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.