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Patient Oriented Therapy Non STE ACS Prof dr Midhat nurkić FESC Director clinic for cardiovascular disease UKC Tuzla.

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Presentation on theme: "Patient Oriented Therapy Non STE ACS Prof dr Midhat nurkić FESC Director clinic for cardiovascular disease UKC Tuzla."— Presentation transcript:

1 Patient Oriented Therapy Non STE ACS Prof dr Midhat nurkić FESC Director clinic for cardiovascular disease UKC Tuzla

2 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. 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----] [----UA NSTEMI STEMI----]

3 Antithrombotic Therapy Stable Angina Unstable Angina Non-Q wave MI Thrombolysis Primary PCI Q wave MI Mins- hours Days- weeks STEMI UA/NSTEMI CAD Cannon CP J Thromb Thrombolysis. 1995;2:

4 Spectrum of Chronic Coronary Syndrome Endstage Heart Disease Congestive Heart Failure Ventricular Dilation Remodeling Arrhythmia & Loss of Muscle Myocardial Infarction Myocardial Ischemia IHD/Angina Pectoris Atherosclerosis Endothelial Dysfunction Risk Factors + Hypertension Coronary Thrombosis Chronic Coronary Syndrome Acute Coronary Syndrome Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2 nd ed

5 Acute Evaluation of ACS ST-segment Elevation Chest pain or Short of Breath Unstable Angina ST-segment Depression – + + Presentation ECG Diagnosis Normal Markers Acute MI – + Rule-Out Anderson JL. J Am Coll Cardiol 2007;50:e1-157

6 Stable Angina Unstable Angina ST Elevation MI Non ST Elevation MI ECG – ST CK-MB Troponin CRP/BNP ECG - ST

7 CHD Mortality Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

8 Recent Trends CHD Mortality Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

9 Cardiovascular Procedure Trends Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

10 What is a UA/NSTEMI Patients Risk of inpatient Cardiac Mortality and ischemic events?

11 Risk Stratification 1. Integral prerequisite to decision making a) Intensive initial assessment b) Continuous clinical assessment c) Targeted ECG and marker data 2. Risk based on contingent probabilities a) Probability of obstructive CAD causing ischemia b) Risk given presence of obstructive CAD 3. 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

12 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 Variables Used in the TIMI Risk Score 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.

13 TIMI Risk Score Downloadable Apps available 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 Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8. TIMI = Thrombolysis in Myocardial Infarction. TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 Days After Randomization %

14 Initial Evaluation - Risk Stratification 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 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 IIIIaIIaIIbIIbIIIIII Anderson JL. J Am Coll Cardiol 2007;50:e1-157

15 UA/NSTEMI Hospital Care Lets Start with the Basics! Assuming the NSTEMI has been ruled in or out

16 ACC/AHA Guidelines ACS Treatment Overview: UA/NSTEMI a If possible, clopidogrel should be withheld for 5-7 days prior to the procedure. Anderson JL, et al. Circulation. 2007;116: Initial invasive management Initial conservative management Diagnosis of UA or NSTEMI is likely or definite Aspirin or clopidogrel (if patient is aspirin intolerant) PCI or CABG a Diagnostic angiography Medical therapy Long-term medical management: Clopidogrel, aspirin, β-blocker, ACEI, statin Evaluation of LV Function in pt with ischemia

17 Selection of Initial Treatment Wright RS et al. Circ 2011;123;

18 Early Treatment Class I Indications Bedrest/chair with continuous ECG Monitoring Bedrest/chair with continuous ECG Monitoring O2 therapy with saturation <90%, respiratory distress, or other high-risk features for hypoxemia 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 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 beta- blockers or ACE IV NTG indicated first 48 hours for treatment of persistent ischemia, CHF or HTN; should not preclude tx with beta- blockers or ACE Oral Beta-Blocker in first 24 hours for pt who do not have Oral Beta-Blocker in first 24 hours for pt who do not have Signs of CHF Signs of CHF Low out-put state Low out-put state Increased risk of cardiogenic shock Increased risk of cardiogenic shock Contraindication to Beta blockers/heart block/COPD Contraindication to Beta blockers/heart block/COPD If Beta-Blockers are contraindicated a nondihydropyridine calcium channel blocker may be used if no LV dysfunction If Beta-Blockers are contraindicated a nondihydropyridine calcium channel blocker may be used if no LV dysfunction Wright RS et al. Circ 2011;123;

19 Early Treatment (Cont.) ACE inhibitor within 24 hours with pulmonary congestion or LVEF < 40% in the absence of hypotension or contraindication 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 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 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 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 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-e Meine T el al. Am Heart J 2005;149:

20 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) 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) 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

