Acute Coronary Syndromes Ranil de Silva Senior Lecturer in Clinical Cardiology Senior Lecturer in Clinical Cardiology National Heart and Lung Institute, Imperial College London National Heart and Lung Institute, Imperial College London Consultant Cardiologist Consultant Cardiologist Royal Brompton and Royal Brompton and Harefield Harefield NHS Foundation Trust NHS Foundation Trust [email protected][email protected]Acute Coronary Syndromes ST depression T wave inversion ST elevation ESC NSTE-ACS Guidelines 2007 or normal ECG Management Aims in ACS o Rapidly establish diagnosis o Determine risks – MACE (Death, non-fatal MI, recurrent ischaemia, heart failure, arrhythmia, re-hospitalisation, stroke) – Iatrogenic complications (bleeding) o Choose and implement treatment strategy – Timely – Reduce risk of MACE – Minimise risk of bleeding – Treat mechanical complications Case 1 o 79 Female o 4 hrs chest burning o Ex-smoker, stopped 30 years ago o Drugs – warfarin, digoxin 125 mcg, amlodipine 5mg, frusemide 40mg, simvastatin 20mg o Physical examination – BP 180/90 mm Hg (R=L) – HR 160 irreg – RR 24/min, O 2 sats 98% on rebreathe – BM 9.6 mmol/L – Bibasal creps o Bloods tests – Hb 10.8, K 4.1, Cr 126, INR 4.3, troponin pending Presenting ECG ECG Diagnosis o Acute LAD syndrome (NSTEACS), rapid AF o Acute posterior STEACS, rapid AF o Acute inferior STEACS, rapid AF o Acute infero-posterior STEACS, rapid AF o Acute pericarditis, rapid AF
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Acute Coronary Syndromes
Ranil de Silva
Senior Lecturer in Clinical CardiologySenior Lecturer in Clinical CardiologyNational Heart and Lung Institute, Imperial College LondonNational Heart and Lung Institute, Imperial College London
Consultant CardiologistConsultant CardiologistRoyal Brompton and Royal Brompton and HarefieldHarefield NHS Foundation TrustNHS Foundation Trust
o Acute LAD syndrome (NSTEACS), rapid AFo Acute posterior STEACS, rapid AFo Acute inferior STEACS, rapid AFo Acute infero-posterior STEACS, rapid AFo Acute pericarditis, rapid AF
Clinical risk assessment
o Low
o Medium
o High– >75 yo– F– >2h from symptom onset– Pulmonary oedema (Killip 3)– STEACS– Warfarin Rx (↑ bleeding risk)
o Radial artery access– Minimise bleeding risk, ~2/3 of major bleeding in
ACS patients are related to femoral access
o Bivalirudino Thrombus aspirationo Avoid DES
– Triple therapy carries major bleeding risk of 7% per yr
– Aspirin + clopidogrel carries 2-3% per yr risk of major bleeding >75y
ACS
PPCITransfer <1hDTB <60 min
Cardiogenic shockCI to lysis
LysisPre-hospital
Pain to Rx <2hIf transfer >2h:Lytic+GpIIbIIIa
PCI within24h
Fail toreperfuse
Rescue PCI
Medical RxRisk Stratification
High/IntermediateRisk
Low Risk
Angiography± Revasc.within 96h
Medical Rx± Revasc.
