1. Patient Oriented Therapy Non STE ACS
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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.
[----UA NSTEMI STEMI----]

3. Stable Unstable Q wave Non-Q Angina Angina MI wave MI CAD UA/NSTEMI
Days-
weeks
Mins-
hours
Our current understanding of the unstable coronary syndromes is that they all fall on a spectrum of disease and begin with a coronary plaque rupture. The degree of thrombus determines the severity of the clinical syndrome, with total occlusion in ST elevation MI or severe (90%) stenosis in patients with non-ST elevation MI or unstable angina.
In addition, it is worthwhile to note that 99% of all plaque ruptures are clinically silent. A small degree of rupture, leads to a small thrombus, which heals over, but leads to progression of the plaque - like rings on a tree. This is the understanding of how atherosclerosis progresses. This emphasized the key role that antithrombotic therapy plays in all both acutely and chronically in patients with unstable coronary syndromes.
Antithrombotic
Thrombolysis
Primary PCI
Therapy
Cannon CP J Thromb Thrombolysis. 1995;2: 2

4. Spectrum of Chronic Coronary Syndrome
Risk Factors + Hypertension
Endothelial Dysfunction
Atherosclerosis
IHD/Angina Pectoris
Chronic
Coronary
Syndrome
Myocardial Ischemia
Acute
Coronary
Syndrome
Coronary Thrombosis
Myocardial Infarction
Arrhythmia & Loss of Muscle
Remodeling
Ventricular Dilation
Congestive Heart Failure
Endstage Heart Disease
Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed 10

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

6. ST Elevation MI Stable Angina Unstable Angina Non ST Elevation MI
ECG – ST ↑
ECG - ST ↓
CK-MB
Troponin
CRP/BNP
<- + Markers Identify MI patients, who are High-Risk Patients ->

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 Integral prerequisite to decision making
Intensive initial assessment
Continuous clinical assessment
Targeted ECG and marker data
Risk based on contingent probabilities
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
Can you do this with bullets?
Anderson JL. J Am Coll Cardiol 2007;50:e1-157

12. 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.

13. Downloadable Apps available
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
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.

14. Initial Evaluation - Risk Stratification
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

15. UA/NSTEMI Hospital Care
Let’s Start with the Basics! Assuming the NSTEMI has been ruled in or out

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

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

18. Early Treatment Class I Indications
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 beta-blockers or ACE
Oral Beta-Blocker in first 24 hours for pt who do not have
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;

19. 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
Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367.
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)
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)
Ongoing clinical trials are evaluating if genotype assessment prior to starting clopidogrel will improve clinical outcomes
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)
ASA on presentation
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
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
Abciximab should not be used in patients who not planned for PCI
Prasugrel contraindicated in patient who >75 years of age, prior stroke/TIA, body weight of <60 kg
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
If recurrent sx continue then a third agent can be added if needed
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)
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)
Can add prasugrel early if risk of bleeding is low and need for CABG is low
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
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
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:
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

28. Hospital Care 2011 Focused update
For patients with USA/NSTEMI in whom CABG is selected post angiography
Continue ASA
Discontinue IV GP Iib/IIIa inhibitor 4 hours before CABG
Continue UFH
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 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…
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

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
Aspirina mg/d indefinitely plus
clopidogrelb 75 mg/d for at least 1 mo, ideally up to 1 yr
Aspirina mg/d for at least 1 mo, then mg/d indefinitely plus
clopidogrelb 75 mg/d or prasugrel 10 mg/d for at least12 months*
Aspirina mg/d for at least 3 mo with Sirolimus and 6 mo paclitaxel, then 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
If no: continue dual antiplatelet therapy
Dipyridamole is not recommended in post USA/NSTEMI pt because it has not been shown to be effective.
aIf patient is allergic to aspirin, use clopidogrel alone (indefinitely) or try aspirin desensitization.
cContinue aspirin indefinitely and warfarin long term, if indicated for specific conditions.
dIf warfarin is added to aspirin and clopidogrel, the recommended INR is
bIf 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
Use the acute event as an opportunity to reevaluate the plan of care - lifestyle and risk factor modification
The acute phase of UA?NSTEMI is usually over within 2 months
Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

32. Reperfusion is the Issue but once stabilized…..
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

33. Secondary Prevention and Long Term Management
Goals Class I Recommendations
Physical activity:
2007 Goal:
30 min 7 d per wk; minimum 5 d per wk
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)
In stable patient sexual activity can cont within 7-10 days after ACS
Driving 7 days post d/c in stable pt’s
In complicated cases driving 2-3 weeks after sx resolved
Air travel should be avoided for 2 weeks after an AMI and only if no angina, dyspnea, or hypoxia at rest. Flies with companion and has NTG