Morton J. Kern MD, MSCAI, FACC, FAHAChief of Medicine, VA Long Beach HSC
Professor of MedicineUniversity California Irvine
Acute Coronary Syndromes
2015
58 yo Man, 58 yo Man, Chest pain Chest pain
after lunch on after lunch on the way to the way to
car.car.Bad sushi?Bad sushi?
CAD is a diffuse process with focal atherosclerotic material (plaque).
Some plaques are obstructive but not thrombotic.Others are potentially thrombotic but not obstructive.
Myocardial Infartion=Death of myocardial cells.
Clinical MI = symptoms, ECG and Biomarkers
Normal Atherosclerotic Plaque
CAD as a cause of Myocardial Ischemia and Infarction
Angiography vs. Pathology
179ACS
LAD
Angiography vs CTA for CAD
Motoyama et al. JACC 2007Motoyama et al. JACC 2007
Fibrous plaque
Positive remodelingSoft plaque
Natural History of CAD : A story of remodeling
•Acute Coronary Syndrome
•72 year-old Man
•Plaque crater, erosion
•Thrombus
•Calcific nodule
What are the Big 5 medications for CAD?
1.BB2.ASA/antiplatelet agents3.Statins4.Nitrates5.Antihypertensive and other risk factor medications
Braunwald’s Heart Disease, 7th Edition
Beta blockersCA blockersACEINTG
NTGASAHeparinGPB’s
Statins
Ranolazine
Perfusion
Abnormalities
Systolic Dysfunction
Δ ECG
Angina
Diastolic Dysfunction
Duration and severity of ischemia
Nuclear Imaging
Stress Echo/MRI
Stress ECG
Ischemic Cascade
EuroIntervention 2015;10:1024-1094 published online ahead of print September 2014
2014 ESC/EACTS Guidelines on myocardial revascularization
Who needs Stress Testing?
Spectrum of ACS Presentations
DefinitionIschemia without
necrosisNecrosis
(nontransmural)Transmural necrosis
DiagnosisNegative Biomarkers Positive biomarkers Positive biomarkers
No ECG ST-segment elevationECG ST-segment
elevation
Treatment Invasive or conservative depending on risk Immediate reperfusion
UA NSTEMI STEMI
Roger VL, Go AS, Lloyd-Jones DM, et al.. Circulation. 2011;123:e18-e209.
Heart Attack Warning Signs• Chest discomfort
– Pressure– Squeezing– Fullness – Pain
• Discomfort in other areas of the upper body– Arms– Jaw– Neck– Back– Stomach
• Shortness of Breath• Cold sweat, nausea or lightheadedness• **Women have atypical presentations!! Be more wary
Who Presents With Atypical Symptoms?
Antman EM, Anbe DT, Armstrong PW, et al. www.acc.org/clinical/guidelines/stemi/index.pdf. Updated 2004. Accessed June 20, 2007.
Key Features of an ECG
P-R T-P Interval
(continues to next heartbeat) T-P Interval
(continued from next heartbeat)
Marieb EN, Hoehn K. Human Anatomy and Physiology. 8th ed. San Francisco, CA: Pearson Benjamin Cummings; 2010.
Example of ST-segment Elevation (STEMI)
J point
STE
Example of ST-segment Depression (UA/STEMI)
J point
STD
Example of T-wave Inversion (UA/STEMI)
T wave changes
Normal 12-lead ECG
http://www.uptodate.com/contents/image?imageKey=CARD%2F1617. Accessed Aug 6. 2011.
INFERIOR
ANTERIORLATERAL
LATERAL
Early-Stage Acute MI (STEMI)
ST-segment elevation ST-segment depression
T-wave inversion
3-Day-Old MI (STEMI)
ST-segment elevation T-wave inversion
UA - NSTEMI
T-wave inversion
Early InvasiveEarly Invasive Initial Initial ConservativeConservative
Braunwald E et al. Available at: www.acc.org.Bowen WE, McKay RG. N Engl J Med. 2001;344:1939-1942.
* Also known as Q-wave MI* Also known as Q-wave MI†† Also known as non-Q-wave MIAlso known as non-Q-wave MI
Treatment of Acute Coronary SyndromeTreatment of Acute Coronary Syndrome
Thygesen K et al. Circulation 2007; available at: http://circ.ahajournals.org.
New clinical classification of MI
Classification Description
1 Spontaneous MI due to coronary event, i.e. plaque erosion and/or rupture, fissuring, or dissection
2 MI secondary to ischemia due to an imbalance of O2 supply and demand, as from coronary spasm or embolism, anemia, arrhythmias, hypertension, or hypotension
3 Sudden unexpected cardiac death, including cardiac arrest, with new ST-segment elevation; new LBBB; or pathologic or angiographic evidence of fresh coronary thrombus--in the absence of reliable biomarker findings
4a MI associated with PCI
4b MI associated with documented in-stent thrombosis
5 MI associated with CABG surgery
Thygesen, K. et al. Circulation 2007;116:2634-2653
Biomarkers of Myocardial Damage
Timing of Release of Various Biomarkers After Acute Myocardial Infarction
Shapiro BP, Jaffe AS. Cardiac biomarkers. In: Murphy JG, Lloyd MA, editors. Mayo Clinic Cardiology: Concise Textbook. 3rd ed.
