4/22/12 1 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 S 3 or murmur Admission Treatment ECG ST ↓ or T ↓ Persistent ST ↑ Invasive Non-invasive Reperfusion Normal ECG 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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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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4/22/12
1
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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2
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
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