Clinical Case Management of ACS...STEMI NSTEMI USA Suspicion of Acute Coronary Syndrome Treatment Diagnosis Risk Stratification Biochemistry ECG Working diagnosis Persistent ST ↑

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Management of ACS Based on ACC/AHA & ESC Guidelines

Dr Badri Paudel

Clinical Case

•  Mr M •  75M •  Poorly controlled diabetic •  Smoker •  Presented on Sat 7pm •  Intense burning in the

retrosternal area

Clinical Case

•  Mr M •  75M •  Poorly controlled diabetic •  Smoker •  Presented on Sat 7pm •  Intense burning in the

retrosternal area

•  96bpm •  110/70 •  Clear chest •  No S3 or

murmur

Admission

NSTEMI USA STEMI

Suspicion of Acute Coronary Syndrome

Treatment

Diagnosis

Risk Stratification

Biochemistry

ECG

Working diagnosis

ST ↓ or T ↓ Persistent ST ↑

Invasive Non-invasive Reperfusion

Normal ECG

High Risk Low Risk

Trop -ve Trop +ve

Chest Pain

ESC guidelines 2007

ST ↓ or prominent T ↓ on ECG

and/or

Positive biomarkers in absence of ST elevation in

an appropriate clinical setting

UA/NSTEMI: Definition

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Trends in ACS

0

50

100

150

200

Incid

ence

(per

100,0

00)

Q Wave Non-Q Wave

1975-78 1981-84 1986-881990-91 1993-95 1997

Furman JACC 2001

Mortality trends

9.3

7.15.7

10.8

0

2

4

6

8

10

12

STEMI NSTEMI

Source: ESC guidelines

In-hospital 1-year

Implications of Statistics

•  NSTE-ACS commoner than STEMI •  ACS patients tend to be

– Older – More diabetes – More renal failure – Other co-morbidities

•  Overall, similar 1-yr mortality

1.  Rest angina

2.  New-onset angina

3.  Increasing angina

Principal Presentations

Pre-hospital Management Aspirin

•  Chest pain pts to have 162.5 -325mg aspirin as early as possible

•  Chewable/soluble aspirin preferred over enteric coated

Pre-hospital Management Sublingual Nitrate

Single dose NTG

Two more doses, But reach ER if

Any pain persists

Call Ambulance And reach ER

Partial relief (only for CSA pts)

No response

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ECG

No ST dep 1mm dep

2mm dep

0 30 60 90 120 180

1.0

0.85

0.7

Follow-up in days

Sur

viva

l

Time Goals

•  Initial ECG performed & interpreted – Within 10 min of arrival

•  Initial ECG non-diagnostic – Serial ECGs 15-60min apart

Admission

NSTEMI USA STEMI

Suspicion of Acute Coronary Syndrome

Treatment

Diagnosis

Risk Stratification

Biochemistry

ECG

Working diagnosis

ST ↓ or T ↓ Persistent ST ↑

Invasive Non-invasive Reperfusion

Normal ECG

High Risk Low Risk

Trop -ve Trop +ve

Chest Pain Cardiac Enzymes

Clinical case

•  M, 75M •  DM, Smoker •  Rest pain •  Clinically stable •  ECG change

Troponin T 0.7ng/mL

Cardiac Troponins in ACS

N Engl J Med 1996

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Troponins for Rx decisions Role of Echo in Risk Assessment

•  RWMA

•  LV dysfunction

•  Associated valvular abnormalities

•  Differential diagnosis

Clinical case

•  M, 75M •  DM, Smoker •  Rest pain •  Clinically stable •  ECG changes •  Positive Trop-T

Echo: Hypokinetic Ant wall. EF 50%

Admission

NSTEMI USA STEMI

Suspicion of Acute Coronary Syndrome

Treatment

Diagnosis

Risk Stratification

Biochemistry

ECG

Working diagnosis

ST ↓ or T ↓ Persistent ST ↑

Invasive Non-invasive Reperfusion

Normal ECG

High Risk Low Risk

Trop -ve Trop +ve

Chest Pain

Risk Stratification - Purpose

1. Likelihood of obstructive CAD

2. Risk of adverse outcomes

TIMI Risk Score for USA/NSTEMI

•  Age ≥ 65 years •  ≥ 3 traditional CAD risks •  Prior coronary lesion ≥ 50% •  ST-segment deviation on admission ECG •  ≥ anginal episodes in last 24 hrs •  Prior aspirin use •  Elevated cardiac enzymes

Elements of TIMI Score for risk stratification in USA

Presence of each element is assigned 1 point

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14-day event risk with TIMI Score

Event rates

4.7% 8.3%

13.2% 19.9% 26.2% 40.9%

TIMI Score

0 or 1 2 3 4 5

6/7

With increasing risk score there is progressively greater benefit from therapies like LMWH, platelet gpIIb/IIIa inhibitors & invasive strategy

Clinical case

•  M, 75M •  DM, Smoker •  Rest pain •  Clinically stable •  Admission ECG •  Trop-T Positive •  RWMA, EF 50%

