Acute Heart Failure in ACS : Early

Clinical Manifestation and

Management

Sodiqur Rifqi

Department of Cardiology and Vascular Medicine

Faculty of Medicine, Diponegoro University/Dr. Kariadi Hospital -
Semarang
 ACUTE CORONARY SYNDROMES SPECTRUM

2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation
Introduction

10% to 20% of patients with ACS have concomitant HF, and up to

10% develop HF during hospitalization
The prognosis of ACS complicated by HF is related to the degree of HF
as measured by the Killip classification
Patients with an ACS in Killip class II or III HF are 4 times more likely to
die during the index hospitalization than Killip class I

Flaherty et al, 2009

 THE CARDIOVASCULAR CONTINUUM
Myocardial
CV
infarction Sudden Death
Arrhythmia
CV &
Coronary loss of muscle Death
thrombosis

Acute heart failure

Myocardial
ischaemia
Remodelling

CAD Ventricular
dilatation
Stroke

Atherosclerosis Congestive
LVH heart failure

Risk factors Death

smoking, HYPERTENSION,
cholesterol, diabetes
Factors Associated with the development of HF in ACS

Older age
Female
Diabetes
Previous MI
Presenting MI (Troponin elevated)
Higher HR

Bahit MC, et al. J Am Coll Cardiol HF 2013;1:2239

ACUTE HEART FAILURE (AHF)

AHF refers to rapid onset or worsening of

symptoms and/or signs of HF. It is a life-
threatening medical condition requiring urgent
evaluation and treatment

ALO CAN PRESENT IN

ANOTHER SUBSET OF AHF

EXCEPTION:
ACUTE RIGHT HF

ESC. 2008
6
CLINICAL SPECTRUM OF AHF
ALO

ESC. 2016
8
ALO

ESC. 2016 9
Acute Heart Failure

10
Management
Patients presenting with ACS should be managed according to the ESC
guidelines on non-ST elevation ACS (NSTE-ACS) and STEMI
Coexistence of ACS and AHF identifies a very-high-risk group where
an immediate invasive strategy (< 2 h from hospital admission in
patients with NSTEMI, analogous to STEMI management) with intent
to perform revascularization is recommended, irrespective of ECG or
biomarker findings
STEMI
 Onset of STEMI Hospital Management Modified from Libby. Circulation 2001;104:365,
- Prehospital issues - Medications Hamm et al. The Lancet 2001;358:1533 and
- Initial recognition and management - Arrhythmias Davies. Heart 2000;83:361.
in the Emergency Department (ED) - Complications
- Reperfusion - Preparation for discharge
Secondary Prevention/
Management Long-Term Management
Before STEMI

Chronology of the
interface between the
1 2 3 4 5 6 patient and the
4 clinician through the
progression of plaque
Presentation
Ischemic Discomfort
formation and the
Acute Coronary Syndrome
Working Dx
onset of complications
ECG No ST Elevation ST Elevation
of STEMI.
UA NSTEMI
Cardiac
Biomarker

Final Dx Unstable NQMI QwMI

Angina
Myocardial Infarction
Pathophysiology of ST-Elevation
Myocardial Infarction

Generally caused by a Results from stabilization of a

completely occlusive platelet aggregate at site of
thrombus in a coronary artery plaque rupture by fibrin mesh

platelet
RBC
fibrin mesh
GP IIb-IIIa
 Risk Stratification
TIMI SCORE

Morrow DA, Antman EM, et al. TIMI Risk Score for ST-Elevation Myocardial Infarction.
Circulation 2000;102;2031-2037
Reperfusion Therapy for Patients with STEMI
Regional Systems of STEMI Care
STEMI Patient

Non PCI-capable
Hospital

Primary PCI-capable
Hospital
EMS

STEMI Patient STEMI Patient

Reperfusion Therapy for Patients with STEMI
Initially seen at a PCI-capable
Hospital
I IIa IIb III
Primary PCI should be performed in patients with STEMI and
ischemic symptoms of less than 12 hours duration.

I IIa IIb III

Primary PCI should be performed in patients with STEMI and
cardiogenic shock or acute severe HF, irrespective of time delay
from MI onset.

