Download Acute coronary Syndromes: An Interactive, Evidence Based

Patient Oriented Therapy
Non STE ACS
Prof dr Midhat nurkić FESC
Director clinic for cardiovascular disease UKC Tuzla
Acute Coronary Syndrome (ACS)

Definition: The spectrum of acute
ischemia related syndromes ranging from
UA to MI with or without ST elevation that
are secondary to acute plaque rupture or
plaque erosion.
[----UA---------NSTEMI----------STEMI----]
Stable
Angina
Unstable
Angina
CAD
Non-Q
wave MI
Q wave
MI
STEMI
UA/NSTEMI
Daysweeks
Minshours
Antithrombotic
Therapy
Thrombolysis
Primary PCI
Cannon CP J Thromb Thrombolysis. 1995;2:205-218.
Spectrum of Chronic Coronary Syndrome
Risk Factors + Hypertension
Endothelial Dysfunction
Atherosclerosis
IHD/Angina Pectoris
Chronic
Coronary
Syndrome
Myocardial Ischemia
Coronary Thrombosis
Myocardial Infarction
Acute
Coronary
Syndrome
Arrhythmia & Loss of Muscle
Remodeling
Ventricular Dilation
Congestive Heart Failure
Endstage Heart Disease
Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.
Acute Evaluation of ACS
Chest pain or Short of Breath
Presentation
ECG
Markers
Diagnosis
Normal
–
+
Rule-Out
ST-segment
Depression
–
+
Unstable
Angina
ST-segment
Elevation
+
Acute MI
Anderson JL. J Am Coll Cardiol 2007;50:e1-157
Stable
Angina
Unstable
Angina
Non ST
Elevation MI
ST Elevation
MI
ECG – ST ↑
ECG - ST ↓
CK-MB
Troponin
CRP/BNP
<- + Markers Identify MI patients,
who are High-Risk Patients ->
CHD Mortality
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209
Recent Trends CHD Mortality
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209
Cardiovascular Procedure
Trends
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209
What is a UA/NSTEMI Patients Risk
of inpatient Cardiac Mortality and
ischemic events?
Risk Stratification
1.
Integral prerequisite to decision making
a)
b)
c)
2.
Risk based on contingent probabilities
a)
b)
3.
Intensive initial assessment
Continuous clinical assessment
Targeted ECG and marker data
Probability of obstructive CAD causing ischemia
Risk given presence of obstructive CAD
Risk scores should be a routine part of
assessment throughout the hospital course and
periodically after discharge
Anderson JL. J Am Coll Cardiol 2007;50:e1-157
Variables Used in the
TIMI Risk Score
•
Age ≥ 65 years =1 point
•
At least 3 risk factors for CAD =1 point
•
Prior coronary stenosis of ≥ 50% =1 point
•
ST-segment deviation on ECG presentation =1 point
•
At least 2 anginal events in prior 24 hours =1 point
•
Use of aspirin in prior 7 days =1 point
•
Elevated serum cardiac biomarkers =1 point
The TIMI risk score is determined by the sum of the presence of the above 7 variables at
admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more
remained relatively insensitive to missing information and remained a significant predictor
of events. Antman EM, et al. JAMA 2000;284:835–42.
TIMI = Thrombolysis in Myocardial Infarction.
TIMI Risk Score
Downloadable Apps available
TIMI
Risk
Score
All-Cause Mortality, New or Recurrent MI, or Severe
Recurrent Ischemia Requiring Urgent Revascularization
Through 14 Days After Randomization %
0-1
4.7
2
8.3
3
13.2
4
19.9
5
26.2
6-7
40.9
Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American
Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.
Initial Evaluation - Risk Stratification
I IIa IIb III
12-lead ECG within 10 min for all patients with
chest pain or symptoms suggestive of ACS
Early risk stratification by symptoms, physical
findings, ECG, cardiac markers
Cardiac markers, Troponins and CK-MB, for
initial assessment
Use of risk stratification models (TIMI,
PURSUIT, GRACE) can be useful to assist in
decision making for treatment options
Anderson JL. J Am Coll Cardiol 2007;50:e1-157
UA/NSTEMI Hospital Care
Let’s Start with the Basics! Assuming the
NSTEMI has been ruled in or out
ACC/AHA Guidelines
ACS Treatment Overview: UA/NSTEMI
Diagnosis of UA or NSTEMI is likely or definite
Initial
conservative
management
Aspirin or clopidogrel (if patient is aspirin
intolerant)
Initial invasive
management
Medical
therapy
Evaluation of LV
Function in pt
with ischemia
aIf
Diagnostic
angiography
PCI or CABGa
Long-term medical management:
Clopidogrel, aspirin, β-blocker, ACEI,
statin
possible, clopidogrel should be withheld for 5-7 days prior to the procedure.
Anderson JL, et al. Circulation. 2007;116:803-877.
Selection of Initial Treatment
Wright RS et al. Circ 2011;123;2022-2060.
Early Treatment
Class I Indications

