“Acute Coronary Syndrome”

“Acute Coronary Syndrome”

July 24, 2013

Item 72• A 78 year old man is evaluated in the ED with chest

pain. The patient reports that the pain, which is present in the left substernal area, began at rest, and has been present for 12 hours. He reports no similar episodes of chest pain. Medical history is significant for hypertension and a 30-pack year history of ongoing tobacco use. His only medication is nifedipine.

• On PE, temperature is 37.90C, BP 130/80 mm Hg, pulse rate is 72/minute and respiration rate is 12/min. BMI is 28. A normal carotid upstroke without carotid bruits is noted, jugular venous pulsations are normal and S1 and S2 are heard without murmurs. Lung fields are clear, distal pulses are normal and no peripheral edema is present.

Item 72 (Con’t)• Serum creatinine kinase level is 500

units/L and troponin I level is 26 ng/mL. Lab findings are otherwise normal.

• EKG shows sinus rhythm at 70/min; 2 mm ST-segment elevation in leads II, III and aVF; and 1 mm ST segment depression in leads V2 and V3. He is taken to the cardiac cath lab and found to have single vessel coronary disease with severe stenosis of the proximal left anterior descending coronary artery.

Item 72 (Con’t)

• Which of the following is the most appropriate treatment?

A. Coronary artery bypass surgery

B. Intracoronary thrombolytic therapy

C. Medical therapy

D. Primary percutaneous coronary intervention

STEMI Care and Time to Treatment Goals

• Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators.

I

AIIa IIb III

2013 ACC/AHA Guideline

JACC 2013;61:e1-63


• Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours

I

AIIa IIb III


JACC 2013;61:e1-63


• Reperfusion therapy is reasonable for patients with STEMI within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population

I

BIIa IIb III


JACC 2013;61:e1-63

Item 38: MKSAP

• A 54 year old man is evaluated in the ED for acute coronary syndrome that began 30 minutes ago. He has type 2 diabetes mellitus and hypertension. He reports no history of bleeding or stroke. He has a remote history of peptic ulcer disease for which he takes no medications. Medications are lisinopril and glipizide.

• On physical exam, he is afebrile, BP is 160/90 mm Hg, pulse rate is 80 and respiration 12/min. CV examination reveals a normal S1 and S2 without an S3 and no murmurs. Lung fields are clear.

MKSAP: Item 38

• Serum troponin and creatinine kinase levels are pending. Hematocrit is 42% and platelet count is 220,000/L

• EKG shows 3 mm ST segment elevation in leads V2 through V4 and a 1 mm ST segment depression in leads II, III and aVF. A chest radiograph is normal.

• There is no cardiac cath lab present at the hospital and it would take approximately 1.5 hours to transfer the patient to the closest facility that performs PCI. -blockers, unfractionated heparin, clopidogrel and aspirin are initiated.

MKSAP: Item 38

• Which of the following is the most appropriate management?

A. Abciximab and thrombolytic therapy

B. Await the results of troponin and CK

C. Thrombolytic therapy

D. Transfer for primary PCI


• If the symptom duration is within 3 hours and the expected door to balloon time minus the expected door to needle time is:–Within 1 hour, primary PCI is preferred

–Greater than 1 hour, fibrinolytic therapy is generally preferred.

I

BIIa IIb III


Circulation 2004;110:588-636

Door to Balloon Time for Transfer and Direct Arrival Patients, National CV Data Registry (NCDR)

Tim

e (

Min

utes

)

0

60

90

120

180

Year

30

2005 QI

Am Heart J 2011;161:76-83

150

210

2005 Q3

2006 Q1

2006 Q3

2007 Q1

2007 Q3

Transfer PCI

Direct PCITarget Door to Balloon

Time

Transfer and Direct PCI Door to Balloon Time P

erce

ntag

e of

Pat

ient

s

0

20

30

40

50

Door to Balloon Time (hours)

10

1 2 3 4 5 6

90 minutes

Direct PCI = 79 min

Transfer PCI = 149 min

9.7%

63.4% (n=86,382)

(n=29,248)

Am Heart J 2011;161:76-83


• Immediate transfer to a PCI-capable hospital for primary PCI is recommended strategy for STEMI patients who initially arrive at or are transported to a non-PCI-capable hospital with a FMC-to-device time goal of 120 minutes or less.

