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1 Heart Attacks: Killers in Disguise! W. Frank Peacock, MD, FACEP Vice Chief, Emergency Department The Cleveland Clinic.

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Presentation on theme: "1 Heart Attacks: Killers in Disguise! W. Frank Peacock, MD, FACEP Vice Chief, Emergency Department The Cleveland Clinic."— Presentation transcript:

1 1 Heart Attacks: Killers in Disguise! W. Frank Peacock, MD, FACEP Vice Chief, Emergency Department The Cleveland Clinic

2 2 Agenda What is an Acute Coronary Syndrome? (a heart attack) Why do you care? –CAD is the number one killer in Scotland Who gets ACS? –What are the symptoms?

3 3 Agenda When should you go to the hospital? –why you should go to the hospital? How do we diagnosis it? What happens if your diagnosed with it? What can be done to prevent getting this?

4 4 How does the heart work? Its just a pump, right?

5 5 Its also a gland Myocardial injuryFall in LV performance Activation of RAAS, SNS, ET, and others Myocardial toxicity Peripheral vasoconstriction Hemodynamic alterations Remodeling and progressive worsening of LV function Heart failure symptoms Morbidity and mortality ANP BNP

6 6 Epidemiology of CHD in the US Single most frequent cause of death –656,000 deaths in 2002 –1 of every 5 deaths Incidence –Each year, 1.2 million Americans will have a new or recurrent coronary event, and >40% will die as a result –700,000 events will be first attacks; 500,000 will be recurrences Prevalence –13 million Americans have a history of CHD (acute MI, other acute ischemic (coronary) heart disease, angina pectoris, atherosclerotic cardiovascular disease, and all other forms of heart disease) CHD = coronary heart disease; MI = myocardial infarction. American Heart Association. Heart Disease and Stroke Statistics2005 Update; 2005.

7 7 Epidemiology of CHD Scotland Single most frequent cause of death Incidence Prevalence CHD = coronary heart disease; MI = myocardial infarction. American Heart Association. Heart Disease and Stroke Statistics2005 Update; 2005.

8 8 Risk for CHD Increases With Additional Risk Factors: INTERHEART Study Yusuf S, et al. Lancet. 2004;364: Smk (1) DM (2) HTN (3) ApoB/A1 (4) 1+2+3All 4+Obes+PSAll RFs Odds ratio (99% Cl) PS = psychosocial

9 9 INTERHEART: Impact on CV Risk of Multiple Risk Factors (Smoking, Lipids, Hypertension, Diabetes, Abdominal Obesity, Diet, Physical Activity, Alcohol, Psychosocial*) Yusuf S, et al. Lancet. 2004;364: Odds Ratio for 1st MI (99% CI) Smk (1) DM (2) HTN (3) ApoB- ApoA1 (4) 1+2+3All 4All 4 + Obes All 4 + Ps All risk factors Smk = smoking DM = diabetes HTN = hypertension Obes = abdominal obesity Ps = psychosocial factors – Large intl case-control study – 15,152 cases – 14,820 controls – 52 countries – Follow-up: 4 years. *eg, stress, depression Note: odds ratio plotted on a doubling scale.

10 10 What does an ACS feel like?

11 11 Symptoms of CAD NONE…….. –Sudden Cardiac Death Chest Pain –Usually a pressure Not seconds Anginal equivalents –Jaw or shoulder pain –Nausea & vomiting –Shortness of breath –Weak & dizzy –Diaphoresis

12 12 Symptoms of Heart Attack Classic presentation Chest pressure –Elephant Sweating Nausea/vomiting Radiation of pain Shortness of breath Anginal equivalents Jaw/shoulder pain Nausea & vomiting Shortness of breath Weak & dizzy Diaphoresis

13 13 Who gets Equivalents? Women Diabetics Elderly Heart Transplant patients Patients who cant perceive/communicate well? –Drunk –Mentally ill

14 14 EMS Transport Onset of symptoms of STEMI EMS dispatch EMS on-scene Encourage 12-lead ECGs Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min GOALS PCI capable Not PCI capable Hospital fibrinolysis: door-to-needle within 30 min EMS triage plan Inter- hospital transfer Golden hr = 1st 60 minTotal ischemic time: within 120 min Patient EMS Prehospital fibrinolysis EMS-to-needle within 30 min EMS transport EMS-to-balloon within 90 min Patient self-transport Hospital door-to-balloon within 90 min Dispatch 1 min 5 min 8 min Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Adapted with permission from Antman EM, et al. Available at: Accessed November 1, 2005.

15 15 What happens in the Ambulance? Paramedics take your history and perform a brief exam IV Oxygen Put on the monitor May receive nitroglycerin under the tongue. (tingle, get a H/A) Maybe: ECG, thrombolytic (clot dissolver)

16 16 What happens when you get to the hospital?

