Mauritius Medical Association

Mauritius Medical Association

Percutaneous Coronary Interventions

(PCI)

In

Acute Coronary Thrombosis

June 2008

Dr U.S RAMJUTUN, Consultant Cardiologist, Victoria Hospital

Aorta

RightCoronary

Artery

Left MainCoronaryArtery

LeftCircumflex Branch

LeftAnteriorDescending

Marginal Branch

Posterior Interventricular

Anterior heart showing coronary vessels

Inferior AMI

II, III, AVF

Septal AMI

V1, V2

Anterior AMI

V3, V4

Lateral AMI

V5, V6 - ( I, AVL )

Location of infarctions

Acute Myocardial Infarction

15 minutes 2 hours 6 hours

% necrosis 0% 50% 90%

Occlusive thrombus on a plaque of atheroma

(Wavefront phenomenon)

Wavefront phenomenon of ischaemic cell death

15 Minutes 40 Minutes

3 Hours >6 Hours

Nonischaemic

Ischaemic (viable)

Necrotic

Acute Coronary Syndrome

Initiating Events

1 Plaque rupture

2 Thrombus formation

3 Vasoconstriction

Lipidpool Lipid-rich

plaque

FissurePlaque

disruption

Occlusivethrombus

Subocclusivethrombus

Acute MI,Q-wave

Unstableangina/

Non-Q-waveMI

Plaque Rupture

Thrombus Formation

Platelet Adhesion

Platelet Aggregation

Thrombus Formation

Thrombus Formation

Fibrin Threads

Acute Coronary Syndrome

SUDDEN DEATH

SUDDEN DEATH

SUDDEN DEATH

UnstableAngina

CoronaryArterial

Thrombosis

Non-Q-WaveMyocardialInfarction

Q-WaveMyocardialInfarction

NSTE ACS

Acute Coronary Syndrome( ACS )

STE ACS

Non Q wave MI

Q wave MI

Unstableangina

History

ECG

Outcome

Evolving myocardial infarction has been established as:

Patients with ST segment elevation, i.e. new ST segment elevation at the J point with the cut off points 0.2mV in V1 through V3 and 0.1mV in other leads

or New LBBB

Established myocardial infarction may be defined by:• Q wave in leads V1 through V3, OR• Q wave 0.03s in leads I, II, aVL, aVF, V4, V5, or V6.

ECG changes indicative of an AMI.

Evolution of an acute myocardial infarction

A. B. C.

D. E.F.

Onset > 1 Hour

Months later

> 24 Hours Days Later

15 Minutes

Elevation of cardiac markers

0 20 40 60 80 100 120 140 160

7x upper limit of normal

6x

5x

4x

3x

2x

1x

Hours from onset of infarction

Total CK

CK-MBTroponin I

Management of Patients with ST Elevation

ST elevation

12 h

Aspirin+ClopidogrelBeta-blocker etc.

Eligible forthrombolysis

> 12 h

Thrombolysiscontraindicated

Not a candidate forreperfusion therapy

Persistent symptoms ?

Thrombolyse PrimaryPTCA or CABG

Other medical therapy:ACE inhibitors

? NitratesAnticoagulants

ConsiderReperfusion

Therapy

No Yes

Thrombolysis

• Perhaps the most significant advances in the early treatment of acute myocardial infarction (AMI) in the last decade are reperfusion therapy (thrombolysis) and angioplasty.

• Many clinical trials have established early thrombolytic therapy as a recommended treatment for patients with ST-segment elevation or new Left Bundle Branch Block.

• Although thrombolysis is not without risk, the benefits, in terms of lives saved, far outweigh these risks.

Abso

lute

benefit

per

10

00

Rx p

ati

ents

Treatment delay (h)

0

0 3 6 9 12 15 18 21 24

20

40

60

80

Absolute 35-day Mortality Reduction Versus Treatment

Delay Per 1000 Patients Treated

0-1 hrs 65/1000

1-2 hrs 37/1000

2-3 hrs 29/1000

3-6 hrs 26/1000

6-12 hrs 18/1000 12-24 hrs

9/1000

Benefits for Early Diagnosis and Thrombolytic Treatment

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

Absolute Contraindications

• Any prior intracranial hemorrhage

• Known structural cerebral vascular lesion (e.g., arteriovenous malformation)

• Known malignant intracranial neoplasm (primary or metastatic)

• Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours

NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

Absolute Contraindications

• Suspected aortic dissection

• Active bleeding or bleeding diathesis (excluding menses)

• Significant closed-head or facial trauma within 3 months

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

• History of chronic, severe, poorly controlled hypertension

• Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg)

• History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications

• Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks)

RelativeContraindications

Contraindications and CautionsContraindications and Cautionsfor Fibrinolysis in STEMIfor Fibrinolysis in STEMI

RelativeContraindications • Recent (< 2 to 4 weeks) internal bleeding

• Noncompressible vascular punctures • For streptokinase: prior exposure (> 5 days

ago) or prior allergic reaction to these agents• Pregnancy• Active peptic ulcer • Current use of anticoagulants: the higher the

INR, the higher the risk of bleeding

Fibrinolysis generally preferred Early presentation ( ≤ 3 hours from symptom onset and delay to invasive strategy)

Invasive strategy not an option Cath lab occupied or not available Vascular access difficulties

No access to skilled PCI lab

Delay to invasive strategy Prolonged transport

Door-to-balloon more than 90 minutes > 1 hour vs fibrinolysis (fibrin-specific agent) now

Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 1:Step 1: Select Reperfusion Treatment. Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.

Invasive strategy generally preferred Skilled PCI lab available

Door-to-balloon < 90 minutes

• High Risk from STEMI Cardiogenic shock, Killip class ≥ 3

Contraindications to fibrinolysis, including increased risk of bleeding and ICH

Late presentation > 3 hours from symptom onset

Diagnosis of STEMI is in doubt

Reperfusion Options for STEMI PatientsReperfusion Options for STEMI Patients Step 2:Step 2: Select Reperfusion Treatment. Select Reperfusion Treatment.

If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.

Percutaneous coronary interventionsPCI

(balloon angioplasty, stenting, debulking, brachytherapy etc)

• Primary PCI• Rescue PCI• Facilitated PCI• Ischaemia driven PCI• Late PCI• Etc.

Primary PCI for AMI

• 1977- first PCI (Gruntzig)• 1979- first primary PCI (Rentrop P et al.)• 2003-metaanalysis of 23 randomized trials:

superiority of primacy PCI compared to thrombolysis

• Pivotal studies: PAMI (1993), GUSTO IIb(1997), DANAMI 2 (1997) PRAGUE 1&2(2000,2003) etc.