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MENWAR AL-ANAZI MD PSCC Acute Coronary Syndrome. Objectives Define acute coronary syndrome Define acute coronary syndrome Review Management Guidelines.

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Presentation on theme: "MENWAR AL-ANAZI MD PSCC Acute Coronary Syndrome. Objectives Define acute coronary syndrome Define acute coronary syndrome Review Management Guidelines."— Presentation transcript:

1 MENWAR AL-ANAZI MD PSCC Acute Coronary Syndrome

2 Objectives Define acute coronary syndrome Define acute coronary syndrome Review Management Guidelines Review Management Guidelines Unstable Angina / NSTEMI Unstable Angina / NSTEMI STEMI STEMI Review secondary prevention Review secondary prevention

3 Scope of Problem (2006 stats) CHD single leading cause of death in United States CHD single leading cause of death in United States 492,327 deaths in the U.S. in 2006 492,327 deaths in the U.S. in 2006 1,260,000 new & recurrent coronary attacks per year 1,260,000 new & recurrent coronary attacks per year 38% of those who with coronary attack die within a year of having it 38% of those who with coronary attack die within a year of having it Annual cost > $320 billion Annual cost > $320 billion

4 Expanding Risk Factors Smoking Smoking Hypertension Hypertension Diabetes Mellitus Diabetes Mellitus Dyslipidemia Dyslipidemia Low HDL < 40 Low HDL < 40 Elevated LDL / TG Elevated LDL / TG Family History—event in first degree relative >55 male/65 female Family History—event in first degree relative >55 male/65 female Age-- > 45 for male/55 for female Age-- > 45 for male/55 for female Chronic Kidney Disease Chronic Kidney Disease Lack of regular physical activity Lack of regular physical activity Obesity Obesity Lack of diet rich in fruit, veggies, fiber Lack of diet rich in fruit, veggies, fiber

5 Acute Coronary Syndromes Similar pathophysiology Similar pathophysiology Similar presentation and early management rules Similar presentation and early management rules STEMI requires evaluation for acute reperfusion intervention STEMI requires evaluation for acute reperfusion intervention Unstable Angina Non-ST-Segment Elevation MI (NSTEMI) ST-Segment Elevation MI (STEMI)

6 Diagnosis of Acute MI STEMI / NSTEMI At least 2 of the following At least 2 of the following Ischemic symptoms Ischemic symptoms Diagnostic ECG changes Diagnostic ECG changes Serum cardiac marker elevations Serum cardiac marker elevations

7 Diagnosis of Angina Typical angina—All three of the following Typical angina—All three of the following Substernal chest discomfort Substernal chest discomfort Onset with exertion or emotional stress Onset with exertion or emotional stress Relief with rest or nitroglycerin Relief with rest or nitroglycerin Atypical angina Atypical angina Noncardiac chest pain Noncardiac chest pain

8 Diagnosis of Unstable Angina Patients with typical angina - An episode of angina Patients with typical angina - An episode of angina Increased in severity or duration Increased in severity or duration Has onset at rest or at a low level of exertion Has onset at rest or at a low level of exertion Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain Patients not known to have typical angina Patients not known to have typical angina First episode with usual activity or at rest within the previous two weeks First episode with usual activity or at rest within the previous two weeks Prolonged pain at rest Prolonged pain at rest

9 Unstable Angina Unstable Angina STEMI NSTEMI NSTEMI Non occlusive thrombus Non specific ECG Normal cardiac enzymes Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/- T wave inversion on ECG Elevated cardiac enzymes Complete thrombus occlusion ST elevations on ECG or new LBBB Elevated cardiac enzymes More severe symptoms

10 Acute Management Initial evaluation & stabilization Efficient risk stratification Focused cardiac care

11 Evaluation Efficient & direct history Efficient & direct history Initiate stabilization interventions Initiate stabilization interventions  Plan for moving rapidly to indicated cardiac care Directed Therapies are Time Sensitive! Occurs simultaneously

