Post on 14-Jul-2015
transcript
Approach to Acute Coronary
Syndrome
Sujood Hussien Khraisat
Hashemite University
Myocardial ischaemia :
• Reduced blood flow due to mechanical obstruction .
• Due to decreased oxygenated Hemoglobin.
• Increased demand for oxygen .
• Myocardial ischaemia most commonly occurs as a result of obstructive coronary artery disease (CAD) in the form of coronary atherosclerosis .
Pathogenesis Of Atherosclerosis
CAD can have the following clinical presentations:• Asymptomatic
• Stable angina pectoris
• Unstable angina pectoris
• Myocardial infarction (MI)—either NSTEMI
or STEMI
• Sudden cardiac death
Acute coronary syndromes
spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. In terms of pathology, ACS is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery.
Unstable angina and NSTEMI
CRITERIA• The diagnosis of UA is based largely on the
clinical presentation. – (1) it occurs at rest (or with minimal exertion),
usually lasting >10 min; – (2) it is severe and of new onset (i.e., within the
prior 4–6 weeks); and/or – (3) it occurs with a crescendo pattern (i.e.,
distinctly more severe, prolonged, or frequent than previously).
• The diagnosis of NSTEMI requires clinicalfeatures of UA + elevated cardiac enzymes.
USA and non–ST segment
elevation MI are often considered
together because it
is very difficult to distinguish
the two based on patient
presentation. If cardiac
enzymes are elevated, then
the patient has non–ST segment
elevation MI
History
• The severity and duration of coronary artery obstruction, the volume of myocardium affected, the level of demand, and the ability of the rest of the heart to compensate are major determinants of a patient's clinical presentation and outcome. A patient may present to the ED because of a change in pattern or severity of symptoms.
History
• Palpitations• Pain, which is usually described as pressure,
squeezing, or a burning sensation across the precordium and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm
• Exertional dyspnea that resolves with pain or rest• Diaphoresis from sympathetic discharge• Nausea from vagal stimulation• Decreased exercise tolerance
• Elderly !
• Diabetics !
• Women !
Cardiac vs Non-Cardiac chest pain
Causes of chest pain
Physical Examination • frequently normal.
• patient will usually lie quietly in bed and may appear anxious, diaphoretic, and pale.
• Hypotension - Indicates ventricular dysfunction due to myocardial ischemia, infarction, or acute valvulardysfunction
• Hypertension - May precipitate angina or reflect elevated catecholamine levels due to anxiety or to exogenous sympathomimetic stimulation
• Diaphoresis
• Pulmonary edema and other signs of left heart failure.
• (S3) , (S4), The latter is especially prevalent in patients with inferior-wall ischemia .
• A new murmur may reflect papillary muscle dysfunction. Rales on pulmonary examination may suggest LV dysfunction or mitral regurgitation.
ECG
• May be normal.
• ST depression and T wave inversion are highly
suggestive for an ACS. The ECG should be
repeated and continuous ST-segment monitoring
is recommended if the patient is in pain.
• Transient ST elevation is seen with coronary
vasospasm or Prinzmetal’s angina.
Workup
CARDIAC BIOCHEMICAL MARKERS
• Elevated CK-MB and troponin distinguish NSTEMI
from unstable angina.
• There is a direct relationship between the degree of
troponin elevation and mortality.
• In patients without a clear clinical history of ACS,
minor troponin elevations have been reported and
can be caused by CHF, myocarditis, or PE, or they
may be false-positive readings. Thus, in patients with
an unclear history, small troponin elevations may not
be diagnostic of an ACS.
Other Investigations ?!
• CBC
• Basic metabolic profile
• CXR
Early Risk Stratification
• The first step in evaluating patients with possible UA/NSTEMI is to
determine the likelihood that CAD is the cause of the presenting
symptoms.
DIAGNOSTIC EVALUATION
DIAGNOSTIC EVALUATION
• For most patients, standard treadmill ECG stress testing is
used, but for patients with fixed abnormalities on the ECG
(e.g., left bundle branch block), perfusion or
echocardiographic imaging is used.