17 17 ED Visits - US 130,000,000 annually 6.24 M suspected or actual cardiac 4.1 M sent home non-cardiac 50,000 MIs 3.1 M non-cardiac (50%) 10.4 M chest pain (8.0%) 1.2 M AMI (20%) 1.5 M UA (24%) 374,400 sudden death (6%)

18 18 ST-segment Elevation Spectrum of Acute Coronary Syndromes Ischemic Discomfort at Rest Unstable Angina (UA) Non-Q-wave MI (NSTEMI) Q-wave MI (STEMI) No ST-segment Elevation – ++ + Cardiac Markers Presentation Emergency Department In-hospital 6-24 hours Adapted from Braunwald E, et al. Available at:

19 19 STEMI: Brief Physical Exam in the Emergency Department Airway, Breathing, Circulation (ABC) Vital signs, general observation Presence or absence of jugular venous distension Pulmonary auscultation for rales Cardiac auscultation for murmurs or gallops Presence or absence of stroke Presence or absence of pulses Presence or absence of systemic hypoperfusion (cool, clammy, pale/ashen) Antman EM, et al. Available at: Accessed November 1, 2005.

20 20 STEMI: Acute Medical Therapy General treatment measures Antman EM, et al. Available at: Accessed November 1, Analgesics Nitrates Oxygen β-blockers (decrease heart rate) Primary PCI or coronary thrombolysis (primary PCI preferred after 3 hours) Aspirin ( mg, acute dose) Heparin If PCI: – Clopidogrel – GP IIb/IIIa inhibitors Infarct size limitation Reperfusion Antithrombotic and antiplatelet therapy

21 21 Chest Pain on a Saturday morning While the physician was examining the ECG, the patient became unconscious and the rhythm on the monitor changed…

22 22 Chest Pain on a Saturday morning 12:01100J DC cardioversion, patient immediately in NSR 12:03Clot box brought to room and catheterization lab team notified 12:04IV line started, 325 mg aspirin chewed and metoprolol given 12:10Open cath table and staff available, heparin iv and clopidogrel po given 12:19Patients stretcher rolls

23 23 Media campaign Patient education Greater use of Methods of Speeding Time to Reperfusion Prehospital ECG and Prehospital Rx, if possible MI protocol Critical pathway Quality improvement program Bolus lytics Dedicated PCI team 5 min< 30 min D-B 90 min D-N 30 min PatientTransportIn-hospitalReperfusion Goals of Reperfusion Therapy Adapted with permission from: Antman EM, et al. Available at: Accessed November 1, 2005.

24 24 Time from Symptom Onset to Treatment Predicts 1 Year MortalityPrimary PCI The relative risk of 1 year mortality increases by 7.5% for each 30 minute delay. De Luca G, et al. Circulation. 2004;109: Y=2.86 (± 1.45) X X 2 P<.001 Roughly 1% every 3 minutes

25 25 Boersma E, et al. Lancet.1996;348:771 Meta-analysis of 50,246 Patients in Lytic Trials (Juice to squeeze) 0 Absolute benefit per 1000 treated patients Time to Treatment

26 26 Primary PCI vs Thrombolysis in STEMI: Meta-analysis (23 RCTs, N=7739) Adapted with permission from Keeley EC, et al. Lancet. 2003;361: PCI Thrombolytic therapy Frequency (%) Short-term Outcomes (4-6 weeks) Death P =.0002 Nonfatal MI P <.0001 Recurrent Ischemia P <.0001 Hemor- rhagic Stroke P <.0001 Major Bleed P =.032 Death, Nonfatal Reinfarction, or Stroke P <.0001 Bonferroni correction 6 variables: p <0.0083

27 27 What if the ECG is not diagnostic? (As it is in >95%)

28 28 Blood Markers Necrosis –Something has to die Strain –Natriuretic peptides Other –Inflammation –Plaque rupture –Ischemia changes the blood

29 29 All NecrosisAll IschemiaSome Ischemia, Some Necrosis ACS Sequence and Timing Plaque Rupture Onset of Pain ED Presentation Discharge 0-12 to 0 hrs 12 to 24 hrs Time Amount of Tissue IMA cTn Ischemia Muscle death Ventricular Overload BNP

30 30 Appearance of necrosis markers Hospital arrival

31 31 Disease vs Events? Time Oxygen Oxygen supply diminishes with disease progression Oxygen demand changes daily and during life Ischemia occurs when O 2 demand exceeds supply

32 32 What is in the future? New better markers

33 33 Human Serum Albumin (HSA) is a circulating protein in blood with a metal binding site at the N- terminus. What is IMA? Bar Or et al, European Journal of Biochemistry, 2001 The N-terminus is altered during an ischemic event, resulting in Ischemia Modified Albumin (IMA). IMA is unable to bind metals at the N-terminus.