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Bedrest/chair with continuous ECG Monitoring
O2 therapy with saturation <90%, respiratory distress, or
other high-risk features for hypoxemia
SL NTG 0.4 mg q5min x3 then assessment of need for IV NTG
IV NTG indicated first 48 hours for treatment of persistent
ischemia, CHF or HTN; should not preclude tx with betablockers or ACE
Oral Beta-Blocker in first 24 hours for pt who do not have
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Signs of CHF
Low out-put state
Increased risk of cardiogenic shock
Contraindication to Beta blockers/heart block/COPD
If Beta-Blockers are contraindicated a nondihydropyridine
calcium channel blocker may be used if no LV dysfunction
Wright RS et al. Circ 2011;123;2022-2060.
Early Treatment (Cont.)
ACE inhibitor within 24 hours with pulmonary congestion or
LVEF < 40% in the absence of hypotension or
contraindication
 Because of the increased risk of mortality, reinfarction, HTN,
CHF, and myocardial rupture NSAIDS except for ASA should
be discontinued at presentation
Class II indications:
 It is reasonable to admin O2 to all UA/NSTEMI pts in first 6
hours. IIa
 Morphine (1-5 mg IV) remains Class I for STEMI although
may increase adverse events in UA/NSTEMI1,2
 It is reasonable to administer morphine sulfate IV if the is
uncontrolled ischemic CP despite NTG. IIa

1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.
2. Meine T el al. Am Heart J 2005;149:1043- 9
Early Hospital Care
2011 Focused update Antiplatelet therapy


ASA should be administered to USA/NSTEMI as
soon as possible after hospital presentation and
continued indefinitely (LOE A)
Clopidogrel (loading dose followed by
maintenance dose) should be administered to
USA/NSTEMI patients who are unable to take
ASA because of hypersensitivity or major
gastrointestinal intolerance (LOE B)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Early Hospital Care
2011 Focused update Antiplatelet therapy

Pt with definite USA/NSTEMI at medium or
high risk and in whom an initial invasive
strategy is selected should receive dualantiplatelet therapy on presentation (LOE
A)
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
ASA on presentation
The second should be given before PCI as
follows…..
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Early Hospital Care
2011 Focused update Antiplatelet therapy
Before PCI:
 Clopidogrel LOE B
 An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide
or tirofiban are the preferred agents
At the time of PCI:
 Clopidogrel if not started before PCI LOE A
 Prasugrel LOE B
 An IV GP IIb/IIIa inhibitor LOE A
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update Antiplatelet therapy

For USA/NSTEMI patients in whom an
initial conservative strategy is selected
clopidogrel (loading dose followed by
maintenance dose) 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
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Loading Doses of Thienopyridine
prior to PCI

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Clopidogrel 300-600mg as early as
possible before the time of PCI (LOE A)
Prasugrel 60mg should be given promptly
and no later than 1 hour after PCI, Once
coronary anatomy is defined and a
decision is made to proceed with PCI (LOE
B)
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update Antiplatelet therapy

For USA/NSTEMI patients in whom an
initial conservative strategy is selected if
recurrent symptoms/ischemia, CHF, or
serious arrhythmias subsequently appear,
then diagnostic angiography should be
preformed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update Antiplatelet therapy


For patients with USA/NSTEMI treated
conservatively without recurrent symptoms, CHF
or arrhythmia a stress test should be performed
If the pt is not classified as low risk after the
stress test then angiography should be
performed
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update

