEMI (NICE clinical guideline 94) for people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive of a NSTEMI or unstable angina until a firm diagnosis is made. Continue to monitor (see recommendation ) Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider followingunstable angina and NSTEMI (NICE clinical guideline 94) if these conditions are likely. Continue to monitor (see recommendation ) Do not exclude an ACS when people have a normal resting 12- lead ECG.

15 NICE primary management of acute coronary syndromes Immediate management of a suspected acute coronary syndrome Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances Offer pain relief as soon as possible. This may be achieved with GTN (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance (Unstable angina and NSTEMI [NICE clinical guideline 94] or local protocols for STEMI) Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, Monitor people with acute chest pain, using clinical judgement to decide how often this should be done, until a firm diagnosis is made.

16 Assessment of acute chest pain

17 All patients with ST elevation myocardial infarction should be treated with Primary PCI Paul Das MD MRCP Consultant Cardiologist Glan Clwyd Hospital & Cardiothoracic Centre Liverpool 18 th Feb 2008

18 North Wales Primary PCI Service

19 North Wales PPCI Service Launched June 2015 Ambulance Network protocol Direct admissions Interhospital transfers from Wrexham & Bangor Mon-Fri 9am-5pm Entire BCUHB region Activations received & managed by ANPs 24/7 service planned Q3 2016

20 BCUHB North Wales 11/05/

21 BCUHB & North Wales Cardiac Network Population c Postcode of admissions to each hospital NWCC West (Bangor) Pop Central (Rhyl) Pop East (Wrexham) 5 th Nov 2014 Pop

22 PPCI pathway activation criteria Symptoms compatible with acute myocardial infarction within the last 12 hours AND one of the following ECG criteria: ST segment elevation >1mm in contiguous limb leads or >2mm in contiguous chest leads Left bundle branch block (LBBB) believed to be new Patients resuscitated from cardiac arrest with return of spontaneous circulation (ROSC) and respiration who meet these ECG criteria

23 Daytime PPCI service: 186 activations 133 emergency angiograms 105 patients stented

24 Recording STEMI admissions for PPCI Median = 120 mins 84% < 150 mins (standard 75%) Median = 34 mins 82% < 45 mins (standard <45)

25 48 hour stay following PPCI Clinical stability Monitor for arrythmias Assess LV function Initiate and titrate medication Phase 1 cardiac rehabilitation

26 Difficult situations in STEMI PPCI OOH cardiac arrest Cardiogenic shock Left bundle branch block

27 Inpatient management of NSTEMI

28 Basic medical treatment for NSTEMI Aspirin Clopidogrel usually 12 months Low-molecular weight heparin as inot Beta blocker - bisoprolol ACE inhibitor - ramipril High dose statin atorvastatin 80mg / day GTN spray

29 Antiplatelets and anticoagulant therapy after MI ANTIPLATELETS Aspirin Clopidogrel 75mg od Ticagrelor 90mg bd Prasugrel 10(5)mg od ANTICOAGULANTS Warfarin Apixaban Dabigatran Rivaroxaban

30 ESC guidance for management of antiplatelets and anticoagulants

31 Cardiac rehabilitation Phase 1 Inpatient, step-change Evaluation, explanation, mobilisation, discharge planning Phase 2 Early post-discharge Support, information Phase 3 Upto 8 wks Structured exercise programme low-mod intensity Education and lifestyle adjustment Phase 4 Long-term maintenance of exercise / lifestyle (BACR: British Association for Cardiac Rehabilitation)

32 2016 DVLA regulations for driving after MI

33 Discharge after MI Communication from secondary / tertiary care Dual antiplatelet therapy 12 months Follow specific advice re. anticoagulation ACE inhibitors Titrate every 1-2 wks to max / tolerated dose U&Es at 1-2 wks / during titration / annually ARB if ACE-I not tolerated Beta blockers Titrate to max tolerated dose

34 Statins in secondary prevention after MI High dose 80mg atorvastatin for upto 12 months then 40mg Target Total-C < 4.0 or LDL-C < 2.0 Check at 3 months then annually, monitor compliance Check LFTs at 3 and 12 months

35 Case 1 79 yo F Intermittent chest pain 6 days HS Trop T 782, 1909 ng/l

36 Case 1

37 Case 1 Echocardiogram severe LV impairment Completed anterior Q wave infarct Medical management Heart failure clinic For viability and arrhythmia studies

38 Case 2 76 yo M AF 30 mins chest pain at rest Trop I 540, 4215 ng/l

39 Case 2

40 Case 2 NSTEMI Echo: mild lateral hypokinesia PCI to circumflex Cardiac rehab HASBLED score=2 so triple antiplatelet therapy upto 6 months

41 Case 3 65 yo man On holiday Hypertension 2 days exertional chest pain HS Trop T 179, 180, 190 ng/l

42 Case 3

43 Case 3 Type 2 infarct, not acute Echo: LV hypertrophy, apical hypokinesia AF with CHADS2VA2Sc score=3 Anticoagulation only Advise cardiac MRI and rhythm monitor

44 Case 4 56 yo M Smoker 2 hours acute chest pain HS Trop T 23, 2303 ng/l

45 Case 4

46 Case 4 Acute inferior STEMI PPCI to right coronary artery Echo: mild inferior hypokinesia Discharge day 2 Cardiac rehab & nicotene patch!

47 Roles of primary and secondary care in management of MI Primary care role: Identification and Referral Secondary care role: Diagnosis, risk stratification and management Secondary / tertiary care role: Appropriate revascularisation Primary care role Cardiac rehabilitation Secondary risk reduction

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