CARE OF NSTEMI PATIENTSLATEST GUIDELINES

CARE OF NSTEMI PATIENTSLATEST GUIDELINES

Rick Barney MD FACEP

Emergency Medicine Beloit Memorial and University of Wisconsin

New NSTEMI Guidelines by ACC/AHAReleased August 6th 2007

New NSTEMI Guidelines by ACC/AHAReleased August 6th 2007

www.americanheart.org

NSTEMI Protocols not followed wellNSTEMI Protocols not followed well

STEMI- straight forward and well followed

NSTEMI- no hospital agreement, under use of available treatment, no agreement even amongst cardiologists

Following ACC/AHA Guidelines Significantly Reduces Risk of Mortality

Following ACC/AHA Guidelines Significantly Reduces Risk of Mortality

2.5%(n = 8,037)

3.7%(n = 9,889)

Adherence toACC/AHAGuidelines

Nonadherenceto ACC/AHAGuidelines

Bhatt DL, et al. JAMA. 2004;292(17):2096-2104.

Incidence of in-hospital mortality was lower with adherence to ACC/AHA Guidelines

32.4%↓ (P < 0.001)

NSTEMI- DefinitionNSTEMI- Definition

Coronary symptoms with ST segment depression, or T wave inversions (new) and/or elevated biomarkers (Troponin

preferred)

Nitro RecommendationNitro Recommendation

If new angina pattern, call 911 if one single nitro has not helped. Take 2nd and 3rd dose while waiting for EMS arrival

If typical stable angina pattern, still recommend call for help if three nitro doses 5 minutes apart does not help.

Aspirin and Pre-Hospital 12 lead ECGAspirin and Pre-Hospital 12 lead ECG

Aspirin should be given immediately to all patients who may have a coronary Syndrome. Only reason to not give is a true allergy.

Strong recommendation for pre-hospital 12 lead analysis

Positive Biomarkers are critical to ED Care

Positive Biomarkers are critical to ED Care

Latest studies show patients with positive Troponins do best with early invasive

management, Clopidogrel, anticoagulation, and glycoprotien II b III a inhibition.

USE OF BETA BLOCKERSUSE OF BETA BLOCKERS

COMMIT Trial shows some risk in using IV Metoprolol.

For NSTEMI-use IV if hyperdynamic, otherwise PO within 24 hours of arrival

Morphine results in higher mortality for NSTEMI patients

Morphine results in higher mortality for NSTEMI patients

Due to blocking pain, yet ischemia still present

Due to hypotension

Due to decreased myocardial perfusion

Many now use Fentanyl instead

Early Invasive Management Improves Outcomes

Early Invasive Management Improves Outcomes

NSTEMI- thus high risk patients in general do better if treated aggressively in ED, then to cath lab in 4-24

hours. 18% death or MI reduction.

Even studies on stabilization and later treatment are predicated on aggressive ED treatment

In general, this includes Clopidogrel, anticoagulant, and Glycoprotein II B III A Inhibition

2007 Anti-platelet Guidelines2007 Anti-platelet GuidelinesNothing new on Aspirin- continue to use

Recommend Clopidogrel or II B III A

OR

Use both Clopidogrel and II B III A

Using both makes more scientific sense as drugs work differently. Some patients are partial or non-responders to Clopidogrel.

Anti-Platelet TherapyAnti-Platelet Therapy

Clopidogrel is irreversible. Will delay CABG 3-5 days.

Integrelin is reversible once infusion is shut off.

Anti-platelet therapy is critical to success and is under-utilized

Coordinated, standard approach at your institution is desirable.

