acute coronary syndrome

ACUTE CORONARY SYNDROMEJose Socrates ‘Dee’ Matuod Evardone

Cardiology RICLevel II CDUH-IM

JULY 2015

CASEProfile:

78F, FilipinoHypertensive,

Non-DM, Non-smoker,

Non-alcoholic beverage drinker

CC: CHEST PAIN

CASEHPI:2 hours PTA- sudden onset of squeezing, retrosternal chest pain, radiating towards the neck, associated with headache. (+) Vomiting x1, pain score of 8/10, not relieved by rest, about >10 minutes. Admitted at primary hospital and managed as essential hypertension with NSSTWCs on ECG.

Subsequently transferred to a Tertiary level for further workup and management

CASEPhysical Exam

Awake, coherent, in mild distress

Warm, good turgor and mobility, CRT <2 seconds,

Anicteric sclerae, pink palpebral conjunctivae,

Equal chest expansion, dec BS on both lower lung fields, with crackles

Distinct heart sounds, , tachycardic, regular, no murmur

Flat, Normoactive bowel sounds, soft, no organomegaly

Strong peripheral pulses, no edema

Neurologic: WNL

BP: 130/60mmHg, HR: 118 bpm, RR: 26 cpm,99% O2 mp: 36.5°

Neck: No JVD, no murmur

CASEIMPRESSION:

1) NSTE-ACS (UA vs NSTEMI)

2) HCVD

CASEDIAGNOSTICS:

ECG – Sinus Rhythm with NSSTWCsCXR – Beginning congestion, inflammatory process bilaterallyTroponin I – 3.13 (elevated)

CASEMANAGEMENT: (ER)

Aspirin 80 mg 4 tabs chewed, swallowedClopidogrel 75mg , 4 tabsClexane 0.4cc Attached to cardiac monitorAdvised ICU/CCU admission

ACUTE CORONARY SYNDROME

SOURCES:


I: Diagnosis and Management of Patients with Stable Ischemic Heart Disease

II: Diagnosis and Management of Patients withNon-ST Elevation Acute Coronary Syndrome

III: Diagnosis and Management of Patients withST Segment Elevation Myocardial Infarction


What is ACS?

- refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina

- in general reserved for ischemia precipitated by acute coronary atherothrombosis

Ischemic Heart Disease

ACUTE CORONARY SYNDROMEIschemic Heart

Disease

Chronic coronary artery disease (CAD) with STABLE ANGINA

Acute Coronary Syndrome

STEMI

1) NSTEMI-ACS 2) Unstable Angina


Classic manifestation of ischemia is angina pectoris:Pressure, Tightness,Squeezing,Heaviness,Burning

ACS most commonly occurs without obvious precipitating factors

Coronary Circulation

LOCALIZATION OF CORONARY CIRCULATION IN M.I.

ANATOMIC ECG LEADS CORONARY ARTERY

Septal V1-v2 Proximal LAD

Anterior V3-V4 LAD

Apical V5-V6 Distal LAD, LCx, or RCA

Lateral I, aVL LCx

Inferior II, III, aVF RCA(85%), LCx (15%)

RV V1-V2 & V4R (most Se) Proximal RCA

Posterior ST depression V1-V3 RCA or LCx


The AmericanCollege of Cardiology (ACC) and American Heart Association (AHA)guidelines list the following as pain descriptions uncharacteristic of

myocardial ischemia:• Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratorymovements or coughing)• Primary or sole location of the discomfort in the middle or lowerabdominal region• Pain that may be localized by the tip of one finger, particularly overthe left ventricular apex• Pain reproduced with movement or palpation of the chest wall orarms• Constant pain that persists for many hours• Very brief episodes of pain that last a few seconds or less• Pain that radiates into the lower extremities

ISCHEMIC HEART DISEASE


The major determinants of myocardial oxygen demand (MVO2) are:

1) heart rate, 2) myocardial contractility, and 3) myocardial wall tension (stress)

About 75% of the total coronary resistance to flow occurs across three sets of arteries:

(1) large epicardial arteries (Resistance 1 = R1), (2) prearteriolar vessels (R2), and (3) arteriolar and intramyocardial capillary vessels (R3)

50% Stenosis: there is a limitation of the ability to increase flow tomeet increased myocardial demand.

80% Stenosis: myocardial ischemia at rest or with minimal stress


Coronary Blood Flow Limitation:• spasm, • arterial thrombi, and, • rarely, coronary emboli • as well as by ostial narrowing due to aortitis• Congenital Anomalies

The severity and duration of the imbalance between myocardial oxygen supply and demand determine whether the damage is :

reversible (≤20 min for total occlusion in the absence of collaterals) or

permanent, with subsequent myocardial necrosis (>20 min).