34 34 Chest Pain at Presentation EP Protocol with good NPV ischemia marker 12% ACS 13% Rule Out 75% Grey Zone Current EP Protocol

35 35 What if the markers are all negative? (And they are in >90%)

36 36 If It Moves, Even Below Your Hospitals Cutpoint, It Is Bad MarkerComparatorOR for 30 day MACE 95% CI ing Tn vs. stable Troponin ing Tn ing CKMB vs. stable CKMB ing CKMB Logistic regression models showing the odds ratios for predicting ACS MACE: MI, revascularization (PCI or CABG), or positive testing (>70% stenosis at catheterization, [+] MPI or non-invasive stress testing) within 30 days of index visit. N=2,188

37 37 All this testing… Whats the end result? Most (88%) of the time, its negative –You go home 18% of the time, something is positive –ECG IMMEDIATE Cath lab –Marker URGENT Cath lab –Stress test Semi-elective Cath lab

38 38 What happens in the Cath Lab? Define the anatomy –Acutely closed vessel fix it –Chronically closed vessel nothing –Stenotic vessel: have options ~50%; either medicine or angioplasty works >70%; most get angioplasty

39 39 Scotland Epidemiology

40 40 Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study. 10,359 men and women aged years from 22 districts in the Scottish Heart Health Study –Described the prevalence rates of coronary heart disease in Scotland in and their relation to the geographical variation in mortality in these districts. Coronary heart disease in Scotland was the highest reported to the WHO from –Angina was more common in men (5.5%) than in women (3.9%) –A history of MI was 3 times more common in men than women –Angina correlated well with mortality from coronary heart disease Br Heart J Nov;64(5):295-8

41 : The good news The Cardiovascular Epidemiology Unit at the University of Dundee celebrated its 20th anniversary with a 40 % decline in coronary mortality rate The steep decline in coronary mortality in Scotland mirrors the pattern in the rest of Britain. Improvement is a combination of: Heightened awareness of health issues Improved diet and more exercise Improvement in treatments. Scotland's record on heart disease is much improved –Russia now has the highest coronary mortality rate.

42 British Women's Heart and Health Study 4286 Women –20% MI, angina, HF, CVA, PVD. –50% HTN, 12% smoked, 25% obese –50% w/ total cholesterol > 6.5 mmol/l, only 3% had low HDL Age adjusted CVD prevalence –highest in Scotland: 25.0% (21.5% to 28.8%) –lowest in S. England: 15.4% (13.5% to 17.6%). –Woman in Scotland are 1.53 times more likely to have CVD Of women with CVD –12% are smokers, 1/3 had uncontrolled HTN, 1/3 were obese –90% had a cholesterol > 5 mmol/l. –Only 41% were taking antiplatelet drugs and 22% were taking a statin. Journal of Epidemiology and Community Health 2003;57:

43 43 In Scotland Coronary Heart Disease –one of the leading causes of death 10,331 deaths in 2005 –Scotland has one of the highest death rates from CHD in the western world –Due to high rates of smoking poor diet deprivation

44 44 In the year ending March Scottish hospitals 48,962 hospital discharges for CHD 16,320 were for AMI(heart attack) CHD discharges represented around 4% of all acute hospital discharges. NHSScotland carried out 2,319 Coronary Artery Bypass Grafts 5,803 angioplasties 17,065 angiographies

45 45 CHD mortality is strongly related to age year olds is 4.1 per 100, , the rate is per 100,000 The incidence of CHD is higher in men, elderly and deprived areas of Scotland Smoking being overweight raised blood pressure raised level of cholesterol

46 46 Cost of Cardiovascular Disease in the UK CVD cost the UK £29.1 billion in 2004 –(exceeds the GDP of Kuwait) –29% (£8.5 billion) was due to Coronary Heart Disease –27% (£8.0 billion) Cerebrovascular Disease CVD Cost break down –60% health care –23% productivity losses –17% informal care-related costs Conclusions: CVD is a leading public health problem in the UK measured by the economic burden of disease. Heart 2006;92:

47 47 Small changes in UK cardiovascular risk factors could halve CHD mortality The UK called for a 40% reduction in CVD mortality by Potential reductions from the year 2000, were calculated for: –Continuation of recent risk factor trends ~10,685 fewer CAD deaths in 2010 than in 2000 –Modest additional reductions in cholesterol and smoking ~51,270 fewer deaths Optimistic changes in obesity, DM, and physical activity, would have relatively small effects. Journal of Clinical Epidemiology 58 (2005) 733–740

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