I IIa IIb III

Primary PCI is reasonable in patients with STEMI if there is clinical
and/or ECG evidence of ongoing ischemia between 12 and 24
hours after symptom onset.
Reperfusion Therapy for Patients with STEMI
Initially seen at a non-PCI capable
Hospital

I IIa IIb III Immediate transfer to a PCI-capable hospital for primary PCI is the
recommended triage strategy for patients with STEMI who initially
arrive at or are transported to a nonPCI-capable hospital, with an
FMC-to-device time system goal of 120 minutes or less.*

I IIa IIb III In the absence of contraindications, fibrinolytic therapy should be

administered to patients with STEMI at nonPCI-capable hospitals
when the anticipated FMC-to-device time at a PCI-capable hospital
exceeds 120 minutes because of unavoidable delays.
NSTEMI
RECOMMENDATIONS FOR DIAGNOSIS, RISK STRATIFICATION, IMAGING AND RHYTHM
MONITORING IN PATIENTS WITH SUSPECTED NON-ST-ELEVATION ACUTE CORONARY
SYNDROMES

2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation
Risk criteria mandating invasive strategy in NSTE-ACS

2015 ESC guidelines

for the management
of ACS in patients
presenting without
persistent ST-segment
elevation
TIMING OF INVASIVE
STRATEGY IN NSTE-
ACS

ESC, 2015
 IMMEDIATE INVASIVE STRATEGY

Performed within 2 hours of hospital admission

(analogous to STEMI management)
Recommended for very high risk patients with at least
one very-high-risk criteria irrespective of ECG /
biomarkers findings)
Centres without STEMI programmes should transfer the
patient immediately

Acute Heart Failure Very High Risk

2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation
 EARLY INVASIVE STRATEGY

Performed within 24 hours of hospital admission

Metaanalysis of 4 RCTs (4013 NSTE-ACS patients)
Early (1,16-14 hours) VS delayed (20,8-86 hours)
no significant differences in terms of death or MI
early invasive : lower risk of recurrent ischaemia (p=0,02), shorter duration
of hospital stay (p<0,001), fewer major bleeds (p=0,13), fewer major
adverse cardiac events (p=0,09)
Updated metaanalysis of 7 RCTs (5370 NSTE-ACS
patients) & 4 observational studies (77499 patients)
Early ( <24 hours ) VS delayed
no significant benefit for death or major bleeds
early invasive lower risk of refractory ischaemia (p=0,008)

2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation
 EARLY INVASIVE STRATEGY

Timing of intervention in Acute Coronary Syndrome

(TIMACS) randomized 3031 NSTE-ACS patients to an early
(<24 h, median time 14 h) or delayed ( median time 50 h)
:
at 6 months : there is no difference in the primary
composite endpoint of death, MI / stroke
Secondary endpoint of death, MI, stroke / refractory
ischaemia reduced by 28% (p=0,003)
In GRACE SCORE > 140 : early invasive strategy lowered
the risk of death, MI / stroke (p=0,0006)
Early invasive strategy is recommended in patients with
at least one high risk criteria
2015 ESC guidelines for the management of ACS in patients presenting without persistent ST-segment elevation
ALGORITHM FOR MANAGEMENT OF PATIENTS WITH DEFINITE OR LIKELY NSTE-ACS

2014 AHA
NSTE-ACS
Guideline
2015 AHA
NSTE-ACS
Guideline
RoffiM, PatronoC EurHeart J.2015 Aug 29. pii: ehv320.41
 ISCHEMIA-GUIDED STRATEGY
VS EARLY INVASIVE STRATEGY

1. The rapid & definitive nature of the evaluation

EARLY INVASIVE 2. Earlier revascularization may prevent further
STRATEGY complication of ACS
3. Early discharge

1. Avoid the routine early use of invasive procedures

unless patients experience refractory / recurrent
ischemic symptoms / develop hemodynamic
ISCHEMIA-GUIDED instability
STRATEGY 2. A plan for non-invasive evaluation (dynamic ECG
changes, myocardial perfusion deffect
3. Very high prognostic risk (TIMI / GRACE)
4. Avoid costly & possibly unnecessary invasive
procedures

2014 AHA NSTE-ACS Guideline

 RESUME
Coexistence of ACS and AHF identifies a very-high-risk group where an
immediate (< 2 h from hospital admission in patients with NSTEMI,
analogous to STEMI management) invasive strategy with intent to perform
revascularization is recommended, irrespective of ECG or biomarker
findings
STEMI Management Reperfusion
NSTEMI Risk StratificationALO = Very High Risk Early Invasive
strategy ( Immediate Invasive Strategy)
Medical treatment of AHF should be given in conjunction with aggresive
management of ACS (complicated with AHF).