Rochester, MN: Mayo Clinic Scientific Press and New York: Informa Healthcare USA, 2007:773–80.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Figure 5.
Cardiac-specific troponins are optimum biomarkers (Level IC)
For STEMI, reperfusion therapy should be initiated as soon as
possible and is not contingent on a biomarker assay (Level IC)
Troponin Elevation and Likelihood for Mortality
Troponin Elevation and Likelihood for Mortality
Antman EMl. N Engl J Med. 1996; 335: 1342-1349.% mortality at 42 days
<0.4 <1.0 <2.0 <5.0 <9.0 9.0
2
4
6
8
0
Troponin levels
Non-MI Causes of Troponin Elevation
J Am Coll Cardiol. 2014;63(3):201-214
54 yo M w 2h severe substernal CP - ECG
Early InvasiveEarly Invasive Initial Initial ConservativeConservative
Braunwald E et al. Available at: www.acc.org.Bowen WE, McKay RG. N Engl J Med. 2001;344:1939-1942.
* Also known as Q-wave MI* Also known as Q-wave MI†† Also known as non-Q-wave MIAlso known as non-Q-wave MI
Treatment of Acute Coronary SyndromeTreatment of Acute Coronary Syndrome
Left Coronary System has mild CAD. RCA is 100%
Final post Stent
PCI vs Fibrinolysis in STEMI Systematic Overview
Short term (4-6 weeks)
Keeley EC et al. Lancet. 2003;361:13-20.
PP=0.0002=0.0002PP=0.0003=0.0003 PP<0.0001<0.0001
PP<0.0001<0.0001
PP=0.0004=0.0004
(23 RCTs, n=7,739)(23 RCTs, n=7,739)(23 RCTs, n=7,739)(23 RCTs, n=7,739)
8.5 7.3 7 .2
22.0
2.0
7.24.9
2.8
6.8
1.00.0
5.0
10.0
15.0
20.0
25.0
D eath D eathS H OC K
excl.
R e in farctio n R ecu rren tischem ia
S tro ke
Perc
ent (
%)
L ysisP C I
Medical Therapy for STEMI Managed Medical Therapy for STEMI Managed by Primary PCIby Primary PCI
ASA
Anticoagulant UFH (Bival)
P2Y12 inhibitor
Clopidogrel 600Prasugrel 60, or Ticagrelor 180
Beta Blocker IV prn Oral within 24h
GP IIb/IIIa
EptifibatideAbciximab
Statin
Presentation Access—Wire—Balloon
EDCCL
Importance of Rapid Reperfusion in STEMI
30-minute delay = 8% increase in 1-year mortality30-minute delay = 8% increase in 1-year mortality
Rathore SS, Curtis JP, Chen J, et al. BMJ. 2009;338:b1807.Antman E. ST-segment elevation myocardial infarction: Management. In: Bonow RO, Mann DL, Zipes P, et al, eds. Braunwald's Heart Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011a:1087-1110.
48 yo Man, 48 yo Man, Chest pain Chest pain after lunch after lunch
while walking while walking to car.to car.
48 yo M, HBP with Chest pain while walking
TIMI Risk Score (n=7)
Antman EM, Cohen M, Bernink PJ, et al. JAMA. 2000;284:835-842.
TIMI Study Group. TIMI Risk Score Calculator. http://www.timi.org/?page_id=294. Updated 2011. Accessed July 7, 2011.
What does TIMI RISK mean?
Increasing TIMI RISK 0/1 to 5/7 increases risk of death, MI, urgent revascularization within 14 days 5% to 41%.
Antman EM et al. TIMI 11B, JAMA 2000;284:835-842
Early InvasiveEarly Invasive Initial Initial ConservativeConservative
Braunwald E et al. Available at: www.acc.org.Bowen WE, McKay RG. N Engl J Med. 2001;344:1939-1942.
* Also known as Q-wave MI* Also known as Q-wave MI†† Also known as non-Q-wave MIAlso known as non-Q-wave MI
Treatment of Acute Coronary SyndromeTreatment of Acute Coronary Syndrome
STEMI?
Differential Dx for ACS Chest Pain Syndromes (beyond STEMI, NSTEMI, UA)
• Aortic dissection
• Pulmonary embolus
• Perforating ulcer
• Pericarditis
• GERD (Gastroesophageal reflux disease)
• Heart failure, Pneumonia, Pneumothorax