If at low risk Post Stress Test:
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Continue ASA
Continue clopidogrel for at least 1 month and
ideally up to 1 year
Discontinue GP Iib/IIIa inhibitor if started
Continue UFH for 48 hours or administer
enoxaparin or fondaparinux for the duration
of hospitalization up to 8 days and then
discontinue
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update

For patients with USA/NSTEMI in whom CABG is
selected post angiography

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Continue ASA
Discontinue IV GP Iib/IIIa inhibitor 4 hours before
CABG
Continue UFH
Discontinue enoxaparin 12-24 hours before CABG and
dose with UFH per institution practice
Discontinue fondaparinux 24 hours before CABG and
dose with UFH per institution practice
Discontinue bivalirudin 3 hours before CABG and dose
with UFH per institution practice
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Hospital Care
2011 Focused update



In patients taking thienopyridine in whom
CABG is planned and can be delayed…
Discontinue clopidogrel for at least 5 days
Discontinue prasugrel for at least 7 days
Unless the need for revascularization and or
the net benefit of the thienopyridine
outweighs the potential risks of excess
bleeding… LOE C
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
ACC/AHA Guidelines update 2011
UA/NSTEMI: Long-Term Medical Management
UA or NSTEMI at hospital discharge
Inhospital management with
medical therapy (without
stenting)
Aspirina
75-162 mg/d
indefinitely plus
clopidogrelb 75 mg/d for at
least 1 mo, ideally up to 1 yr
aIf
patient is allergic
to aspirin, use
clopidogrel alone
(indefinitely) or try aspirin
desensitization.
bIf
patient is allergic to clopidogrel,
use ticlodipine 250 mg PO bid.
Inhospital therapy with
drug-eluting stent
implantation
Inhospital therapy with baremetal stent implantation
Aspirina
162-325 mg/d for at
least 1 mo, then
75-162 mg/d indefinitely plus
clopidogrelb 75 mg/d or
prasugrel 10 mg/d for at
least12 months*
Aspirina 162-325 mg/d for at
least 3 mo with Sirolimus and
6 mo paclitaxel, then
75-162 mg/d indefinitely plus
clopidogrelb 75 mg/d or
prasugrel 10 mg/d for at
least 12 mo
Is an indication for
anticoagulation present?
If yes: add
warfarinc,d
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
If no: continue dual
antiplatelet therapy
cContinue
aspirin indefinitely
and warfarin long term, if
indicated for specific conditions.
dIf
warfarin is added to aspirin
and clopidogrel, the
recommended INR is 2.0-2.5.
Evaluating Recurrent Risk
Secondary Prevention Strategies
Broad Goals during Hospital discharge phase


Prepare the patient for normal activities
Use the acute event as an opportunity to
reevaluate the plan of care - lifestyle and
risk factor modification
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209
Reperfusion is the Issue but once
stabilized…..
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ASA
Anti-platelet Therapy
Cholesterol goal
Blood Pressure goal
Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone)
Discharged with sublingual NTG and instructed in its use
Diabetes management: HbA1c < 7%
Warfarin for Afib/flutter or LV thrombus or other indication
Daily physical activity 30 min 7 d/wk, minimum 5 d/wk
Ask, advise, assess, and assist patients to stop smoking
Cardiac Rehabilitation recommended esp. for those with
mult. Risk factors or mod/high risk
Annual influenza immunization
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367
Secondary Prevention and Long Term Management
Goals
Physical activity:
2007 Goal:
30 min 7 d per
wk; minimum 5 d
per wk
Class I Recommendations
For all patients, it is recommended that risk be assessed
with a physical activity history and/or an exercise test to
guide prescription.
For all patients, encouraging 30 to 60 min of moderateintensity aerobic activity, such as brisk walking, on most,
preferably all, days of the week, supplemented by an
increase in daily lifestyle activities (e.g., walking breaks at
work, gardening, household work).
Advising medical supervised programs (cardiac
rehabilitation) for high-risk patients (e.g., recent acute
coronary syndrome or revascularization, HF) is
recommended.
Encouraging resistance training 2 d per week may be
reasonable (Class IIb; LOE: C)