TIMI risk 4 points

Rx Benefit of Risk Scoring

Antman et al JAMA 2000

Other Markers of Risk - BNP

NEJM 2001

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Quick Re-Cap

•  NSTE-ACS as important as STEMI

•  Risk stratification aims at CAD diagnosis & estimating risks to help Rx decisions

•  Newer Markers are emerging, but risk scores are currently the best way to predict outcomes

Hospital Management

History, examination, ECG & initial biomarkers should help classify chest pain patients into:

– Possible ACS – Definite ACS – Chronic stable angina – Non cardiac diagnosis

Hospital Management Possible ACS

•  Normal ECG – Observe, serial ECGs, Serial enzymes –  If negative, discharge after stress test*

•  Abnormal ECG (or follow-up ECGs/enzymes turn positive) – Treat as definite ACS

* Or schedule stress test on OP basis

•  Admit to CCU or step-down unit

•  Continuous ECG ± SpO2 monitoring

• Supplemental oxygen to pts with low SpO2, respiratory distress, basal creps

Hospital Management Definite ACS

Anti-ischemic Therapy

•  Rest / Oxygen

•  Nitrates (sublingual/oral/topical, IV for ongoing pain)

•  Morphine IV (pain, CHF)

•  β-blocker (oral, IV for ongoing pain)

•  Non-dihydropyridine Ca2+ blocker (verapamil /diltiazem)

•  ACE Inhibitors

Anti-Ischemic Therapy Contraindications for nitrates

Nitrates contraindicated in: – SBP < 90mmHg or ≥ 30mmHg below

baseline – Severe bradycardia (< 50 bpm) – Tachycardia (>100 bpm) – RVMI – Pts with ED who took sildenafil in

last 24h or tadalafil in last 48h

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Anti-Ischemic Therapy Beta-blockers

•  Start β-blocker within first 24h for patients who do not have: – signs of HF –  low-output state – high risk for cardiogenic shock – AV block, asthma

Anti-Ischemic Therapy Calcium channel blockers

•  Verapamil or diltiazem: initial therapy if LV function is normal & if β# cannot be given

•  Immediate-release dihydropyridine Ca- antagonists not to be used unless combined with a β-blocker

Anti-Ischemic Therapy ACEI/ARB

•  ACEI for pulmonary congestion or LVEF ≤ 40% •  Contraindicated if

–  hypotension (SBP <100 mmHg or <30 mmHg below baseline)

–  or other known contraindications •  ARB may be used in pts intolerant of ACEI

Anti-coagulants

UFH LD: 60 U/ kg (max 4000 U) Infusion: 12 U/kg/ h (max 1000 U/ h) Maintain aPTT 1.5- 2.0 times control

Enoxaparin LD: 30 mg IV bolus MD: 1 mg/ kg SC q12h

Fonduparinux 2.5 mg SC once daily

Platelet GP IIb/IIIa Receptor Antagonists

1.  In all patients managed with invasive Rx

2.  Patients who continue to have ischemia despite ASA+CLOP+heparin

3.  Patients in the high risk group

Clinical case

•  M, 75M •  DM, Smoker •  Rest pain •  Clinically stable •  Admission ECG •  Trop-T Positive •  RWMA, EF 50%

Pain persists Same ECG

Eptifibatide bolus followed By infusion started

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Choice of GpIIbIIIa blocker

•  IV eptifibatide or tirofiban is the preferred choice

•  Abciximab is indicated only if PCI is likely without appreciable delay

Select Management Strategy:

Initial Invasive Versus

Initial Conservative Strategy

1.  First contact INITIAL EVALUATION

2. diagnosis/risk assessment VALIDATION

3. Invasive strategy

• Chest pain type • Physical • Risk factors • ECG

ACS

ACS unlikely

STEMI

• Troponins • Biochem • Special markers • Serial ECGs • Assess risk score

• Persistent angina • Persistent ECGs • CHF/instability • VT/VF

• ↑troponins • Dynamic ECGs • DM/Renal dysfunction • LV dysfunction • Post MI angina • Prior MI/PCI/CABG • High risk scores

• No CP recurrence • No CHF • No ECG/Trop change

UR

GE

NT

EA

RLY

N

O o

r E

LEC

TIV

E

ESC 2007

1.  First contact INITIAL EVALUATION

2. diagnosis/risk assessment VALIDATION

3. Invasive strategy

• Chest pain type • Physical • Risk factors • ECG

ACS

ACS unlikely

STEMI

• Troponins • Biochem • Special markers • Serial ECGs • Assess risk score

• Persistent angina • Persistent ECGs • CHF/instability • VT/VF

• ↑troponins • Dynamic ECGs • DM/Renal dysfunction • LV dysfunction • Post MI angina • Prior MI/PCI/CABG • High risk scores