I

BIIa IIb III

2013 ACCF/AHA Guideline

STEMI Patient, First Medical Contact

PCI Capable Hospital

FMC* to Device Time

≤90 mins

Non-PCI Capable Hospital

*FMC: First Medical Contact

Anticipated FMC* to Device Time

≥120 min

Thrombolytic Therapy within

30 mins

FMC* to Device Time ≤120 min

Cath Lab for PCI

Door In Door Out (DIDO) ≤30

mins

Transfer for Primary PCI

JACC 2013;61:e1-63

Acute Coronary Syndrome

Definition

A constellation of clinical symptoms due to acute

myocardial ischemiaCirculation 2011,123:e426-e579

Myocardial Infarction

DefinitionMyocardial necrosis (or

myocardial cell death) due to prolonged ischemia.

Circulation 2012,126:2020-2035

Third Universal Definition of MI

Causes of Acute Coronary Syndrome

• Congenital

• Embolic

• Vasospasm• Trauma

• Compression - Muscle bridges - Aortic aneurysm

• Drugs - Sumatriptan - Ergot alkaloids - Cocaine

• Arteritis

• Aortic dissection

• Intimal proliferation - Fibromuscular hyperplasia - Radiation

• Atherosclerosis

- Anomalous origin- Anomalous course- Single artery

- Vegetations- Tumor- Calcium

3 Major Causes of ACS

• Atherosclerosis

• Atherosclerosis

• Atherosclerosis

Types of Myocardial Infarction

Type 1: Spontaneous MI due to plaque rupture, ulceration, fissuring, erosion, etc.

Type 2: MI secondary to an ischemic imbalance

Type 3: MI resulting in death and biomarkers are unavailable

Type 4a: MI related to PCI

Type 4b: MI related to stent thrombosis

Type 5: MI related to CABG

Circulation 2012;126:2020-2035

MI Type 1

Plaque Rupture

Healed Plaque

Erosion

Atherosclerotic Vessel

Thrombotic Occlusion

Progressive Narrowing of the Arterial Lumen

Lipid CoreVessel Lumen

Progressive Narrowing (Time)

Clot

Atherosclerotic Vessel

Plaque Rupture

Platelet Adhesion

Activation and Aggregation

Thrombus Formation

Thrombotic Occlusion

MI

Stroke

Vascular Death

Plaque Rupture and Atherothrombosis

Lipid CoreVessel Lumen

Am J Med 1996;101:199-209

Thrombus

Circulation 1988;78:1157-1166

Baseline Study

Most MI’s Arise From Smaller Stenoses

Circulation 1988;78:1157-1166

13 Days Later


Circulation 1988;78:1157-1166

Baseline Study


Circulation 1988;78:1157-1166

2 months later


Most MI’s Arise From Smaller StenosesM

I P

atie

nts

(%)

0

20

40

60

80

< 50% 50-70% > 70%

Percentage Stenosis

68%

18%14%

Circulation 1995;92:657-671

Symptomatic

Asymptomatic

Acute Coronary SyndromeCirculation 2002;105:2000-2004

PCI With Stent

Systemic Medical Therapy to Stabilize Plaque

• Aspirin

• Clopidogrel/Prasugrel/Ticagrelor

• Statins

• ACE Inhibitors/ARBs

• Beta Blockers

• Smoking Cessation

Multiple Plaques in ACSM

I P

atie

nts

(%)

0

10

20

30

40

Culprit Lesion 2 3

Number of Ruptured Plaques in Addition to Culprit Lesion Detected by IVUS

21%25%

12.5%

Circulation 2002;106:804-808

1

29%

7.5%4.5%

4 5

79% of patients had >1 plaque ruptured

The Asymptomatic Progression of CAD

Initial Presentation

0 10 20 30 40 706050

Levy D, Textbook of CV Medicine 1998

WOMEN (70.4 years)

MEN (65.8 years)

ACS or Sudden Cardiac Death

46%

62%

AHA: Heart Disease and Stroke Statistics-2006 Update

Ventricular Fibrillation

Ventricular Fibrillation and SurvivalP

ropo

rtio

n S

urvi

ving

0

0.4

0.6

0.8

1.0

Minutes

0.2

1 2 3 4 5 6 7 8 9 10

Ventricular Fibrillation

Deaths due to Acute MI

• In-hospital mortality had improved significantly– 1960’s – prior to introduction of CCUs, in-

hospital mortality averaged ~25-30%.– 1980’s – CCU, pre-reperfusion era ~16%– 1990 - 2000’s – era of fibrinolysis, coronary

interventions, those who participated in clinical trials, one month mortality is ~4-6%