21 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 dual- antiplatelet therapy on presentation (LOE A) Pt with definite USA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual- antiplatelet therapy on presentation (LOE A) ASA on presentation ASA on presentation The second should be given before PCI as follows….. The second should be given before PCI as follows….. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

22 Early Hospital Care 2011 Focused update Antiplatelet therapy Before PCI: Clopidogrel LOE B Clopidogrel LOE B An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide or tirofiban are the preferred agents 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 Clopidogrel if not started before PCI LOE A Prasugrel LOE B Prasugrel LOE B An IV GP IIb/IIIa inhibitor LOE A An IV GP IIb/IIIa inhibitor LOE A Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

23 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 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

24 Loading Doses of Thienopyridine prior to PCI Clopidogrel mg as early as possible before the time of PCI (LOE A) Clopidogrel mg 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) 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

25 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 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

26 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 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 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

27 Hospital Care 2011 Focused update If at low risk Post Stress Test: If at low risk Post Stress Test: Continue ASA Continue ASA Continue clopidogrel for at least 1 month and ideally up to 1 year Continue clopidogrel for at least 1 month and ideally up to 1 year Discontinue GP Iib/IIIa inhibitor if started 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 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

28 Hospital Care 2011 Focused update For patients with USA/NSTEMI in whom CABG is selected post angiography For patients with USA/NSTEMI in whom CABG is selected post angiography Continue ASA Continue ASA Discontinue IV GP Iib/IIIa inhibitor 4 hours before CABG Discontinue IV GP Iib/IIIa inhibitor 4 hours before CABG Continue UFH Continue UFH Discontinue enoxaparin hours before CABG and dose with UFH per institution practice Discontinue enoxaparin hours before CABG and dose with UFH per institution practice Discontinue fondaparinux 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 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

29 Hospital Care 2011 Focused update In patients taking thienopyridine in whom CABG is planned and can be delayed… In patients taking thienopyridine in whom CABG is planned and can be delayed… Discontinue clopidogrel for at least 5 days Discontinue clopidogrel for at least 5 days Discontinue prasugrel for at least 7 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

30 ACC/AHA Guidelines update 2011 UA/NSTEMI: Long-Term Medical Management UA or NSTEMI at hospital discharge Inhospital management with medical therapy (without stenting) Inhospital therapy with bare- metal stent implantation Inhospital therapy with drug-eluting stent implantation Aspirin a mg/d indefinitely plus clopidogrel b 75 mg/d for at least 1 mo, ideally up to 1 yr Aspirin a mg/d for at least 1 mo, then mg/d indefinitely plus clopidogrel b 75 mg/d or prasugrel 10 mg/d for at least12 months* Aspirin a mg/d for at least 3 mo with Sirolimus and 6 mo paclitaxel, then mg/d indefinitely plus clopidogrel b 75 mg/d or prasugrel 10 mg/d for at least 12 mo Is an indication for anticoagulation present? If yes: add warfarin c,d If no: continue dual antiplatelet therapy a If patient is allergic to aspirin, use clopidogrel alone (indefinitely) or try aspirin desensitization. c Continue aspirin indefinitely and warfarin long term, if indicated for specific conditions. d If warfarin is added to aspirin and clopidogrel, the recommended INR is b If patient is allergic to clopidogrel, use ticlodipine 250 mg PO bid. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

31 Evaluating Recurrent Risk Secondary Prevention Strategies Broad Goals during Hospital discharge phase Prepare the patient for normal activities Prepare the patient for normal activities Use the acute event as an opportunity to reevaluate the plan of care - lifestyle and risk factor modification 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

32 Reperfusion is the Issue but once stabilized….. ASA ASA Anti-platelet Therapy Anti-platelet Therapy Cholesterol goal Cholesterol goal Blood Pressure goal Blood Pressure goal Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone) Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone) Discharged with sublingual NTG and instructed in its use Discharged with sublingual NTG and instructed in its use Diabetes management: HbA1c < 7% Diabetes management: HbA1c < 7% Warfarin for Afib/flutter or LV thrombus or other indication Warfarin for Afib/flutter or LV thrombus or other indication Daily physical activity 30 min 7 d/wk, minimum 5 d/wk Daily physical activity 30 min 7 d/wk, minimum 5 d/wk Ask, advise, assess, and assist patients to stop smoking Ask, advise, assess, and assist patients to stop smoking Cardiac Rehabilitation recommended esp. for those with mult. Risk factors or mod/high risk Cardiac Rehabilitation recommended esp. for those with mult. Risk factors or mod/high risk Annual influenza immunization Annual influenza immunization Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

33 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 moderate- intensity 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) Physical activity: 2007 Goal: 30 min 7 d per wk; minimum 5 d per wk Goals Class I Recommendations Secondary Prevention and Long Term Management

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