• No CP recurrence • No CHF • No ECG/Trop change

UR

GE

NT

EA

RLY

N

O o

r E

LEC

TIV

E

ESC 2007

1.  First contact INITIAL EVALUATION

2. diagnosis/risk assessment VALIDATION

3. Invasive strategy

• Chest pain type • Physical • Risk factors • ECG

ACS

ACS unlikely

STEMI

• Troponins • Biochem • Special markers • Serial ECGs • Assess risk score

• Persistent angina • Persistent ECGs • CHF/instability • VT/VF

• ↑troponins • Dynamic ECGs • DM/Renal dysfunction • LV dysfunction • Post MI angina • Prior MI/PCI/CABG • High risk scores

• No CP recurrence • No CHF • No ECG/Trop change

UR

GE

NT

EA

RLY

N

O o

r E

LEC

TIV

E

ESC 2007

Evidence for Early Invasive Rx

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0.1 1 10

Odds Ratio ( 95%CI)

Invasive strategy in non-ST elevation ACS Is there reduction in death or non-fatal MI?

Invasive better Conservative better N=8114 P=0.005

OR 0.85 (95% CI 0.75-0.95)

NNT 43

Inv Con

19.9% 24.5%

7.9% 16.7%

7.3% 9.5%

15.9% 19.5%

6.3% 22.4%

5.8% 11.8%

23.0% 15.3%

14.8% 17.1%

Trial FU months

FRISC2 60

TRUCS 12

TACTICS 6

RITA 3 60

VINO 6

ISAR COOL 1

ICTUS 32

TOTAL 37

0.1 1 10

Odds Ratio ( 95%CI)

Invasive strategy in non-ST elevation ACS Is there a mortality benefit?

Invasive better Conservative better

Trial FU months

FRISC2 60

TRUCS 12

TACTICS 6

RITA 3 60

VINO 6

ISAR COOL 1

ICTUS 32

TOTAL 38

N=8375 P=0.05

OR 0.85 (95% CI 0.73-1.00)

NNT 83

Inv Con

9.6% 10.0%

3.9% 12.5%

3.3% 3.5%

11.4% 14.4%

3.1% 13.4%

0.0% 1.4%

7.5% 6.7%

7.3% 8.5%

Routine vs Selective Invasive Strategies in ACS

To Cath or Not to Cath That Is No Longer the Question

How Soon should we cath?

ISAR-COOL: Major results at 30 days

End point Cooling off (%)

Early intervention(%)

Death/MI 11.6 5.9

Death 1.5 0

Nonfatal MI 10.1 5.9

Q-wave MI 3.4 2.0

Significant reduction in primary endpoint (p=0.04)

Neumann FJ. AHA Scientific Sessions 2002

0

2

4

6

8

10

12

Early Delayed

Death/MI/Revasc

TIMACS trial Timing of intervention in patients with acute coronary syndromes

1515.5

1616.5

1717.5

1818.5

1919.5

Early Delayed

Death/refractory isch/stroke

Secondary endpoints

CAG<24h v/s >36h

Shamir Mehta. AHA scientific sessions 2008

Clinical Case

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Cardiac cath

CAD No Discharge from protocol

Yes

Left main disease Yes CABG

No

1- or 2- Vessel

Disease

3- or 2-vessel disease with proximal LAD involvement

LV dysfunction or treated diabetes*

No

PCI or CABG

Medial Therapy, PCI

or CABG

Yes CABG

*There is conflicting information about these patients. Most consider CABG to be preferable to PCI. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 20.

Revascularization Strategy in UA/NSTEMI Post-Discharge care

•  Drugs required in the hospital to control ischemia should be continued after hospital discharge

•  Education about symptoms of AMI & how to seek help

•  ASA 75 to 325 mg/d

•  Clopidogrel 75 mg/d

•  β-Blockers if no contraindications

•  Lipid-lowering agents & diet

•  ACEI if CHF, LVEF<0.40, HT or diabetes

Long-Term Antithrombotic Therapy at Hospital Discharge after UA/NSTEMI

Medical Therapy without Stent

Bare Metal Stent Group

Drug Eluting Stent Group

ASA 162 to 325 mg/d for 1 month, then 75 to 162 mg/d indefinitely

& Clopidogrel 75 mg/d for at least 1

month and up to 1 year

Add: Warfarin (INR 2.0 to 2.5) Continue with dual antiplatelet therapy as above

Yes No

Indication for Anticoagulation?

ASA 75 to 162 mg/d indefinitely &

Clopidogrel 75 mg/d at least 1 month & up to 1 year

ASA 162 to 325 mg/d for 3- 6 months, then 75 to 162 mg/d

indefinitely

&

Clopidogrel 75 mg/d for at least 1 year

Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 11. INR = international normalized ratio; LOE = level of evidence.

UA/NSTEMI Patient Groups at Discharge

Special Subsets Diabetes Mellitus

•  Aggressive Rx approach just like non-diabetics

•  Focus on good glycemic control

•  Prefer CABG if multivessel disease suitable for both Rx modes

Special Subsets Older Patients

•  Management intent similar to the young

•  Include functional status & co-morbidities in decision making

•  Dosage adjustments

• No difference in medical Rx

• Recommendations for invasive strategy: similar to those of men

• In women with low-risk features: conservative strategy similar to men

Special Subsets Women

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Thank You