• For patients who cannot walk, pharmacologic stress is used.
• By demonstrating normal myocardial perfusion, sestamibi or
thallium imaging can reduce unnecessary hospitalizations by
excluding acute ischemia.
• CT angiography can also be used to exclude obstructive CAD
RISK STRATIFICATION AND PROGNOSIS
• Thrombolysis in Myocardial Infarction (TIMI)
score is useful both in predicting the risk of
recurrent cardiac events and in identifying
those patients who would derive the greatest
benefit from antithrombotic therapies more
potent than unfractionated heparin, such as
low-molecular-weight heparin (LMWH) and
glycoprotein (GP)IIb/IIIa inhibitors, and from
an early invasive strategy.
Used to estimate percent risk at 14
days of MI, or revascularization
RISK STRATIFICATION AND PROGNOSIS
• Other risk factors include DM, LV dysfunction,
and elevated levels of creatinine, ANP, and
CRP.
• CRP and BNP, a marker of increased
myocardial wall tension, correlate
independently with increased mortality (and,
in some studies, recurrent cardiac events) in
patients presenting with UA/NSTEMI.
Management of ACS
• General Measures ECG , Nitroglycerine , Morphine , Beta-Blockers , ACE Inhibitors , Atropine
• Parenteral Anti-coagulation ( UFH , Enoxaparin , Fondaparinux )
and Anti-platelets (Aspirin , Clopidogerl , Abciximab )
• Fibrinolytic therapy
• Anti-arrhythmic drug
Unstable angina and NSTEMI
ANTI-ISCHEMIC DRUGS
Nitrates
• Should first be given sublingually or by buccal spray (0.3–0.6
mg) if the patient is experiencing ischemic pain.
• If pain persists after 3 doses given 5 min apart, i.v. GTN 50 mg
in 50 ml 0.9% saline at 2-10 ml/h.
• The only absolute contraindications to the use of nitrates are
hypotension or the use of sildenafil (Viagra) or other drugs in
that class within the previous 24 h.
Unstable angina and NSTEMI
ANTI-ISCHEMIC DRUGS
ß-blockers
• I.V. metoprolol (Lopressor) 5 mg infusion over 1-2 minuets. It
is repeated every 5 min for a total dose of 15 mg. Followed in
1–2 h by 25–50 mg by mouth every 6 h continue for 48 hours;
then administer a maintenance dose of 100 mg twice daily.
• I.V. esmolol (Brevibloc)
• I.V. atenolol (Tenormin) 5 mg slow I.V. over 5 minutes; may
repeat in 10 minutes. Follow I.V. dose with 100 mg/day or 50
mg twice daily for 6 to 9 days postmyocardial infarction.
Unstable angina and NSTEMI
ANTI-ISCHEMIC DRUGS
ß-blockers
• Contraindications:
– PR interval (ECG) >0.24 s, 2° or 3° atrioventricular block
– HR <60 beats/min, BP <90 mmHg
– Shock
– Left ventricular failure with congestive heart failure
– Severe reactive airway disease
Unstable angina and NSTEMI
ANTI-ISCHEMIC DRUGS
Morphine sulfate
• If pain persists despite intravenous nitroglycerin and beta blockade, morphine sulfate, 1–5 mg intravenously, can be administered every 5–30 min as needed.
Unstable angina and NSTEMI
ANTITHROMBOTIC DRUGS
Aspirin and clopidogrel
• Aspirin blocks the formation of thromboxane A2 and so prevents platelet aggregation. In ACS patients 150-300 mg initially; then 75–150 mg aspirin reduced the relative risk of death or myocardial infarction by about 35–50%.
