Acute Coronary Syndrome - Case Review - Young-Guk Ko, MD Yonsei Cardiovascular Center Yonsei University College of Medicine
Case 1
M/39 #4306212 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) 435.4 ng/ml T.chol/TG/HDL/LDL 180/150/48/102 mg/dl
EKG : Initial in ER
Chest AP
Management in ER Aspirin 250 mg p.o. Clopidogrel 300 mg p.o. Nasal O 2 Heparin i.v.. 5000 IU Morphin 3 mg => Cath room
Coronary Angiography
PCI with protection device Cypher 3.0 x 18 mm
Aspirate from culprit coronary artery
EKG : 90 min after PCI
EKG : at discharge HD #4
Echocardiography LVEF 55%
Heart MRI
Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 120 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1
Stone GW et al. JACC 2002 Post Procedure Angiography 173 pts with AMI treated with PTCA < 24 h
Survival in Patients with TIMI-3 3 Flow Months Stone GW et al. JACC 2002
Protection Devices
Frequency (%) 100 80 60 40 20 0 98 FilterWire TM System - Case-matched controlled study, Single center, Pisa - p=0.03 85 TIMI 3 Flow Grade 3 Myocardial Blush n=47 (FW group) Distal Protection (n=53) PCI Alone (n=53) 66 p=0.006 36 80 p=0.006 54 Complete (>70%) ST Resolution Change in LVEF (%) at 30D 14 10 6 2-2 -4 FW p <0.02 Control Limbruno U, et al. Circulation 2003;108:171-6.
EMERALD (1) n=501, STEMI 6 hr, 2mm ST or LBBB, No cardiogenic shock 80 60 Myocardial Blush (% Patient) p=ns GuardWire Control 60.1 52.7 80 60 ST-Segment Resolution at 30min p=ns GuardWire (n=233) Control (n=216) 62.2 60.6 40 20 14.9 21.2 25 26.1 40 20 9.5 12.5 28.3 26.9 0 0 / 1 2 3 Final 0 Absent ( < 30%) Partial (30-70%) Complete ( > 70%) Stone GW. JAMA. 2005;293:1063-1072.
EMERALD (2) n=501, STEMI 6 hr, 2mm ST or LBBB, No cardiogenic shock Infarct Size by 99m Tc-SPECT 40 30 20 10 p=ns GuardWire Control 26.3 22.3 17.1 14.3 10.4 9.5 20 15 10 5 30 Days MACE (% Patient) p=ns 2.9 2.1 GuardWire (n=243) Control (n=244) 14 13.1 0 All (n=427) LAD (n=171) RCA/LCx (n=256) 0 Death MACE Stone GW. JAMA. 2005;293:1063-1072.
YUMC data
infarcted mass/lv mass (%) P = 0.03 Initial MRI Follow up MRI YUMC data
Delayed hyperenhancement at MRI in patients with AMI Kim et al. NEJM 2000;343:1445-53
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% 76-100% Percent of segments with functional improvement 12/119(10.1%) Transmural extent of hyperenhancement(%) 2005. ACC abstract, YUMC data
Case 2
F/66 #4315619 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 194.9 ng/ml T.chol/TG/HDL/LDL 187/34/46/134 mg/dl
EKG : Initial in ER
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
EKG : 10 min after TNK injection
Coronary Angiography
PCI Cypher 3.5 x 23 mm
EKG : 90 min after PCI
Case 3
M/50 #4315619 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 236.2 ng/ml AC Glucose 182 mg/dl, HbA1c 7.2% T.chol/TG/HDL/LDL 180/150/48/102 mg/dl
EKG : Initial in ER
Chest AP
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
Coronary Angiography
PCI with protection device Cypher 3.5 x 18 mm
EKG : 90 min after PCI
EKG : at discharge
Echocardiography
Heart MRI
Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 120 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1 Glimepiride 2mg #1
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
Dauerman Dauerman and and Sobel Sobel. J Am. J Am Coll Coll Cardiol Cardiol 2003;42:646 2003;42:646
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
ASSENT-3 3 investigators. Lancet 2001;358:605 ASSENT-3 Tenecteplase + LMWH / Abciximab / Heparin 6,095 pts with AMI < 6h Probability (%) 20 10 0 Tenecteplase + Heparin Tenecteplase + Enoxaparin Tenecteplase + Heparin + Abciximab log-rank p=0.0001 0 5 10 15 20 25 30 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 %
Case 4
M/60 # 1874435 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 58.55 ng/ml Tn-T 0.128 ng/ml, hscrp 0.353 mg/l T.chol/TG/HDL/LDL 153/219/32/101 mg/dl
EKG : Initial in ER
Chest PA
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
EKG : 8 hours later
Echocardiography Normal sized cardiac chambers No regional wall motion abnormality LVEF = 73%
Coronary Angiography HD #3
PTCA with Stenting Cypher 2.75 x 33 mm
PTCA with Stenting Pre Post stenting
Heart MRI
Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Propanolol 60 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1
Placebo GP IIb/IIIa antagonist 30 day mortality & MI 20% 16% 12% 8% 4% P=0.015 P=0.042 15.5% 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
30-Day Death or MI N All PCI Trials 17393 All ACS Trials 24311 ACS Troponin (+) 1368 ACS PCI 2311 ACS no PCI ACS Troponin (-) 12685 2901 RRR Placebo IIb/IIIa 0.66 8.5% 5.6% 0.89 12.8% 11.4% 0.42 16.3% 6.9% 0.66 14.4% 9.6% 0.93 14.3% 13.3% 1.05 6.2% 6.5% 0.25 1 2.0 IIb/IIIa better Placebo Better Chew & Moliterno JACC 2000; 36:2028
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 12-48 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
Case 5
F/77 #3256042 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 71.22 ng/ml, Troponin-T T 0.448 ng/ml => peak CKMB 79.81 ng/ml T.chol/TG/HDL/LDL 169/83/63/129 mg/dl
Chest AP
EKG : Initial in ER
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
EKG : 12 hours later
Coronary Angiography
PTCA with Stenting Vision 3.5 x 15 mm
PTCA with Stenting
Aspirate from culprit coronary artery
EKG : after PCI
Echocardiography
Medication Aspirin 100 mg # 1 Clopidogrel 75 mg # 1 Diltiazem 90 mg # 3 Captopril 150 mg # 3 Atorvastatin 10 mg #1
EKG : at discharge
EKG : 4 months later