Acute Coronary Syndrome (NSTEMI)

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Information about Acute Coronary Syndrome (NSTEMI)
Education

Published on February 4, 2014

Author: drasimrana

Source: slideshare.net

Description

Acute Coronary Syndrome especially NSTEMI is a very often missed diagnosis in ICU patients. The presentation addresses Emergenc

Acute Coronary Syndrome Non ST Elevation MI Muhammad Asim Rana MBBS, MRCP, SF-CCM, EDIC, FCCP Department of Critical Care Medicine King Saud Medical City Riyadh Saudi Arabia

Disclosures We are not promotional speakers for any company but we do accept the breakfast in our presentations (just for fun) A very special man is here to see U doctor!!

Session Objectives    Utilize both clinical evaluation and risk scoring in selecting the appropriate initial management strategy for patients with UA/NSTEMI Identify potential updates to current UA/NSTEMI critical pathways based on the latest ACC/AHA UA/NSTEMI guidelines and recent UA/NSTEMI clinical trial results Evaluate current approaches to discharge planning and follow-up, and modify them as necessary to promote adherence to medical and rehabilitative therapies

Deaths from ACS others 23% ACS 48% Hypertension 5% CHF 5% Atherosclerosis 2% 0.5% 0.5% Stroke 17%

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI† STEMI 1.24 million .33 million Admissions per year Admissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

Ischemic Heart Disease Evaluation Based on the patient’s • • • History / Physical exam Electrocardiogram Biochemical markers Patients are categorized into 2 groups   Non Cardiac Chest Pain Pain cardiac in origin USA/NSTEMI/STEMI

Spectrum of Coronary Syndromes Risk Factors + Hypertension Endothelial Dysfunction Atherosclerosis IHD/Angina Pectoris Myocardial Ischemia Chronic Coronary Syndromes Coronary Thrombosis Myocardial Infarction Acute Coronary Syndromes Arrhythmia & Loss of Muscle Remodeling Ventricular Dilation Congestive Heart Failure Endstage Heart Disease Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.

Acute Coronary Syndrome  Definition The term ACS refers to a spectrum of presentations caused by myocardial ischemia that includes    Unstable Angina Non ST elevation myocardial infarction ST elevation myocardial infarction

Diagnosis      Diagnosis requires a rise and/or fall in serum levels (preferably troponin) together with: Evidence of Myocardial Ischaemia Defined clinically by patient history ECG (new ST-T wave changes, new left bundle branch block or evolving pathological Q waves) Imaging evidence of new regional wall motion abnormality.

Acute Coronary Syndromes Pathophysiology  The embracing term reflects the common pathophysiology of  Plaque disruption  Intravascular thrombosis  Impaired myocardial blood supply

STEMI Result of complete epicardial occlusion following plaque disruption & leads to propagation of thrombus & epicardial vasoconstriction NSTEMI Incomplete & transient epicardial occlusion with platelet-rich & phasic distal embolisation

Pathophysiology

Summary of events & outcome

Acute ST Elevation MI

Normal ECG

Acute Coronary Syndrome Clinical Diagnosis MONA Morphine Oxygen NTG Aspirin Blood Tests: Troponin at 12 hours after onset of pain, U&E, cholesterol, FBC, coagulation Admission or subsequent ECG

High Risk ECG changes: (2 or more contiguous leads) ST depression > 1mm T inversion > 1mm Transient BBB Minor/ transient ST elevation NO High Risk Clinical features: Ongoing rest pain. Haemodynamic instability. Arrythmias Troponin Elevated? NO Low Risk Patient Discharge Able to exercise ? YES NO Consider investigations: Perfusion scan Angiography Cardiology Referral ETT ETT Normal ETT Inconclusive

High Risk ECG changes: (2 or more contiguous leads) ST depression > 1mm T inversion > 1mm Transient BBB Minor/ transient ST elevation High Risk UnStable Ongoing pain ECG changes GPIIbIIIa Urgent cath. pre-morbidity suitability for revasc. 1. 2. 3. 4. 5. High Risk Clinical features: Ongoing rest pain. Haemodynamic instability. Arrythmias Troponin Elevated High Risk LMWH Clopidogrel 300 stat, 75mg OD Aspirin 75 mg OD Beta Blockers: (metopr)25 mg tds Hyperglycaemic control DIGAMI protocol, if RBS > 10 mmol 6. Morphine and / or IV nitrates if continuing pain, titrate to pain and blood pressure. High Risk Stable Cardiac Cath. pre-morbid state and suitability for revasc.

What is UA/NSTEMI Patients Risk of inpatient Cardiac Mortality and ischemic events?

Variables Used in the TIMI Risk Score • Age ≥ 65 years =1 point • At least 3 risk factors for CAD =1 point • Prior coronary stenosis of ≥ 50% =1 point • ST-segment deviation on ECG presentation =1 point • At least 2 anginal events in prior 24 hours =1 point • Use of aspirin in prior 7 days =1 point • Elevated serum cardiac biomarkers =1 point The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42. TIMI = Thrombolysis in Myocardial Infarction.

TIMI Risk Score TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 Days After Randomization % 0-1 4.7 2 8.3 3 13.2 4 19.9 5 26.2 6-7 40.9 Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8. TIMI = Thrombolysis in Myocardial Infarction.