Eur HJ 2208;29:2909-2945

Mortality in Acute MI

Pre-Hospital

24 Hrs- InHospital

48 Hrs- InHospital

30 Days

Pre-Hospital

52%

24 Hours In-Hospital

48 Hours In-Hospital

30 Days

21%

19%

8%

One-half of all deaths occur “in the field” within one hour after symptom onset


• ST elevation myocardial infarction

• Non-ST elevation myocardial infarction

• Unstable Angina

Hospitalizations in the US due to ACS

Acute Coronary Syndromes

1.57 Million Hospital Admissions

0.33 million admissions 1.24 million admissions

Heart Disease and Stroke Statistics 2007 UpdateCirculation 2007;115:69-171

0.67 million UA0.57 million NSTEMI

79%21%STEMI UA/NSTEMI

ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

Rates of Acute MI, 1999 - 2008In

cide

nce

Ra

te

(No

. of c

ase

s/10

0,0

00

pe

r p

ers

on-y

ear)

0

100

150

200

250

Year

50

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

JACC 2013;61e7300

STEMI

Non-STEMI

MI


• Typical Symptoms:

–Central chest pain– Chest discomfort– Chest pressure– Chest tightness– Heaviness – Cramping or burning sensation– Indigestion or heartburn

Call 911


Symptoms of Acute MI

Call 911

Ambulance Transport

Self Transport

Recommended Discouraged

Hospitalized

JACC 2008;51:210-247

Percentage of Patients with ACS Calling 911

• National Registry of MI -2 53%

• Survey of confirmed ACS patients in 20 US communities

Emergency Medical System 10-48% (23%)

Emergency Medical System

Driven by someone else 60%

Drove themselves 16%

Circulation May, 2011 e440


• Physical signs:– No physical signs diagnostic of Acute MI

– Activation of autonomic nervous system• Pallor• Sweating• Hypotension or narrow pulse pressure• Irregularities in heart rate, bradycardia,

tachycardia

– Basal rales

– Third heart sound


Symptoms of Acute MI

Ambulance

JACC 2008;51:210-247

Self Transport

12 Lead-ECG

Hospital/ED

Obtained and Interpreted <10 mins

12-Lead ECG

Hospitalizations in the US due to ACSAcute Coronary

Syndrome

1.57 Million Hospital Admissions

UA/NSTEMI STEMI

1.24 million Admissions per year

0.33 millionAdmissions per year

Heart Disease and Stroke Statistics 2007 UpdateCirculation 2007;115:69-171

79% 21%

ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

Pathophysiology

Fuster V et al. NEJM. 1992; 326: 310-318.Davies MJ et al. Circulation. 1990; 82 (Suppl II): II-38, II-46.

Lipid Lipid Pool

MacrophagesMacrophages

Stress, tensile,Stress, tensile,internalinternal

Shear forces,Shear forces,externalexternal

Atheroscleroticplaque

Fissure

Plaquerupture

LargeLargeFissureFissure

SmallSmallFissureFissure

Mural thrombusMural thrombus(unstable angina/(unstable angina/non-ST elevation MI)non-ST elevation MI)

Occlusive thrombusOcclusive thrombus(ST Elevation MI)(ST Elevation MI)

Thrombus

Acute Coronary Syndromes

TIMI Flow Grade

TIMI 0 Complete Occlusion

TIMI 1

TIMI 2

TIMI 3

Penetration of obstruction by contrast but no distal perfusion

Perfusion of entire artery but delayed flow

Full perfusion, normal flow

Myocardial Ischemia

Heart Rate

Oxygen Demand Blood Supply

Blood Pressure Inotropicity

ST elevation = coronary artery is completely occluded

TIMI 0 Flow

= TIMI 0 blood flow

ST Elevation MIB

enef

it (%

)

0

40

60

80

100

Hours

20

1 2 3 4 5 6 7 8

“Time is Muscle”