Evaluation of the

patient with known

or suspected ischemic

heart disease

Requirements : • Two sets of cardiac enzymes at 4-hr intervals should be normal • ECG at the time of arrival and preexercise 12-lead ECG show no significant abnormality • Absence of rest electrocardiographic abnormalities that would preclude accurate assessment of the exercise ECG • From admission to the time that results are available from the second set of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms, or persistent atypical symptoms • Absence of ischemic chest pain at the time of exercise testing

Indications and Contraindications for Exercise Electrocardiographic Testing in the Emergency Department

Contraindications • New or evolving electrocardiographic abnormalities on the rest tracing • Abnormal cardiac enzyme levels • Inability to perform exercise • Worsening or persistent ischemic chest pain symptoms from admission to the time of exercise testing • Clinical risk profiling indicating that imminent coronary angiography is likely

ACUTE CORONARY

SYNDROME

STABLE ISCHEMIC HEART DISEASELaboratory Tests:

1. Fasting lipid profile 2. Fasting glucose and/or glycated hemoglobin (HbA1c) level if

available; additional oral glucose tolerance test (OGTT) if both are inconclusive;

3. Complete blood count (CBC);4. Creatinine level with estimation of glomerular filtration rate

(GFR);5. Biochemical markers of myocardial injury (Troponin T or I) if

clinical evaluation suggests an Acute Coronary Syndrome (ACS);

6. Thyroid hormone levels7. Liver function tests early after beginning statin therapy.

ISCHEMIC HEART DISEASEPre-Test Probability (PTP) AssessmentDiamond and Forrester pre-test probability of cad by age, sex and symptoms

ISCHEMIC HEART DISEASEESTABLISHING DIAGNOSIS

Non-invasive stress testingStress Imaging


Exercise ECG (Treadmill Exercise Test or TET)

its simplicity, lower cost and widespread availability, the TET is the initial test of choice to identify inducible ischemia in the majority of patients with intermediate PTP who are able to exercise

The low sensitivity of the TET (45% to 50%) despite a high specificity (85% to 90%) is the reason why it is not recommended in patients with a PTP greater than 65%

In the latter case,a stress imaging study is more appropriate.


CORONARY ARTERIOGRAPHYCoronary arteriography is indicated in: (1) patients with chronic stable angina pectoris who are severely symptomatic despite medical therapy and are being considered for revascularization, i.e., a percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); (2) patients with troublesome symptoms that present diagnostic difficulties in whom there is a need to confirm or rule out the diagnosis of IHD; (3) patients with known or possible angina pectoris who have survived cardiac arrest; (4) patients with angina or evidence of ischemia on noninvasive testing with clinical or laboratory evidence of ventricular dysfunction; and (5) patients judged to be at high risk of sustaining coronary events based on signs of severe ischemia on noninvasive testing, regardless of the presence or severity of symptoms


MANAGEMENTLifestyle Modification and Treatment of Risk Factors

1) Healthy Diet2) Physical Activity3) Hypertension4) Smoking5) DM6) Weight Management7) Lipid Management


MANAGEMENTPharmacologic Therapy to Improve Prognosis

Whether or not revascularization is being considered, receive the following medications to improve prognosis, thereby reducing the risk for MI and death:

1. Aspirin low-dose (80 to 160 mg/day)2. Clopidogrel in case of aspirin intolerance (75 mg/day)3. Statins irrespective of LDL-cholesterol levels4. Beta blockers post-MI5. ACEIs or ARBs (especially in patients with concomitant HF,hypertension or diabetes)

Pharmacologic Therapy to Improve Prognosis

REVASCULARIZATIO

N

Non-ST-Segment ElevationAcute Coronary Syndrome

(Non-ST-Segment ElevationMyocardial Infarction andUnstable Angina)

NSTE-ACS

Pathophysiology:1. imbalance between oxygen supply and oxygen

demand resulting from a partially occluding thrombus forming on a disrupted atherothrombotic coronary plaque or on eroded coronary artery endothelium

2. dynamic obstruction 3. severe mechanical obstruction 4. increased myocardial oxygen demand

NSTE-ACS

NSTE-ACSDIAGNOSIS:

Clinical :(1) it occurs at rest (or with minimal exertion),

lasting >10 minutes; (2) it is of relatively recent onset (i.e., within the

prior 2 weeks); and/or (3) it occurs with a crescendo pattern (i.e., distinctly

more severe, prolonged, or frequent than previous episodes)