12 Chest pain suggestive of ischemia 12 lead ECG 12 lead ECG Cardiac enzymes Cardiac enzymes Electrolytes, CBC, lipids, BUN/Cr, glucose, coagulation Electrolytes, CBC, lipids, BUN/Cr, glucose, coagulation CXR CXR Immediate assessment within 10 Minutes Establish diagnosis Establish diagnosis Read ECG Read ECG Identify complications Identify complications Assess for reperfusion Assess for reperfusion Initial labs and tests Emergent care History & Physical IV access IV access Cardiac monitoring Cardiac monitoring Oxygen Oxygen Aspirin Aspirin Nitrates Nitrates

13 Focused History Aid in diagnosis and rule out other causes Aid in diagnosis and rule out other causes Palliative/Provocative factors Palliative/Provocative factors Quality of discomfort Quality of discomfort Radiation Radiation Symptoms associated with discomfort Symptoms associated with discomfort Cardiac risk factors Cardiac risk factors Past medical history - especially cardiac Past medical history - especially cardiac Reperfusion questions Timing of presentation ECG c/w STEMI Contraindication to fibrinolysis Degree of STEMI risk

14 Targeted Physical Recognize factors that increase risk Hypotension Tachycardia Pulmonary rales, JVD, pulmonary edema, New murmurs/heart sounds Diminished peripheral pulses Signs of stroke Examination Examination Vitals Vitals Cardiovascular system Cardiovascular system Respiratory system Respiratory system Abdomen Abdomen Neurological status Neurological status

15 ECG assessment ST Elevation or new LBBB STEMI Non-specific ECG Unstable Angina ST Depression or dynamic T wave inversions NSTEMI

16 Normal or non-diagnostic EKG

17 ST Depression or Dynamic T wave Inversions

18 ST-Segment Elevation MI

19 New LBBB QRS > 0.12 sec L Axis deviation Prominent R wave V1-V3 Prominent S wave 1, aVL, V5-V6 with t-wave inversion

20 Cardiac markers Troponin ( T, I) Troponin ( T, I) S pecific and more sensitive than CK S pecific and more sensitive than CK 4-8 hours after injury 4-8 hours after injury Elevated for up to two weeks Elevated for up to two weeks Provide prognostic information Provide prognostic information Elevated with renal disease, dermatomyositis Elevated with renal disease, dermatomyositis CK-MB isoenzyme 4-6 hours after injury and peaks at 24 hours Elevated 36-48 hrs Positive if CK/MB > 5% of total CK and 2 times normal Predictive of mortality False positives with exercise, trauma, muscle disease, PE

21 Prognosis with Troponin Mortality at 42 Days 8311741481345067  % % % % % %

22 Risk Stratification UA or NSTEMI - Evaluate for Invasive vs. conservative treatment - Directed medical therapy Based on initial Evaluation, ECG, and Cardiac markers - Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy STEMI Patient? YESNO

23 Cardiac Care Goals Myocardial necrosis Myocardial necrosis LV function LV function Major adverse cardiac events Major adverse cardiac events Complications Complications

24 STEMI cardiac care STEP 1: Assessment STEP 1: Assessment Time since onset of symptoms Time since onset of symptoms 90 min for PCI / 12 hours for fibrinolysis 90 min for PCI / 12 hours for fibrinolysis Is this high risk STEMI? Is this high risk STEMI? KILLIP classification KILLIP classification If higher risk may manage with more invasively If higher risk may manage with more invasively Determine fibrinolysis candidacy Determine fibrinolysis candidacy Meets criteria with no contraindications Meets criteria with no contraindications Determine PCI candidacy Determine PCI candidacy Based on availability and DTB time Based on availability and DTB time

25 Fibrinolysis indications ST segment elevation >1mm in two contiguous leads ST segment elevation >1mm in two contiguous leads New LBBB New LBBB Symptoms consistent with ischemia Symptoms consistent with ischemia Symptom onset less than 12 hrs prior to presentation Symptom onset less than 12 hrs prior to presentation

26 Absolute contraindications for fibrinolysis therapy in patients with acute STEMI Any prior ICH Structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months

27 Relative contraindications for fibrinolysis therapy in patients with acute STEMI History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation ( SBP greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks).