9 10 11 12

Circulation 1992;85;2311-2315

The 12-Lead ECG

The 12-lead ECG is the only modality that can best identify the presence of a

completely occluded coronary artery

Diagnostic and Therapeutic Pathways in Patients With and Without ST-Segment Elevation

Hamm CW et al. Lancet. 2001;358:1533-1538.2002 ACC/AHA UA/NSTEMI Guideline Update. Available at: www.acc.org


ECG

ST Elevation

Thrombolysis, PCIAspirin, clopidogrel,UFH or LMWH, 2B/3A

antagonists-blockers, nitrates

No ST Elevation

Normal ECG


ST Elevation MI


Chest PainASA

Aspirin

• Give ASA as soon as possible unless there is GI bleed or patient is allergic to aspirin

• Dose 162 - 325 mg one dose• Aspirin should be chewable or soluble• If patient cannot take ASA due to nausea or GI

disorder, use ASA suppositories• Other than ASA, do not make the mistake of

giving NSAID such as Motrin, Naprosyn, Celebrex, etc since NSAID increases mortality, re-infarction, myocardial rupture, CHF, and HBP

JACC 2007;50:652-726


ST Elevation

NTG

NTG

NTG

Chest Pain

ECG within 10 minutes

ASA NTG

Arrival in ED

ST Segment Elevation

Baseline ECG


After NTG

ST Segment ElevationBaseline ECG

After NTG


Baseline


After NTG


After NTG

Baseline

Nitroglycerin

• For relief of chest pain, give NTG up to 3 doses at 3-5 minute intervals until pain is relieved or blood pressure is low

• Dose of NTG is 0.4 mg sublingual tablet or spray

JACC 2007;50:652-726

Nitroglycerin

• Do not give if: – Taking PDE Inhibitors for erectile dysfunction

• sildenafil (Viagra, Revatio) 24 h • taladafil (Cialis, Adcirca) 48 h • vardenafil (Levitra) ?

– Systolic BP <90 mm Hg or there is a drop of >30 mm Hg below baseline BP

– Bradycardia of <50 beats per minute– Tachycardia of >100 beats per minute– Suspected right ventricular MI

JACC 2007;50:652-726

ST Elevation MI

ST Elevation

NTG

NTG

NTG

Primary PCI

EMS transport: <90 mins

Self-Transport: Door to Needle

<30 mins

EMS Transport: <30 mins

Self-Transport: Door to Balloon

<90 mins

Chest Pain

Thrombolytic Therapy


ASA NTG

Acute Inferior MI


Post Thrombolytic Therapy

One Hour Later

Initial ECG

Thrombolysis: One Hour Later

Thrombolysis

• No contraindication to thrombolysis• Best results within 2 hours after onset of

symptoms• Hemodynamically stable:

– Not in cardiogenic shock or CHF or with mechanical complications of AMI

Absolute Contraindications• Any prior ICH• Known structural cerebral

vascular lesion (AVM)• Known malignant intracranial

neoplasm (primary/metastatic)• Ischemic stroke within 3

months• Suspected aortic dissection• Active bleeding or bleeding

diathesis (excluding menses)• Closed head or facial trauma

within 3 months

Relative Contraindications• History of chronic severe, poorly

controlled hypertension• Severe uncontrolled hypertension

(SBP >180 mm Hg or DBP >110 mm Hg)

• History of prior ischemic stroke >3 mos, dementia or IC pathology

• Traumatic or prolonged (>10 mins) CPR or major surgery <3 weeks

• Recent (2-4 weeks) internal bleeding

• Pregnancy

• Active peptic ulcer

• Current use of anticoagulants

Contraindications to Thrombolysis

Thrombolytic Therapy and Mortality According to Admission ECG

Live

s S

aved

per

Tho

usan

d

0

20

40

60

BBB Anterior ST Elevation

Inferior ST Elevation

49%

37%

8%

Lancet 1994;343:311-322

10

30

50

-10

-14%

ST DepressionAdmission ECG

ST Elevation Criteria for STEMI

• ≥1 mm any 2 adjacent standard leads

• In V2 and V3:

– Males• <40 years of age ≥2.5 mm for males• ≥40 years of age ≥2.0 mm for males

– Females (any age)• ≥1.5 mm

• ST elevation is measured at the J point

JACC 2009;53:982-991

Fibrinolytic Agents

Fibrin-specific

JACC 2013;61e78-140

● Tenecteplase (TNK-tPA)