ISAR-REACT 2 study shows adding Glycoprotein IIBIIIA

The Central Role of the Platelet in NSTE ACS

The Central Role of the Platelet in NSTE ACS

Thrombin

Fibrin Mesh

Fibrinogen cross links to form platelet-rich thrombus

Activation of GP IIb-IIIa

TxA2ADP

AT III*

FactorXa

LMWH

Thrombolytics

ASA

Clopidogrel

Platelet Activation

Agonist degranulation

Prothrombin

Platelet recruitment and aggregation

Formation of mature thrombus

Plasma clotting cascade

Intrinsic Pathway

Bivalirudin

UFH

*AT III = antithrombin III.

Stein B, et al. J Am Coll Cardiol. 1989;14(4):813-836; DeJong MJ, et al. Crit Care Nurs Clin N Am. 1999;11(3):355-371; White HD. Am J Cardiol. 1997;80(4A):2B-10B.

Sites of Antithrombotic Drug ActionSites of Antithrombotic Drug ActionCoagulation cascadeCoagulation cascade Platelet cascadePlatelet cascade

GP IIb-IIIainhibitors

Other agonists

Results from cross-linking of platelets by fibrinogen at

platelet receptors GP IIb-IIIaat site of plaque rupture

Platelet

Fibrinogen

Rupturedplaque

GP IIb-IIIa

NSTE ACS is generally caused by partially occlusive,

platelet-rich thrombus in a coronary artery

Unobstructedlumen

Thrombus

Artery wall

Van de Werf F. Thromb Haemost. 1997;78(1):210-213; Moser M, et al. J Cardiovasc Pharmacol. 2003;41(4):586-592; Reprinted with permission from Davies MJ. Heart. 2000;83(3):361-366. © BMJ Publishing Group Ltd. 2005.

The Role of the Platelet in Non-ST-segmentElevation Acute Coronary Syndrome (NSTE ACS)

The Role of the Platelet in Non-ST-segmentElevation Acute Coronary Syndrome (NSTE ACS)

The Thrombus in STEMIThe Thrombus in STEMI

Results from stabilization by fibrin mesh of a platelet aggregate at

site of plaque rupture

platelet

RBC*

fibrin mesh

STEMI is generally caused by a completely occlusive fibrin-rich thrombus in a coronary artery

*RBC = red blood cell.GP IIb-IIIa inhibitors are not indicated for STEMI.Van de Werf F. Thromb Haemost. 1997;78(1):210-213; White HD. Am J Cardiol. 1997;80(4A):2B-10B; Davies MJ. Heart. 2000;83(3):361-366.

Microembolization in Unstable Angina

Microembolization in Unstable Angina

Courtesy of C. Michael Gibson, MS, MD, Director TIMI Data Coordinating Center, Brigham & Women’s Hospital, Associate Chief of Cardiology, Interventional Cardiologist, Beth Israel Deaconess Medical Center, Harvard Medical School.

Variable Clopidogrel Response Variable Clopidogrel Response

At 5 DaysUA Patients* (n = 32)

At 4 HoursHealthy Volunteers† (n = 25)

Responders47%

Responders72%

Low responders32%

Nonresponders16%Nonresponders

22%

Low responders

12%

*Received an oral loading dose of 300 mg of clopidogrel followed by 75 mg daily; †Received a 450-mg loading dose of clopidogrel.The use of clopidogrel in this study was not consistent with applicable FDA-approved Prescribing Information.Gurbel PA, et al. Circulation. 2003;107(23):2908-2913; Lau WC, et al. Circulation. 2004;109(2):166-171.

Response measured after elective coronary artery stent implantationResponse measured after elective coronary artery stent implantation

GP IIb-IIIa Inhibitors Are an ACC/AHA Guidelines IA Recommendation

GP IIb-IIIa Inhibitors Are an ACC/AHA Guidelines IA Recommendation

Braunwald E, et al. J Am Coll Cardiol. 2002;40(7):1366-1374.

