Inpatient Management of Non-ST Elevation Acute Coronary Syndromes Edward McNulty MD, FACC Assistant Clinical Professor UCSF Director, SF VAMC Cardiac Catheterization Laboratory Disclosures None New Guidelines for Non-ST Elevation MI/Unstable Angina ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST- Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. 1
Algorithm: Algorithm Simplified: Questions 1. Need to be an inpatient? 2. What Anticoagulation? 3. Need stress or cath? Tools 1. History/Exam 2. ECG 3. Troponin Case 1 - History 35 year old with no prior medical history reports vague chest discomfort and muscle soreness one day after lifting weights. No history of tobacco, cocaine or other illicit drug use On no meds 2
Case 1 - Exam BP 125/70 HR 80 sinus No signs of heart failure No signs of structural heart disease Partially reproduce symptoms with palpation/movement ECG Decision Time! Questions 1. Need to be an inpatient? 2. What Anticoagulation? 3. Need stress or cath? Tools 1. History/Exam 2. ECG 3. Troponin 3
Symptoms & Likelihood of MI OR (95% CI) Right arm/shoulder radiation 4.7 (1.9-12) Both arms/shoulders 4.1 (2.5-6.5) Exertional 2.4 (1.5-3.8) Left arm 2.3 (1.7-3.1) Pressure 1.3 (1.2-1.5) Pleuritic.2 (.1 -.3) Positional.3 (.2 -.5) Reproduced with palpation.3 (.2 -.4) Nitroglycerin responsive NS Swap et al JAMA 2005 ECG & in hospital mortality ST elevation 8.8% ST depression 8.5% T-wave inversion 4.9% (GUSTOIIb) Normal ECG = 1-6% chance of MI (Audience Response) The patient is admitted to your service because the chest pain unit is not operational. You decide to: (1) discharge to home right away (2) get more data 4
Troponin Troponin I is sent and is 2.5 ng/dl! Troponin & prognosis figure Waxman et al 2006 Case 2 - History 65 year old smoker with HTN presents with two weeks of right shoulder tightness and exertional dyspnea while playing golf. Had a mild episode after breakfast and decided to come to the ED PMHx also notable for high LDL for which he takes simvastatin in addition to aspirin 5
Case 2 - Exam BP 140/75 HR 90 s JVP difficult to assess Few bibasilar crackles No murmurs,s3, or S4 No edema Diminished pedal pulses bilaterally with ABI of <.9 bilaterally ECG Case 2 - Troponin Initial Troponin I is negative 6
Decision Time! Questions 1. Need to be an inpatient? 2. What Anticoagulation? 3. Need stress or cath? Tools 1. History/Exam 2. ECG 3. Troponin Combine tools TIMI score: Age > 65 1 History CAD 0 >2 risk factors 1 Recurrent severe angina 0 Aspirin use 1 +biomarkers 0 ST deviation 0 TIMI score and prognosis 45 40 35 30 25 20 15 10 5 0 0/1 2 3 4 5 '6/7 Death/MI/UR (%) Antman et al JAMA 2000 7
(Audience Response) Admitted to your service. For anticoagulation you choose aspirin plus: (1) heparin (2) enoxaparin (3) one of above + eptifibatide (4) clopidogrel Anticoagulation choices, simplified aspirin aspirin + clopidogrel heparin + aspirin heparin + clopidogrel + aspirin enoxaparin + aspirin enoxaparin + clopidogrel + aspirin enoxaparin + clopidogrel heparin + eptifibatide + aspirin heparin + abciximab + aspirin enoxaparin + eptifibatide + aspirin enoxaparin + abciximab + aspirin heparin +eptifibatide +clopidogrel heparin +abciximab +clopidogrel enoxaparin + abciximab + clopidogrel enoxaparin + eptifibatide + clopidogrel bivalirudin + aspirin bivalirudin + clopidogrel bivalirudin + eptifibatide + aspirin bivalirudin + abciximab + aspirin bivalirudin + eptifibatide + clopidogrel bivalirudin + abciximab + clopidogrel (fondaparinux & permutations involving early