● Reteplase (rPA)

● Alteplase (tPA)

Non-fibrin-specific

● Streptokinase

Patency Rate90 min TIMI 2 or 3

85%

84%

73-84%

60-68%(No longer marketed in the US)

ST Elevation MI

ST Elevation

NTG

NTG

NTG

Primary PCI

EMS transport: ≤90 mins

Self-Transport: Door to Needle

<30 mins

EMS Transport: <30 mins

Self-Transport: Door to Balloon

≤90 mins

Chest Pain



ASA NTG

AMI: Post PCI


Admission

Post PCI

STEMI PCI: National CV Data Registry

In hospital mortality of 43,801 patients with STEMI undergoing PCI: JACC 2009;54:2205-2241

30 mins

60 mins

3% 3.5%4.3%

90 mins

120 mins

5.6%

5

10

150 mins

7.0%

180 mins

8.4%

Mor

talit

y

Delay in Reperfusion in Minutes

P <0.001

Primary PCI vs IV Thrombolytic Therapy for Acute MI: Review of 23 Randomized Trials

• 23 randomized clinical trials with 7739 patients with STEMI– Thrombolytic therapy = 3867– Primary PCI = 3872

• Results: Primary PCI was better than thrombolytic therapy at reducing short-term and long-term death, non-fatal reinfarction, stroke and combined endpoint of death, non-fatal reinfarction and stroke

• Conclusion: Primary PCI is more effective than thrombolytic therapy for the treatment of STEMI

Lancet 2003;361:13-20

PCI Vs Thrombolytic Therapy: Short Term OutcomesF

requ

ency

(%

)

0

5

10

15

20

25

Death

P=0.0002

P=0.0003

Death Excluding SHOCK

data

P<0.0001

Non-fatal MI

P<0.0001

Recurrent Ischemia

Thrombolytic TherapyPCI

P=0.0004

Total Stroke

Death, non-fatal re-

infarction or stroke

P<0.0001

Lancet 2003;361:13-20

PCI Vs Thrombolytic Therapy: Long Term Outcomes

Fre

quen

cy (

%)

0

10

20

30

40

50

Death

P=0.0019

P=0.0053

Death Excluding SHOCK

data

P<0.0001

Non-fatal MI

P<0.0001

Recurrent Ischemia

Thrombolytic TherapyPTCA

Data Not Available

Total Stroke

Death, non-fatal re-

infarction or stroke

P<0.0001

Lancet 2003;361:13-20

* *

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

9-1-1EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.

• Consider prehospital fibrinolytic if capable and EMS-to-needle within

30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage

Plan

Inter-HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90

min..Patient self-transport

Hospital door-to-balloon within 90 min.

Dispatch1 min.

5 min.

8 min.

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December 10, 2007. Available at http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001.

http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.10.001

PCIcapable

Fibrinolysis Door-to-Needle or

FMC to Needle

< 30 mins

Coronary Angioplasty VS Fibrinolytic Therapy in Acute Myocardial Infarction

EMS Transport

PCI Door-to-Balloon or FMC

to Balloon ≤ 90 mins

Not PCIcapable

PCIcapable

Not PCIcapable

Coronary Angioplasty VS Fibrinolytic Therapy in Acute Myocardial Infarction

EMS Transport



2004 STEMI Guideline



2013 STEMI Guideline

PCI Door-to-Balloon or FMC to Balloon ≤ 120 mins

DIDO30 mins

Mortality and Ejection FractionO

ne Y

ear

Car

diac

Mor

talit

y (%

)

0

20

30

40

50

Radionuclide Ejection Fraction (%)

10

10 20 30 40 50 60 70 800

< 20%N = 799

Mean EF = 46%

> 60%40-59%

20-39%

STEMI: Standard Therapy

• Thrombolytic Agent or PCI• Aspirin

• Beta Blockers within 24 hours

• ACE Inhibitors or ARB’s within 24 hours

• Aldosterone antagonists for EF ≤40%

• Statins before hospital discharge

• Heparin

• Clopidogrel

Date post:	15-Jan-2016
Category:	Documents
Upload:	vilmos
View:	50 times
Download:	0 times

“Acute Coronary Syndrome”

Documents