ANTITHROMBOTIC DRUGS
Aspirin and clopidogrel
• Clopidogrel (Plavex), which blocks the platelet P2Y12
(adenosine) receptor (in combination with aspirin), was
shown in the CURE trial to confer a 20% relative reduction in
cardiovascular death, MI, or stroke, compared with aspirin
alone in both low- and high-risk patients with UA/NSTEMI, but
to be associated with a moderate (absolute 1%) increase in
major bleeding, which is more common in patients who
undergo coronary artery bypass grafting, so it is best avoided
if urgent CABG is likely.
• Clopidogrel should be given (preferably more than 6 hours)
after planned PCI, but may be omitted if coronary
angiography is planned immediately.
ANTITHROMBOTIC DRUGS
• Intravenous GP IIb/IIIa inhibitors (abciximab, tirofiban, and eptifibatide) reduce cardiac complications in patients undergoing percutaneous coronary intervention (PCI).
• Small molecule inhibitors eptifibatide and tirofibanshow benefit, while the monoclonal antibody abciximabappears not to be effective in patients treated conservatively, (i.e., in those not undergoing coronary angiography or PCI).
• Concomitant tirofban is particularly useful in diabetic patients.
• Patients receiving GP IIb/IIIa inhibitors should be monitored for 24 hours for bleeding and thrombocytopenia.
ANTITHROMBOTIC DRUGS
Anticoagulants
• Unfractionated heparin (UFH) is the mainstay of
therapy.
• The LMWH enoxaparin (Clexane ®) is superior to UFH
in reducing recurrent cardiac events, especially in
conservatively managed patients.
• The Factor Xa inhibitor fondaparinux is equivalent
with enoxaparin but appears to have a lower risk of
major bleeding and thus may have the best benefit
risk ratio.
ANTITHROMBOTIC DRUGS
Anticoagulants
• However, UFH, LMWH, or a direct thrombin
inhibitor such as bivalirudin should be used
during cardiac catheterization or PCI. • Bivalirudin is a direct thrombin inhibitor as effective as
heparin plus GPIIb/IIIa inhibitors in reducing ischaemicevents in patients pretreated with a thienopyridine and undergoing diagnostic angiography or percutaneous intervention, but with less bleeding.
ANTITHROMBOTIC DRUGS
INVASIVE THERAPY
• In high-risk patients, following treatment with anti-ischemic and antithrombotic agents, coronary arteriography is carried out within ~48 h of admission, followed by coronary revascularization (PCI or coronary artery bypass grafting), depending on the coronary anatomy.
LONG-TERM THERAPY
• Risk factor modification: smoking cessation, achieving optimal weight, daily exercise following an appropriate diet, blood pressure control, tight control of hyperglycemia, and lipid management.
• Beta blockers.
• Statins (at a high dose, e.g., atorvastatin 80 mg/d) and ACE inhibitors are recommended for long-term plaque stabilization.
• Antiplatelet therapy: combination of aspirin and clopidogrelfor at least 9–12 months, with aspirin continued thereafter.
STEMI
• Primary PCI is generally more effective than fibrinolysis and is preferred, especially when diagnosis is in doubt, cardiogenic shock is present, bleeding risk is increased, or if symptoms have been present for >3 h.
STEMI
Fibrinolytic drugs
• Proceed with IV fibrinolysis if PCI is not available or if logistics would delay PCI >1 h longer than fibrinolysis could be initiated.
• Door-to-needle time should be <30 min for maximum benefit.
• Those treated within 1–3 h benefit most; can still be useful up to 12 h if chest pain is persistent or ST remains elevated in leads that have not developed new Q waves.
• Complications include bleeding, reperfusion arrhythmias, and, in case of streptokinase (SK), allergic reactions.
STEMI
INITIAL THERAPY
Fibrinolytic drugs
• Coadmnister enoxaparin or heparin and maintain activated partial thromboplastin time (aPTT) at 1.5–2.0 × control (~50–70 s).
• If chest pain or ST elevation persists >90 min after fibrinolysis, consider referral for rescue PCI.
• Later coronary angiography after fibrinolysis generally reserved for pts with recurrent angina or positive stress test.
Thank You !
:D