and late clopidogrel omitted) Anticoagulation simplified, take two: Agent Heparin Pros Experience Cons Inconvenient Enoxaparin IIb/IIIa inhibitors (eptifibatide if not in or going directly to cath) Clopidogrel Bivalirudin Fondaparinux Convenient, slight advantage in higher risk patients Good in high risk pts &/or those destined for cath Convenient, helps longterm in noninvasive approach Less bleeding, may obviate need for IIb/IIIa Less bleeding? More bleeding; renal & PCI issues Bleeding, expensive Slow onset, bleeding, issues if urgent CABG needed Studied primarily in invasive context Less experience, issues with PCI 8
IIb/IIIa inhibitors help in Troponin+ Combined ischemic endpoint (%) 20 18 16 14 12 10 8 6 4 2 0 Troponin - Troponin+ N=973 N=1049 Kastrati JAMA 2006 Abciximab Placebo Hospital Course Serial troponins negative No further symptoms Stress shows mild ischemia Normal EF on echo No symptoms on beta blocker discharged on clopidogrel for 9 months, lopressor, simvastatin Case 3 - History 39 year old insulin requiring diabetic presents with one month of increasing exertional dyspnea and neck discomfort with minimal exertion. One episode of pain walking from the parking lot to the VA for elective cath - admitted to telemetry 9
Case 3 - History PMHx Anterior MI, primary angioplasty Diabetes LDL 170 No hx HTN Meds: insulin, aspirin, acei/statin/lopressor Allergies: NTG (Viagra) No Fam Hx premature CAD No tobacco Case 3 Exam + Troponin obese, HR/BP well controlled not in CHF Cr of 4.9 (recent baseline 3-4) Troponin 3.3 ng/dl ECG new prior 10
Decision Time! Questions 1. Need to be an inpatient? 2. What Anticoagulation? 3. Need stress or cath? Tools 1. History/Exam 2. ECG 3. Troponin Combine tools TIMI score: Age > 65 0 Hx CAD 1 >2 risk factors 0 Recurrent severe angina 0 Aspirin use 1 +biomarkers 1 ST deviation 0 Hospital Course Started on heparin, aspirin continued. No further chest symptoms. 11
(Audience Response) You decide to: (1) Go to Cath (2) Stress test first, cath if high risk stress (3) D/C on meds Modern early invasive v. conservative randomized controlled studies positive RITA 3* TACTICS TIMI 18 FRISC II ISAR-COOL ICTUS negative *also late mortality advantage Higher risk patients benefit from early invasive approach Apples & Oranges 60 50 40 30 20 conservative early inv 10 0 ICTUS RITA 3 Actual rates of revascularization, as treated 12
Case 3 - Angiography Patent LAD stent, restenosis in diagonal Clot in proximal RCA, distal to high grade stenosis Abciximab + heparin PCI Drug Eluting Stent with intravascular ultrasound guidance Aspirin, clopidogrel for 6-12 months Summary -Algorithms & scores don t replace clinical judgement! -Higher risk patients benefit from more aggressive anticoagulation & an early invasive approach -Future: CTA? Virtual histology? 13
References 2007 Guidelines for the management of non st segment MI/unstable angina (acc.org) Swap et al Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes JAMA 2005 294:2623-2629. Waxman et al A Model for Troponin I as a Quantitative Predictor of In-Hospital Mortality JACC 2006 Goodman et al The prognostic value of the admission and predischarge electrocardiogram in acute coronary syndromes: the GUSTO-IIb ECG Core Laboratory experience. Am Heart Jor 2006 Aug;152(2):277-84 2006 Antman et al The TIMI Risk Score for Unstable Angina/Non ST Elevation MI JAMA 2000;284:835-842 Kastrati et al Abciximab in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention After Clopidogrel Pretreatment JAMA 2006;295:1531-1538 14