28 Relative contraindications for fibrinolysis therapy in patients with acute STEMI Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase : prior exposure (more than 5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

29 STEMI cardiac care STEP 2: Determine preferred reperfusion strategy STEP 2: Determine preferred reperfusion strategy Fibrinolysis preferred if: Fibrinolysis preferred if: <3 hours from onset <3 hours from onset PCI not available/delayed PCI not available/delayed DTB > 90min DTB > 90min DTB-DTN > 1hr DTB-DTN > 1hr (DTN goal <30min) (DTN goal <30min) No contraindications No contraindications PCI preferred if: PCI preferred if: PCI available PCI available DTB < 90min DTB < 90min DTB-DTN < 1hr DTB-DTN < 1hr Fibrinolysis contraindications Fibrinolysis contraindications Late Presentation > 3 hr Late Presentation > 3 hr High risk STEMI High risk STEMI Killip 3 or higher Killip 3 or higher STEMI dx in doubt STEMI dx in doubt

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32 Medical Therapy Morphine (class I, level C) Morphine (class I, level C) Analgesia Analgesia Reduce pain/anxiety—decrease sympathetic tone, systemic vascular resistance and oxygen demand Reduce pain/anxiety—decrease sympathetic tone, systemic vascular resistance and oxygen demand Careful with hypotension, hypovolemia, respiratory depression Careful with hypotension, hypovolemia, respiratory depression Oxygen ( 2-4 liters/minute) (class I, level C) Oxygen ( 2-4 liters/minute) (class I, level C) Up to 70% of ACS patient demonstrate hypoxemia Up to 70% of ACS patient demonstrate hypoxemia May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation

33 Nitroglycerin (class I, level B) Nitroglycerin (class I, level B) Analgesia—titrate infusion to keep patient pain free Analgesia—titrate infusion to keep patient pain free Dilates coronary vessels—increase blood flow Dilates coronary vessels—increase blood flow Reduces systemic vascular resistance and preload Reduces systemic vascular resistance and preload Careful with recent ED meds, hypotension, bradycardia, tachycardia, RV infarction Careful with recent ED meds, hypotension, bradycardia, tachycardia, RV infarction Aspirin (160-325mg chewed & swallowed) (class I, level A) Aspirin (160-325mg chewed & swallowed) (class I, level A) Irreversible inhibition of platelet aggregation Irreversible inhibition of platelet aggregation Stabilize plaque and arrest thrombus Stabilize plaque and arrest thrombus Reduce mortality in patients with STEMI Reduce mortality in patients with STEMI Careful with active PUD, hypersensitivity, bleeding disorders Careful with active PUD, hypersensitivity, bleeding disorders

34 Beta-Blockers (class I, level A) Beta-Blockers (class I, level A) 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI 14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms Be aware of contraindications (CHF, Heart block, Hypotension) Be aware of contraindications (CHF, Heart block, Hypotension) Reassess for therapy as contraindications resolve Reassess for therapy as contraindications resolve ACE-Inhibitors / ARB (class I, level A) ACE-Inhibitors / ARB (class I, level A) Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension Start in first 24 hours Start in first 24 hours ARB as substitute for patients unable to use ACE-I ARB as substitute for patients unable to use ACE-I

35 Heparin (class I, level C to class IIa, level C) Heparin (class I, level C to class IIa, level C) LMWH or UFH (max 4000u bolus, 1000u/hr) LMWH or UFH (max 4000u bolus, 1000u/hr) Indirect inhibitor of thrombin Indirect inhibitor of thrombin less supporting evidence of benefit in era of reperfusion less supporting evidence of benefit in era of reperfusion Adjunct to surgical revascularization and thrombolytic / PCI reperfusion Adjunct to surgical revascularization and thrombolytic / PCI reperfusion 24-48 hours of treatment 24-48 hours of treatment Coordinate with PCI team (UFH preferred) Coordinate with PCI team (UFH preferred) Used in combo with aspirin and/or other platelet inhibitors Used in combo with aspirin and/or other platelet inhibitors Changing from one to the other not recommended Changing from one to the other not recommended