NSTEMI - elevated levels of biomarkers of cardiac necrosis

NSTE-ACSDIAGNOSIS:

3 major noninvasive tools are used in the evaluation of NSTEMI-ACS: 1. the electrocardiogram (ECG), 2. cardiac biomarkers, and 3. stress testing

GOALS :(1) recognize or exclude myocardial infarction (MI) using

cardiac biomarkers, preferably cTn;(2) detect rest ischemia (using serial or continuous ECGs);

and (3) detect significant coronary obstruction at rest with CCTA

and myocardial ischemia using stress testing

Causes of

elevated troponin

MEDICAL TREATMENT• Bed rest• Continuous ECG monitoring• Ambulation only if

No recurrence of ischemia (symptoms or ECG changes)Does not develop an elevation of a biomarker of necrosis for

12–24 h

ANTI-ISCHEMIC ANTITHROMBOTIC

NSTE-ACSDrugs Commonly Used in Intensive Medical Management of

Patients with UA and NSTEMI

Nitrates

Beta Blockers

Calcium Channel Blockers

Morphine Sulfate

NSTE-ACS

MEDICAL TREATMENT

ANTI-ISCHEMIC THERAPY

ANTITHROMBOTIC THERAPY

antiplatelet drugs

anticoagulants.

NSTE-ACS

ORAL ANTIPLATELETS

Aspirin Initial dose of 325 mg nonenteric formulation followed by 75–100 mg/d of an enteric or a nonenteric formulation

Clopidogrel Loading dose of 300–600 mg followed by 75 mg/d

Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d

Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily

Intravenous Antiplatelet Therapy

Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 μg/ kg per min (maximum 10 μg/min) for 12–24 h

Eptifibatide 180 μg/kg bolus followed 10 min later by second bolus of 180 μg with infusion of 2.0 μg/kg per min for 72–96 h following first bolus

Tirofiban 5 μg/kg per min followed by infusion of 0.15 μg/kg per min for 48–96 h

NSTE-ACS

HEPARINSUnfractionated heparin(UFH)

Bolus 70–100 U/kg (maximum 5000 U) IV followedby infusion of 12–15 U/kg per h (initial maximum1000 U/h) titrated to ACT 250–300 s

Enoxaparin 1 mg/kg SC every 12 h; the first dose may be precededby a 30-mg IV bolus; renal adjustment to1 mg/kg once daily if creatine clearance <30 cc/min

Fondaparinux 2.5 mg SC qd

Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of1.75 mg/kg per h.

NSTE-ACS

Class I Recommendations for Use of an Early InvasiveStrategy in Patients with Non-ST-Segment ElevationAcute Coronary Syndrome:Class I (Level of Evidence: A) Indications1. Recurrent angina at rest/low-level activity despite treatment2. Elevated TnT or TnI3. New ST-segment depression4. CHF symptoms, rales, MR5. EF <0.406. Sustained VT7. PCI <6 months, prior CABG8. High-risk findings from noninvasive testing9. Hemodynamic instability10. Mild-to-moderate renal dysfunction11. Diabetes mellitus12. High TIMI Risk Score (>3)b

NSTE-ACS

PRINZMETAL’S VARIANT ANGINA- syndrome of severe ischemic pain that usually occurs at rest and is associated with transient ST segment elevation- focal spasm of an epicardial coronary artery, leading to severe

transient myocardial ischemia and occasionally infarction- may be related to hypercontractility of vascular smooth muscle

due to adrenergic vasoconstrictors, leukotrienes, or serotonin- has decreased substantially during the past few decades- PVA are generally younger and have fewer coronary risk factors- The clinical diagnosis of PVA is made by the detection of

transient ST-segment elevation with rest pain- Focal spasm is most common in the right coronary artery

NSTE-ACSPRINZMETAL’S VARIANT ANGINA

Diagnosis:Hyperventilation or intracoronary acetylcholine has been

used to provoke focal coronary stenosis on angiography or to provoke rest angina with ST-segment elevation to establish the diagnosis

TREATMENTNitrates and Calcium Channel BlockersAspirin- may actually increase the severity of ischemic episodes

PROGNOSIS1. Survival at 5 years is excellent ( 90–95%)∼2. Nonfatal MI occurs in up to 20% of patients by 5 years3. There is a tendency for symptoms4. and cardiac events to diminish over time

NSTE-ACS

CORONARY ANGIOGRAPHY

IS NOT RECOMMENDED in patients with• extensive co-morbidities (e.g., liver or pulmonary

failure; cancer);• in whom the risks of revascularization are not likely to

outweigh the benefits; • in patients with acute chest pain and a low likelihood

of ACS;• or in patients who will not consent to

revascularization regardless of the findings.

NSTE-ACS

Revascularization by PCI

PCI IS RECOMMENDED for NSTE-ACS patients with 1- to 2-vessel CAD, with or without significant proximal left anterior descending CAD, but with a large area of viable myocardium and high-risk criteria on noninvasive testing.

NSTE-ACS

Revascularization by CABG Surgery

CABG IS RECOMMENDED for patients with1. significant left main disease, and is the

preferred revascularization strategy for patients with

2. multi-vessel coronary disease; 3. vessels with lesions not favorable for PCI; 4. depressed systolic function (LVEF lower than

50%); and diabetes.

NSTE-ACS

Drug/Medication Management

Strongly RECOMMENDED for patients with1. aspirin indefinitely, and ticagrelor 90 mg twice daily

or clopidogrel 75 mg daily, for 12 months2. underwent stenting, with aspirin indefinitely, plus

ticagrelor 90 mg twice daily or prasugrel 10 mg daily or clopidogrel 75 mg daily, for 12 months in patients with drug-eluting stents, and 6 months in patients with bare metal stents

3. beta blockers be continued indefinitely for all NSTE-ACS patients unless contraindicated

ST-Segment Elevation Myocardial Infarction

(STEMI)

STEMICriteria for Acute Myocardial Infarction

• Detection of a rise and/or fall of cardiac biomarker values (preferably cardiac troponin [cTn]) with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following:

• Symptoms of ischemia• New or presumed new significant ST-segment T-wave (ST-T) changes or new left bundle branch block (LBBB)• Development of pathologic Q waves in the electrocardiogram (ECG)• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality• Identification of an intracoronary thrombus by angiography or autopsy

• Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic ECG changes of new LBBB, but death occurred before cardiac biomarkers were obtained or before cardiac biomarker values would be increased.

STEMICriteria for Acute Myocardial Infarction

• Percutaneous coronary intervention (PCI)–related MI is arbitrarily defined by elevation of cTn values (>5 × 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, either

• Coronary artery bypass grafting (CABG)–related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 × 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL). In addition, either

(i) symptoms suggestive of myocardial ischemia, or (ii) new ischemic ECG changes, or (iii) angiographic findings consistent with a procedural complication, or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion

abnormality are required.

• Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/ or fall of cardiac biomarker values with at least one value above the 99th percentile URL.

(i) new pathologic Q waves or new LBBB, or (ii) angiographic documented new graft or new native coronary artery occlusion, or (iii) imaging evidence of new loss of viable myocardium or new regional wall motion

abnormality.

STEMI

Classification of Myocardial Infarction

Type I: Spontaneous Myocardial InfarctionType 2: Myocardial Infarction Secondary to an Ischemic ImbalanceType 3: Myocardial Infarction Resulting in Death When Biomarker Values Are UnavailableType 4a: Myocardial Infarction Related to Percutaneous Coronary Intervention (PCI)Type 4b: Myocardial Infarction Related to Stent ThrombosisType 5: Myocardial Infarction Related to Coronary Artery Bypass Grafting (CABG

STEMI

MEDICAL TREATMENT

ANTI-ISCHEMIC THERAPY

ANTITHROMBOTIC THERAPY

Antiplatelet drugs

Anticoagulants

FIBRINOLYSIS

STEMI

the goals for the management of patients with suspected STEMI include:1. control of cardiac discomfort,2. rapid identification of patients who are candidates for

urgent reperfusion therapy, 3. triage of lower-risk patients to the appropriate location

in the hospital, and 4. avoidance of inappropriate discharge of patients with

STEMI

MANAGEMENT IN THE EMERGENCY DEPARTMENT

Aspirinis essential in the management of patients with suspected STEMI and is effective across the entire spectrum of acute coronary syndromes

OXYGENO2 should be administered by nasal prongs or face mask (2–4 L/min) for the first 6–12 h after infarction

STEMI

1) Sublingual nitroglycerinUp to three doses of 0.4 mg should be administered at about 5-min intervals

2) Morphine3) Intravenous beta blockers/ Oral Beta blockers

CONTROL OF DISCOMFORT

in the first 24 h for patients who do nothave any of the following: (1) signs of heart failure, (2) evidence of a low-output state, (3) increased risk for cardiogenic shock, or (4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds, second- or third-degree heart block, active asthma, or reactive airway disease).

Fifteen minutes after the last intravenous dose, an oralregimen is initiated of 50 mg every 6 h for 48 h, followed by 100

mg every 12 h

STEMI

Initial ER Management

• Aspirin 160 to 320 mg tablet (non-enteric coated, chewed);• Clopidogrel 300 to 600 mg whether or not fibrinolysis will begiven;• Clopidgrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg whena patient will undergo PCI;• Nitrates, either via sublingual or intravenous(IV) routes. Nitratesare contraindicated in patients with hypotension or those whotook a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrsfor tadalafil);• Morphine 2 to 4 mg IV for relief of chest pain, and;• Supplemental oxygen MAY BE RECOMMENDED during the first 6hours to patients with arterial oxygen saturation of less than 90%.

STEMI

In-hospital Treatment

Reperfusion therapy IS RECOMMENDED to all eligible patients with STEMI with symptom onset within the prior 12 hours.Early revascularization, the goal being 12 hours, is a primary treatment goal in patients with STEMI

STEMI

Fibrinolysis

15-mg bolus followed byTPA• 50 mg intravenously over the first 30 min,• followed by 35 mg over the next 60 min

1.5 million units (MU) intravenously over 1 hStreptokinase

given as a single weight-based intravenous bolus of 0.53 mg/kg over 10 s

Tenecteplase (TNK)

double-bolus regimen consisting of a 10-MU bolus given over 2–3 min, followed by Reteplase (rPA)

• second 10-MU bolus 30 min later

STEMI

TIMI FLOW GRADE — The degree of perfusion in the infarct-related artery (IRA) is typically described by the TIMI flow grade:

●TIMI 0 refers to the absence of antegrade flow beyond a coronary occlusion.●TIMI 1 flow is faint antegrade coronary flow beyond the occlusion, although filling of the distal coronary bed is incomplete.●TIMI 2 flow is delayed or sluggish antegrade flow with complete filling of the distal territory.●TIMI 3 flow is normal flow which fills the distal coronary bed completely.

TIMI

STEMIPrimary Percutaneous Coronary

Intervention (PCI)

1. RECOMMENDED in patients with STEMI and ischemic symptoms of less than 12 hours’ duration

2. RECOMMENDED in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact.

3. RECOMMENDED in patients with STEMI and cardiogenic shock or acute severe heart failure (HF), irrespective of time delay from MI onset

4. MAY BE RECOMMENDED in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset

STEMICoronary Artery Bypass Grafting (CABG)

1. IS RECOMMENDED in failed PCI with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery

2. IS RECOMMENDED in persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, and are not candidates for PCI or fibronolytic therapy

3. RECOMMENDED in patients with STEMI at the time of operative repair of mechanical defects.

STEMIAntiplatelets and Antithrombotics

1. It IS RECOMMENDED that aspirin should be used indefinitely in all patients with STEMI with a dosage of 80 to 100 mg/day.

2. It IS RECOMMENDED that clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI and maintained for at least 14 days

3. It IS RECOMMENDED that patients who are truly intolerant to aspirin can instead receive clopidogrel 75 mg per day as long-term secondary prevention

STEMIDuration of Dual Antiplatelet Therapy and Antithrombotic

Combination Therapies after STEMI

1. Combination Therapies after STEMI DAPT by combining aspirin and an ADP-receptor blocker (clopidogrel, prasugrel or ticagrelor) IS RECOMMENDED in patients with STEMI who are undergoing primary PCI (for up to 12 months) or (clopidogrel) fibrinolysis (for up to 12 months, although the data available pertain only to one month of DAPT), and in those who have not undergone reperfusion therapy (for at least 1 month and up to 12 months).

STEMI

Lipid Lowering Agents

1. High-dose statins are RECOMMENDED in all patients during the first 24 hours of admission for STEMI, irrespective of the patient’s cholesterol concentration, in the absence of contraindications (allergy, active liver disease).

2. Atorvastatin or Rosuvastatin are recommended during the early phase of therapy up to at least four weeks.

3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to 40 mg) or atorvastatin (40 to 80 mg) therapy before emergency percutaneous coronary intervention to 1. reduce periprocedural inflammatory response, 2. to reduce myocardial dysfunction, and 3. to prevent contrast-induced nephropathy

THANK YOU

STABLE ISCHEMIC HEART DISEASERecommended:

EchocardiographyAmbulatory ECG Monitoring

STABLE ISCHEMIC HEART DISEASE


RISK FACTORS


Definition of Myocardial Infarction


Classification of Myocardial Infarction

acute coronary syndrome

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