CAUTIONARY INFORMATION No clopidogrel within 5-7 days prior to CABG surgery No enoxaparin within 24 hours prior to CABG surgery

No abciximab, if PCI is not planned

RECOMMENDED TREATMENT REGIMEN Aspirin (IA); clopidogrel if aspirin is contraindicated (IA)

LMWH or UFH (IA) GP IIb-IIIa inhibitor (IA)

Beta blocker (IB) Nitrates (IC)

PCI or CABG SURGERY IF CORONARY ANATOMY IS SUITABLE (IA)

SEND FOR CATHETERIZATION & REVASCULARIZATION WITHIN 24-48 HOURS

AT PRESENTAIONAT PRESENTAION

HIGH-RISK FEATURES Signs of ischemia at rest > 20 minutes AND ST-segment depression and/or elevated cardiac biomarkers

LEVELS OF EVIDENCE LEVELS OF EVIDENCE RANKI. Evidence and/or agreement that treatment is effective A. Based on large, randomized trialsIIa. Weight of evidence favors use B. Based on smaller trials or careful analysesIIb. Usefulness less well established C. Based on expert consensusIII. Evidence and/or agreement that treatment is not effective

Changes in Cardiac Arrest Management

Changes in Cardiac Arrest Management

PharmacologyPharmacology

No improvements evident based on science with drugs to improve outcome

Epinephrine every 5 minutes

No added benefit to Vasopressin

Amiodarone and Lidocaine equal effectiveness

DefibrillationDefibrillation

Primary treatment for V-fib at 3 minutes and under

Should be delayed until good CPR for 2 minutes if down time over 3 minutes

Biphasic should be used

AED’s good in 3 minutes, bad after

One shock only with no pulse checks after

Vascular AccessVascular Access

Avoid ET drugs whenever possible

Peripheral IV’s OK

Central IV’s slightly better, but compression interruption frequent with placement

Interosseous recommended when peripheral IV’s not obtainable

Pathophysiology of V-Fib ArrestPathophysiology of V-Fib Arrest

How Compressions move bloodHow Compressions move blood

What about AED’s?What about AED’s?

Great in first 3 minutes. Must be in community.

Deadly after this as delay to shock is over 30 seconds. Manual defib required after 3 minutes.

DefibrillationDefibrillation

No more stacked shocks

Takes too long

All shocks maximum energy.

EMS probably should not use AED’s

Biphasic increases efficacy

Pulse ChecksPulse Checks

Deadly!!

Only check pulses when rhythm appears to have converted thru CPR on ECG or signs of life

ECC says check before shock delivered after 5 cycles of 30:2 CPR

What about intubation?What about intubation?

In first 6 minutes, not a priority (V-fib) ASAP in PEA and Asystole.

Understand that positive pressure breaths decrease cardiac output.

Some air exchange from CPR plus gasping.

Once intubated, 1 second breaths,six per minute. NO MORE.

AirwayAirwayCombitube or ET equivalent

RSA Mentality-view and see cords place ET, otherwise immediate Combitube first

try.

ProtocolProtocol

Dispatch instructs CCC

If good CPR on EMS arrival, shock max X1

If no or poor CPR, immediate compressions

ProtocolProtocol

OP airway

Non-rebreather face mask @ 90+%

200 compressions

IV access

Epinephrine 1mg IVP

Vasopressin 40 units IVP ASAP

One shock, 3-5 seconds, no pulse checks.

ProtocolProtocol

Begin second round of 200 compressions

Amiodarone 300mg IVP

Shock X1 at max joules

No pulse checks, not off chest more than 5 seconds.

ProtocolProtocol

Begin 3rd round of compressions

Epinephrine 1mg IVP

Shock X1 after 200 compressions

ProtocolProtocol

During 4th round of compressions place definitive airway without halting compressions

on first attempt.

ProtocolProtocol

200 compressions alternating epinephrine with antidysrhythmic drug and shock X1.

Remain on scene and work until pulse or non-shockable rhythm.

48% Neuro-intact survivors!!48% Neuro-intact survivors!!

10% before new protocol

QUESTIONS??QUESTIONS??