36 Additional medication therapy Clopidogrel (class I, level B) Clopidogrel (class I, level B) Irreversible inhibition of platelet aggregation Irreversible inhibition of platelet aggregation Used in support of cath / PCI intervention or if unable to take aspirin Used in support of cath / PCI intervention or if unable to take aspirin 3 to 12 month duration depending on scenario 3 to 12 month duration depending on scenario Glycoprotein IIb/IIIa inhibitors (class IIa, level B) Glycoprotein IIb/IIIa inhibitors (class IIa, level B) Inhibition of platelet aggregation at final common pathway Inhibition of platelet aggregation at final common pathway In support of PCI intervention as early as possible prior to PCI In support of PCI intervention as early as possible prior to PCI

37 STEMI care CCU Monitor for complications: Monitor for complications: Recurrent ischemia, cardiogenic shock, ICH, arrhythmia Recurrent ischemia, cardiogenic shock, ICH, arrhythmia Review guidelines for specific management of complications & other specific clinical scenarios Review guidelines for specific management of complications & other specific clinical scenarios PCI after fibrinolysis, emergent CABG, etc… PCI after fibrinolysis, emergent CABG, etc… Decision making for risk stratification at hospital discharge and/or need for CABG Decision making for risk stratification at hospital discharge and/or need for CABG

38 Unstable angina/NSTEMI cardiac care Evaluate for conservative vs. invasive therapy based upon: Evaluate for conservative vs. invasive therapy based upon: Risk of actual ACS Risk of actual ACS TIMI risk score TIMI risk score ACS risk categories per AHA guidelines ACS risk categories per AHA guidelines Low Intermediate High

39 Assessment Findings indicating HIGH likelihood of ACS Findings indicating INTERMEDIATE likelihood of ACS in absence of high-likelihood findings Findings indicating LOW likelihood of ACS in absence of high- or intermediate- likelihood findings History Chest or left arm pain or discomfort as chief symptom Reproduction of previous documented angina Known history of coronary artery disease, including myocardial infarction Chest or left arm pain or discomfort as chief symptom Age > 50 years Probable ischemic symptoms Recent cocaine use Physical examination New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales Extracardiac vascular diseaseChest discomfort reproduced by palpation ECG New or presumably new transient ST-segment deviation (> 0.05 mV) or T- wave inversion (> 0.2 mV) with symptoms Fixed Q waves Abnormal ST segments or T waves not documented to be new T-wave flattening or inversion of T waves in leads with dominant R waves Normal ECG Serum cardiac markers Elevated cardiac troponin T or I, or elevated CK-MB Normal Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome

40 TIMI Risk Score Predicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days

41 ACS risk criteria Low Risk ACS   No intermediate or high risk factors   <10 minutes rest pain   Non-diagnositic ECG   Non-elevated cardiac   markers   Age < 70 years Intermediate Risk ACS   Moderate to high likelihood of CAD   >10 minutes rest pain, now resolved   T-wave inversion >2mm   Slightly elevated cardiac markers

42 High Risk ACS   Elevated cardiac markers   New or presumed new ST depression   Recurrent ischemia despite therapy   Recurrent ischemia with heart failure   High risk findings on non-invasive stress test   Depressed systolic left ventricular function   Hemodynamic instability   Sustained Ventricular tachycardia   PCI with 6 months   Prior Bypass surgery

43 Low risk High risk Conservative Therapy Invasive Therapy Chest Pain Center Intermediate risk

44 Invasive therapy option UA/NSTEMI Coronary angiography and revascularization within 12 to 48 hours after presentation to ED. For high risk ACS (class I, level A ). Morphea /Oxygen/Nitrates/ASA B-blockers/ACEI/Heparin (UFH) Clopidogrel 20% reduction death/MI/Stroke – CURE trial 1 month minimum duration and possibly up to 9 months 1 month minimum duration and possibly up to 9 months Glycoprotein IIb/IIIa inhibitors Glycoprotein IIb/IIIa inhibitors

45 Conservative Therapy for UA/NSTEMI Early revascularization or PCI not planned Early revascularization or PCI not planned Morphea/Oxygen/Nitrates/ASA Morphea/Oxygen/Nitrates/ASA Beta-blockers/ACEI/Heparin (LMW or UFH) Beta-blockers/ACEI/Heparin (LMW or UFH) Clopidogrel Clopidogrel Glycoprotein IIb/IIIa inhibitors Glycoprotein IIb/IIIa inhibitors Only in certain circumstances (planning PCI, elevated TnI/T) Only in certain circumstances (planning PCI, elevated TnI/T) Surveillance in hospital Surveillance in hospital Serial ECGs Serial ECGs Serial Markers Serial Markers

46 Secondary Prevention Disease Disease HTN, DM, HLP HTN, DM, HLP Behavioral Behavioral smoking, diet, physical activity, weight smoking, diet, physical activity, weight Cognitive Cognitive Education, cardiac rehab program Education, cardiac rehab program

47 Secondary Prevention disease management Blood Pressure Blood Pressure Goals < 140/90 or <130/80 in DM /CKD Goals < 140/90 or <130/80 in DM /CKD Maximize use of beta-blockers & ACE-I Maximize use of beta-blockers & ACE-I Lipids Lipids LDL < 100 (70) ; TG < 200 LDL < 100 (70) ; TG < 200 Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids Diabetes Diabetes A1c < 7% A1c < 7%

48 Secondary prevention behavioral intervention Smoking cessation Smoking cessation Cessation-class, meds, counseling Cessation-class, meds, counseling Physical Activity Physical Activity Goal 30 - 60 minutes daily Goal 30 - 60 minutes daily Risk assessment prior to initiation Risk assessment prior to initiation Diet Diet DASH diet, fiber, omega-3 fatty acids DASH diet, fiber, omega-3 fatty acids <7% total calories from saturated fats <7% total calories from saturated fats

49 Secondary prevention cognitive Patient education Patient education In-hospital – discharge –outpatient clinic/rehab In-hospital – discharge –outpatient clinic/rehab Monitor psychosocial impact Monitor psychosocial impact Depression/anxiety assessment & treatment Depression/anxiety assessment & treatment Social support system Social support system

50 Medication Checklist after ACS Antiplatelet agent Antiplatelet agent Aspirin* and/or Clopidorgrel Aspirin* and/or Clopidorgrel Lipid lowering agent Lipid lowering agent Statin* Statin* Fibrate / Niacin / Omega-3 Fibrate / Niacin / Omega-3 Antihypertensive agent Antihypertensive agent Beta blocker* Beta blocker* ACE-I*/ARB ACE-I*/ARB Aldactone (as appropriate) Aldactone (as appropriate)

51 Prevention news… From 1994 to 2004 the death rate from coronary heart disease declined 33%... But the actual number of deaths declined only 18% Getting better with treatment… But more patients developing disease –need for primary prevention focus

52 Summary ACS includes UA, NSTEMI, and STEMI ACS includes UA, NSTEMI, and STEMI Management guideline focus Management guideline focus Immediate assessment/intervention (Morph/Oxyg/Nitrate/ASA+BB/ACEI/Hep) Immediate assessment/intervention (Morph/Oxyg/Nitrate/ASA+BB/ACEI/Hep) Risk stratification (UA/NSTEMI vs. STEMI) Risk stratification (UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMI Conservative vs Invasive therapy for UA/NSTEMI Aggressive attention to secondary prevention initiatives for ACS patients Aggressive attention to secondary prevention initiatives for ACS patients Beta blocker, ASA, ACE-I, Statin Beta blocker, ASA, ACE-I, Statin

53 Thank You


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