GRACE Risk Score Variable Odds ratio Older age 1.7 per 10 y Killip class 2.0 per class Systolic BP 1.4 per 20 mm Hg ↑ ST-segment deviation 2.4 Cardiac arrest during presentation 4.3 Serum creatinine level 1.2 per 1-mg/dL ↑ Positive initial cardiac biomarkers 1.6 Heart rate 1.3 per 30-beat/min ↑ The sum of scores is applied to a reference monogram to determine the corresponding all-cause mortality from hospital discharge to 6 months. Eagle KA, et al. JAMA 2004;291:2727–33. The GRACE clinical application tool can be found at www.outcomes-umassmed.org/grace. Also see Figure 4 in Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157. GRACE = Global Registry of Acute Coronary Events.

Why R U Confusing us?

UA/NSTEMI Hospital Care Let’s Start with the Basics! Assuming the NSTEMI has been our diagnosis

ACC/AHA Guidelines ACS Treatment Overview: UA/NSTEMI Diagnosis of UA or NSTEMI is likely or definite Aspirin or clopidogrel (if patient is aspirin intolerant) Initial conservative management Initial invasive management Medical therapy Evaluation of LV Function in pt with ischemia aIf Diagnostic angiography PCI or CABGa Long-term medical management: Clopidogrel, aspirin, β-blocker, ACEI, statin possible, clopidogrel should be withheld for 5-7 days prior to the procedure. Anderson JL, et al. Circulation. 2007;116:803-877.

Selection of Initial Treatment Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment Class I Indications     Bed rest with continuous ECG Monitoring O2 therapy if saturation <90%, respiratory distress, or other high-risk features for hypoxemia SL NTG 0.4 mg q5min x3 then assessment of need for IV NTG IV NTG indicated first 48 hours for treatment of persistent ischemia, CHF or HTN; should not preclude Rx with beta-blockers or ACE Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment Class I Indications   Oral Beta-Blocker in first 24 hours for pt who do not have  Signs of CHF  Low out-put state  Increased risk of cardiogenic shock  Contraindication to Beta blockers/heart block/COPD If Beta-Blockers are contraindicated a nondihydropyridine calcium channel blocker may be used if no LV dysfunction Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment (Cont.) ACE inhibitor within 24 hours with pulmonary congestion or LVEF < 40% in the absence of hypotension or contraindication  Because of the increased risk of mortality, reinfarction, HTN, CHF, and myocardial rupture NSAIDS except for ASA should be discontinued at presentation Class II indications:  It is reasonable to admin O2 to all UA/NSTEMI pts in first 6 hours. IIa  Morphine (1-5 mg IV) remains Class I for STEMI although may increase adverse events in UA/NSTEMI (1,2)  It is reasonable to administer morphine sulfate IV if there is uncontrolled ischemic Chest Pain despite NTG. IIa  1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367. 2. Meine T el al. Am Heart J 2005;149:1043- 9

Rx for all NSTEMI Early Hospital Care 2011 Focused update Antiplatelet therapy   ASA should be administered to USA/NSTEMI as soon as possible after hospital presentation and continued indefinitely (LOE A) Clopidogrel (loading dose followed by maintenance dose) should be administered to USA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance (LOE B) Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Look who is sleeping

Conservative Rx Hospital Care 2011 Focused update Antiplatelet therapy  For USA/NSTEMI patients in whom an initial conservative strategy is selected clopidogrel (loading dose followed by maintenance dose) should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month and ideally up to 1 year Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Conservative Rx Hospital Care Initial Conservative Strategy: Anticoagulant Therapy   Anticoagulant therapy should be added to antiplatelet therapy in UA/NSTEMI patients as soon as possible after presentation. For patients in whom a conservative strategy is selected, regimens using either enoxaparin* or UFH (LOE A) or fondaparinux (LOE: B) have established efficacy.  In patients in whom a conservative strategy is selected and who have an increased risk of bleeding, fondaparinux is preferable. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367 *Limited data are available for the use of other lowmolecular-weight heparins (LMWHs), e.g., dalteparin.

Time to use your grey matter   An 65 year-old woman presented to the ED at 6 AM with a history of intermittent chest pain x 1 week. She has long-standing hypertension and chronic kidney disease, and started hemodialysis recently. Her anti-hypertensive medications are: metoprolol, diltiazem, hydralazine, and lisinopril. She has been taking aspirin 325 mg daily since having a TIA one year ago. Her blood pressure is 180/100. She has bibasilar rales and an S3 gallop. Her serum troponin is mildly elevated. Her CXR shows pulmonary congestion. The patient does not want to undergo invasive diagnostic studies. Which of the following therapies are not contraindicated: a. Clopidogrel b. Prasugrel c. Enoxaparin d. Eptifibatide e. An intravenous fibrinolytic drug

Time to use your grey matter   An 65 year-old woman presented to the ED at 6 AM with a history of intermittent chest pain x 1 week. She has long-standing hypertension and chronic kidney disease, and started hemodialysis recently. Her anti-hypertensive medications are: metoprolol, diltiazem, hydralazine, and lisinopril. She has been taking aspirin 325 mg daily since having a TIA one year ago. Her blood pressure is 180/100. She has bibasilar rales and an S3 gallop. Her serum troponin is mildly elevated. Her CXR shows pulmonary congestion. The patient does not want to undergo invasive diagnostic studies. Which of the following therapies are most appropriate a. ASA 325 mg daily b. ASA 325 mg daily and clopidogrel 75 mg daily c. Intravenous unfractionated heparin d. ASA 325 mg daily and Intravenous heparin e. ASA 325 mg OD & Clopidogrel 75mg OD & IV heparin

Time to use your grey matter    An 65 year-old woman presented to the ED at 6 AM with a history of intermittent chest pain x 1 week. She has long-standing hypertension and chronic kidney disease, and started hemodialysis recently. Her anti-hypertensive medications are: metoprolol, diltiazem, hydralazine, and lisinopril. She has been taking aspirin 325 mg daily since having a TIA one year ago. