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Acute Coronary syndrome

Pearl & Pitfall

W. Wiwatworapan MD. Cardiologist, Maharat Nakorn Ratchasima Hospital

Outline
STEMI ACC guideline 2013
Management algorithm Pitfall in STEMI

NSTE-ACS
Management algorithm Pitfall in NSTE-ACS

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STEMI

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Treatment Delayed is Treatment Denied

Symptom Recognition

Call to Medical System

PreHospital

ED

Cath Lab

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

Management Guideline

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Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In PCI-capable center In non-PCI-capable center

DIDO 30 minutes

Primary PCI FMC-device time 90 min

Transfer for primary PCI if FMC-device time 120 min

Fibrinolytic within 30 minutes if FMC-device time > 120 min

PCI or CABG or Medication

Urgent transfer for PCI If fail reperfusion or reocclusion

Transfer for CAG within 3-24 hr (pharmacoinvasive strategy)

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion

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Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In PCI-capable center

Primary PCI FMC-device time 90 min

PCI or CABG or Medication

Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In non-PCI-capable center

DIDO 30 minutes

Transfer for primary PCI if FMC-device time 120 min

Fibrinolytic within 30 minutes if FMC-device time > 120 min

PCI or CABG or Medication

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Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In non-PCI-capable center

DIDO 30 minutes

Fibrinolytic within 30 minutes if FMC-device time > 120 min

Except Posterior wall MI Suspected acute Left main stenosis

Fibrinolytic Agents
Need adjunctive anticoagulant Higher patency rate More complication

Anaphylaxis Should repeat dose within 6 months

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Fibrinolytic Agents - Contraindications

Adjunctive Antiplatelet to Support Reperfusion With Fibrinolytic Therapy

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Adjunctive Anticoagulant to Support Reperfusion With Fibrinolytic Therapy

Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In non-PCI-capable center

DIDO 30 minutes

Fibrinolytic within 30 minutes if FMC-device time > 120 min

PCI or CABG or Medication

Urgent transfer for PCI If fail reperfusion or reocclusion

Transfer for CAG within 3-24 hr (pharmacoinvasive strategy)

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Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion
In PCI-capable center In non-PCI-capable center

< 12-24 hr Cardiogenic shock Contraindication for fibrinolytic Inconclusive

Loading 2 antiplatelet DIDO 30 minutes anticoagulant

Transfer for primary PCI Fibrinolytic within 30 minutes Primary PCI if FMC-device time 120 min if FMC-device time > 120 min FMC-device time 90 min Loading 2 Urgent transfer Transfer for CAG antiplatelet for PCI within 3-24 hr If fail reperfusion (pharmacoinvasive PCI or reocclusion strategy) or CABG or Medication

Pitfall in STEMI

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Female 50 y, chest pain 1 h

A. Repeat ECG B. Refer for primary PCI C. Fibrinolytic agent D. Work up other cause of chest pain

F/U ECG 10 min later

A. Repeat ECG B. Refer for primary PCI C. Fibrinolytic agent D. Work up other cause of chest pain

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Post SK 30 min

Post SK 60 min At ER

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Post SK 70 min

A. Urgency refer for PCI B. Refer for CAG in 3-24 hr C. Optimize medication & refer next few days D. Medication only

Pearl & Pitfall

In inconclusive ECG
Look for reciprocal change Serial ECG Or.. Echocardiogram if you can

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Female 50 y, chest pain 1 h

After given fibrinolytic agent, patient developed hypotension & cannot palpate left brachial pulse

Calcium sign

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Pearl & Pitfall

In Acute inferior wall MI (esp. RV infarct)
Carefully exam pulse 4 extremities Consider CXR
Wide mediastinum Calcium sign

Female 50 y, chest pain 1 h

A. Repeat ECG in 10 minutes B. Repeat ECG with V3R, V4R C. Repeat ECG with V7-V9 D. Rx as UA/NSTEMI

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Pearl & Pitfall

In ACS with suspected Posterior wall MI
Tall R in V1-2 with ST depression ECG V7-9

Male 70 y, chest pain 1 h

EKG .

A. Prinzmetals angina B. Acute RV infarct C. Tako tsubo cardiomyopathy D. Left main stenosis

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EKG 2

ST elevation in aVR
ST elevation greater 0.5 mm in aVR in NSTEMI with often very significant ST depression in many leads (8) favors the diagnosis of occlusion of left main trunk.

The 12 lead ECG in ST elevation myocardial infarction : a practical approach for clinicians

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Female 50 y, chest pain 1 h

A. Anterior wall MI B. Inferior wall MI C. Lateral wall MI D. Not MI

Pearl & Pitfall

In other causes of ST elevation (Not MI)
No Dynamic change No progression to Q wave Involve > 1 coronary territories

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NSTE-ACS

What should you know about NSTE-ACS

Assessment of Likelihood of ACS Early Hospital care Early Risk Stratification Invasive vs. Conservative Strategy Pharmacotherapy Long-term secondary prevention

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Likelihood of ACS
High Symptoms Chest or left arm discomfort reproducing prior documented angina Know history of CAD Transient MR Hypotension Rales ST deviation 1 mm T wave inversion in multiple lead Positive Intermediate Chest or left arm discomfort Low Symptom in absence of any intermediate likelihood character Recent Cocaine use

History Physical Examination ECG

> 70 years Male, DM

Manifestation of Chest pain extracardiac vascular reproduced by disease palpation Q wave ST depression 0.5 1 mm Normal Normal

Cardiac Biomarkers

Normal
ACC/AHA UA/NSTEMI Guideline 2007

Early Hospital Care

Class I Bed rest & Telemetry Oxygen (maintain saturation > 90%) Nitrate Oral Beta-blockers in 1st 24-hours if no contraindications (IV Beta-blockers class IIa) ACE-I in 1st 24-hours for heart failure of LVEF < 40% (Class IIa for all other patients) Statin

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Early Hospital Care

Class III Nitrates if SBP < 90 mmHg or RV infarction Nitrates within 24-hrs of Sildenafil or 48-hrs of Tadalafil use IR-CCB in absence of Beta-blockers NSAIDs & COX-2 inhibitors

Early Risk Stratification

Rapid clinical determination Troponin is the preferred biomarker If normal, repeat biomarker at 6-12 hours after onset of symptoms

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Troponin I Levels to Predict the Risk of Mortality in ACS

TIMI III B Trial N=1,404

Antman EM, et al. N Engl J Med. 1996;335:1342-1349.

TIMI risk score

14-d Death, MI, or Urgent Revascularization (%) 50
Age 65 years 3 risk factors for CAD Prior stenosis > 50% ST-segment deviation 2 anginal in 24 hours Use of aspirin in 7 days cardiac biomarkers

10 times
40.9 26.2

40 30 20 10 0 0/1 2 3 4 5 Number of Risk Factors 4.7 8.3 19.9

13.2

6/7

Antman EM, et al. JAMA. 2000;284:835-842.

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JAMA 2004;291:2727-33

Management Strategies for Non ST elevation ACS

Definite/Possible ACS Initiate ASA, Beta-blockers, Nitrates, ECG monitor

Early Invasive Strategy TIMI Risk Score 3 New ST segment deviation Positive biomarkers Hemodynamic instability Refractory angina PCI in past 6 months CABG LVEF < 40%
Coronary angiography

Conservative TIMI Risk Score < 3 No ST segment deviation Negative biomarkers

Recurrent symptoms Heart failure Serious arrhythmia

LVEF < 40% Stress test +ve

Stable

Assessment of EF Stress Test

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Antithrombotic in ACS
At least 2 Antiplatelet

1 Anticoagulant

Antiplatelet (At least 2)

ASA +

Clopidogrel Conservative PCI Thrombolytic Dose Variability of Response Risk of Bleeding Genotyping Transition to elective Sx Antiplatelet effect OD ++ + CYP 2C19 5d Slowwer

Prasugrel X X OD + ++ Not establish 7d Faster

Ticagrelor X b.i.d + + Not establish 3-5 d Faster

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Anticoagulant (Indirect)
Heparin Molecular Wt Target Bioavailability (hr) Renal excretion Antidote HIT 15,000 Xa and IIa 30% 1 No Complete <5% LMWH 5,000 Xa > IIa 90% 4 Yes Partial <1% Fondaparinux 1,728 Xa 100% 17 Yes No Very rare

Initial Conservative Strategy

Mortality Antiplatelet trialist

ASA (I A) Clopidogrel if ASA intolerant (I B)

Death/MI/RI compare with UFH

Prefer Enoxaparin or Fondaparinux (IIa)

Initiate Anticoagulant (I A) UFH (I A) Enoxaparin (I A) Fondaparinux (I B)

Less bleeding Contra. If CrCl < 30

Clopidrogrel (I B) Ticagrelor (I B) IV GP IIb/IIIa inh (Eptifibatide or Tirofiban) (IIb)

GP IIb/IIIa inh for recurrent ischemia (IIa)

No evidence of Prasugrel

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Early Invasive Strategy

ASA (I A) Clopidogrel if ASA intolerant (I B)
Bleeding ? Should not switch from UFH UFH if CAG

Initiate Anticoagulant (I A) UFH (I A) Enoxaparin (I A) Bivalirudin (I B) Fondaparinux* (I B)

Clopidogrel + GP IIb/IIIa inh (IIa) : Favor if Delay CAG High risk feature

MACE Bleeding Use in PCI case only

Clopidrogrel (I A) Prasugrel (I B) Ticagrelor (I B) IV GP IIb/IIIa inh (I A)

NSTE-ACS
Clopidogrel 75 mg OD Indefinite Therapy (IIa B) ASA intolerant

ASA 162-325 mg LD (I A)

ASA 75-162 mg OD Indefinite Therapy (I A)

Medication

PCI

Clopidogrel 300600 mg LD before or at time of PCI (I B)

Clopidogrel 75 mg OD (I A) or Ticagrelor 90 mg BID (I B) At least 1 mo (I A) & up to 12 mo in the absence of risk of bleeding (I B)

Clopidogrel 75 mg OD (I A) or Ticagrelor 90 mg BID (I B) for 12 mo Continuation > 12 months may be considered in pt with a high risk of thrombosis and a low risk of bleeding (IIb C) Plasugrel at time of PCI (I B) Risk of stent thrombosis Prasugrel 10 mg daily may be Considered (12 mo) in the absence of : Increased bleeding risk Likely to undergo CABG within 7 days History of stroke or TIA Age > 75 years Weight < 60 kg (Class IIa, Level B) (I B for ACC)

Canadian Journal of Cardiology 27 (2011) S1S59

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Secondary Prevention
Class I Indications

Aspirin Beta-blockers ACE-I : CHF, LVEF <40%, HT, DM (All patients- Class Iia) ARB : ACE-I intolerant & CHF with LVEF <40% Aldosterone antagonist On ACE-I, CHF with LVEF < 40% Standard Risk Factor Management

Secondary Prevention
Class III

Hormone Replacement Therapy Anti-oxidant (Vit C, Vit E) Folic acid

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1
Likelihood of ACS

2 antiplatelet + 1 anticoagulant + Other medication

4
Reperfusion

5
Risk stratification Revascularization

Acute Coronary syndrome

Pearl & Pitfall

W. Wiwatworapan MD. Cardiologist, Maharat Nakorn Ratchasima Hospital

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