Acute Coronary Syndrome Sonny Achtchi, DO
Objectives Understand evidence based and practice based treatments for stabilization and initial management of ACS Become familiar with ACS risk stratification and its implications for treatment
ACC/AHA Guidelines, LOE Anderson. JACC 2007; 50: 1-157
ACC/AHA Guidelines, LOE Anderson. JACC 2007; 50: 1-157
Features of ACS entities Angina Biomarkers ST elevation UA + - - NSTEMI + + - STEMI + + +
Spectrum of disease Unstable Angina NSTEMI STEMI AMI ACS Similar pathophysiology Similar management Anderson. JACC 2007; 50: 1-157
Plaque Thrombosis
STEMI LM LAD LCx
Why ST elevations vs other ST segment deviations? Resting membrane potential higher in peri-infarct ischemic tissue leaky membranes generate potential Higher T-P segment in nontransmural b/c peri infarct areas generate current toward index electrodes ST depression Lower in transmural infarction ST elevation http://www.cvphysiology.com/cad/cad012 ST segment changes.gif
Unstable Angina Definitions -AUC Anderson. JACC 2007; 50: 1-157
Definition of AMI Causes of myocardial damage JACC. 2012 Oct 16;60(16):1581-98.
Definition of AMI - DDx JACC. 2012 Oct 16;60(16):1581-98.
Definition of AMI JACC. 2012 Oct 16;60(16):1581-98.
Definition of AMI and prior MI
Clinical Entities Anderson. JACC 2007; 50: 1-157
Diagnostic Tools EKG Biomarkers Echocardiography Stress Testing Coronary angiography Catheter based (left heart cath) IVUS, OCT Computed Tomography
EKG early risk stratification I B IIa IIb III 12 lead ECG within 10 minutes of arrival If initial is not diagnostic and patient remains symptomatic, serial ECGs are recommended
ECG patterns in ACS and mortality ST Depression & Elevation ST Depression! ST Elevation Twave inversion Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA 1999;281:707 13.
ACS risk stratification STEMI? YES NO
ACS risk stratification STEMI? YES NO
ACS risk stratification STEMI? YES NO
Cardiac Biomarkers Troponin Rises 4-8 hrs after injury Remain elevated for up to two weeks Prognostic information False positives CK-MB Rises 4-6 hours Remain elevated for 48-72 hours > 5% of total CPK or 2x ULN Can be predictive of mortality False positives
Cardiac biomarkers Anderson. JACC 2007; 50: 1-157
Biomarker elevation and mortality
Acute Therapy?
Acute Therapy MONA? Prior to decision re: early invasive vs conservative strategy
Aspirin/Antiplatelet Therapy I A IIa IIb III Aspirin should be administered as soon as possible and continued indefinitely. I A IIa IIb III Clopidogrel should be administered to patients who are unable to take ASA.
Proportional effects of antiplatelet therapy on vascular events (myocardial infarction, stroke, or vascular death) in five main high risk categories. British Medical Journal Publishing Group et al. BMJ 2002;324:71-86 2002 by British Medical Journal Publishing Group
Morphine I Class II IIa IIb III B Benefit >> Risk Procedure/ Treatment is RECOMMENDED to be administered or performed Reduces pain/anxiety, sympathetic tone, systemic vascular resistance and oxygen demand Can exacerbate hypotension or cause respiratory depression Use only after other treatments to address pathophysiology
Oxygen I IIa IIb III C Class II NC, 2-4 L per minute Thought to improve O2 delivery via higher O2 tension and Hgb saturation. Benefit >> Risk Procedure/ Treatment is RECOMMENDED to be administered or performed
Oxygen I IIa IIb III C Class II NC, 2-4 L per minute Thought to improve O2 delivery via higher O2 tension and Hgb saturation. Benefit >> Risk Procedure/ Treatment is RECOMMENDED to be administered or performed
O2 Benefit or risk? Moradkhan, R. JACC. 2010 Sep 21;56(13):1013-6.
Nitroglycerin I C IIa IIb III Dilates coronary vessels Reduces SVR (arterial) and preload (venous) Caution if hypotension or RV infarction Caution if PDE inhibitors within 24-48 hours (sildenafil, tadalafil) I IIa IIb III C
Dual antiplatelet therapy - Clopidogrel I B IIa IIb III Clopidogrel should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month and ideally up to 1 year. Should be used regardless of LHC plans, but prior to LHC if invasive strategy
CURE Trial: MI/Stroke/CV Death 12,562 patients with ACS, only 21% with PCI The CURE Trial Investigators. N Engl J Med. 2001;345:494-502.
Beta Blockers I IIa IIb III Oral beta-blocker therapy should be initiated within the first 24 hrs for patients without: 1) signs of HF 2) evidence of a low-output state 3) increased risk for cardiogenic shock 4) PR greater than 0.24 s 5) second or third degree heart block 6) active asthma B
COMMIT Trial Small reduction in reinfarction and ventricular fibrillation Increase in cardiogenic shock, occurred early (first day) and primarily in pts with HD compromise or at high risk for shock Lancet 2005;366:1622 32.
ACE inhibitors I A IIa IIb III An ACE inhibitor should be administered orally within the first 24 h to patients with pulmonary congestion or LV ejection fraction (LVEF) 40%.
NSAIDS I IIa IIb III C NSAIDS should not be administered during hospitalization because of the increased risks of mortality, reinfarction, hypertension, CHF, and myocardial rupture.
Addition of UFH to ASA in ACS Meta-analysis RR: 0.67 (0.44-1.02) * LMWH has equivalent benefit with regard to mortality, slight benefit with regard to MACE NNT= 107 (JAMA 2004;292(1)86-89) Oler, A. JAMA 1996;276:811-6 I A IIa IIb III
Management Strategy Conservative Early Invasive (LHC in 24-48 hrs) How does one decide which?
Rehospitalization in UA mean follow up 13 months Bavry AA, et al. JACC. 2006; 48:1319-1325
Recurrent MI mean f/u 2 years Bavry AA, et al. JACC. 2006; 48:1319-1325
Mortality mean f/u 2 years Bavry AA, et al. JACC. 2006; 48:1319-1325
Who benefits? European Heart Journal (2005) 26, 865 872
TIMI risk score Age >65 Three or more risk factors for CAD Prior stents ST deviation on ECG At least 2 angina events in prior 24 hours ASA use in prior 7d Elevated biomarkers Antman EM, et al. JAMA 2000;284:835 42.
Selecting a strategy Early Invasive Recurrent angina/ischemia at rest with low-level activities despite intensive medical therapy + biomarkers New ST-segment depression Signs/symptoms of heart failure or new/worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG High risk score (e.g., TIMI, GRACE) Reduced left ventricular function (LVEF < 40%) Conservative Low risk score (e.g., TIMI, GRACE) Absence of high-risk
Take home points All patients with ACS should get evidence based medical therapy morbidity and mortality benefit Risk stratification is an important part of initial ACS management and dictates management strategy Involve your cardiology colleagues early
Questions?