STEACS Treatment Options
o PPCI (Keeley et al. Lancet 2005)
– Door to balloon <90 min
– Transfer time < 1h
o Thrombolysis (≡ PPCI if pain to Rx time <2h)
– Pre-hospital (CAPTIM, PRAGUE-2)
– In-hospital
– Routine angiography within 24h post-lysis (TRANSFER-AMI)
o Pharmacoinvasive
– Transfer time >2h
– Half dose lytic + GpIIbIIIa (CARESS-AMI)
STEACS Immediate Drug Treatment
PPCIo Aspirin 300mgo P2Y12 receptor antagonist
– Clopidogrel 600mg (CURRENT-OASIS7)
– Prasugrel 60mg (TRITON-TIMI38)
– Ticagrelor 180 mg (PLATO)
o Antithrombin– UFH
– Enoxaparin (ATOLL)
– Bivalirudin (HORIZONS-AMI)
Lysiso Fibrin specific
– Tenecteplase
o Aspirin 300mgo P2Y12 receptor
antagonist– Clopidogrel 300mg
(CLARITY-TIMI28)
o Antithrombin– UFH
– Enoxaparin (EXTRACT-TIMI25)
– Fondaparinux (OASIS-6)
PPCI for STEMI PPCI v FibrinolysisKeeley et al Lancet 2003;361:13Keeley et al. Lancet 2007
Case 2o 74 Asian female
o Admitted with septic arthritis of L kneeo Chest pain and hypotension post-operatively
o PMHx– IHD – PCI to LAD (DES) 3 months previously– T2D– Hyperlipidaemia
Physical findings
o Pale, cool peripheries, sweaty
o HR 80 irregular
o BP 80/60 mmHg
o O2 sats 90% on rebreathe O2
12 lead ECGECG Diagnosis
o Acute inferior NSTEACS, SRo Acute inferior NSTEACS, Mobitz I AV blocko Acute inferior NSTEACS, Mobitz II AV blocko Acute anterior STEACS, SRo Acute anterior STEACS, Mobitz I AV blocko Acute anterior STEACS, Mobitz II AV block
Risk assessment
o Low
o Medium
o High
What’s happened?
o Clopidogrel stopped by admitting surgical team
o STENT THROMBOSISo ACUTE LAD STEACS + MOBITZ II AV
BLOCKo CARDIOGENIC SHOCK
Immediate Management
o Clopidogrel 600 mg stato Atropine + TPWo Intubate + ventilateo Consider inotropes
– dopamine/dobutamine– norepinephrine
o Frusemide iv infusion
o Immediate transfer to PCI capable facility– Reperfusion– Mechanical haemodyamic support
Stent Thrombosis
Management of Cardiogenic Shock
Hochman et al. NEJM 1999Hochman et al. JAMA 2000
47%50%
53%56%
63%66%
0%
10%
20%
30%
40%
50%
60%
70%
30 days (n=302) 6 months (n=301) 12 months (n=299)
Mortality (%)
ERV
IMS
Early reperfusion improves short and long term mortalityMechanical support (IABP, Impella, Tandem Heart) improves outcomes
Risk Factors for Stent Thrombosis with DES
CASE FATALITY RATE
45% !!
Iakovou et al. JAMA 2005;293:2126-2130
Learning points
o Anterior STEACS + AV block has poor prognosis, indicating proximal LAD occlusion
o Cardiogenic shock is an indication for urgent revascularisation + haemodynamic support
o Acute stent thrombosis carries ~50% mortality rate
o Do not stop clopidogrel within 1 year of DES implantation without specific consultation with a cardiologist
Case 3
o 68M Inf MI, Rx’d with tenecteplase
o R arm weakness
o CT shows small L frontal intracerebral haemorrhage
o Recurrent chest pain
o 12 lead ECG: 5mm ST↑ II, III, aVF
Options
o Transfer for rescue PCI
o Repeat thrombolysis
o Conservative
Phone a friend!o Interventional Cardiologist
– No mortality benefit from Rx’ing uncomplicated inferior MI
– Prognosis from completed inf MI better than extending ICH from further anti-thrombin and anti-platelet Rx
o Neurologist– Discontinue aspirin and clopidogrel
In the thrombolysed patient
o 20% of arteries remain occluded
o Normal coronary flow in ~65% at 90 min
o Reduced tissue perfusion in ~75%
o Increased major bleeding risk (ICH 0.6-1.4%)
o ~15% risk of recurrent ischaemia/re-infarction Post-thrombolysis
Failure to reperfuse
o <50% reduction in ST↑ at 60 min after fibrinolysis
o Look carefully at the post-fibrinolysisECGs!
o Ongoing symptoms (beware masking effect of analgesics), arrhythmia, haemodynamic instabilityGershlick et al. NEJM 2005;353:2758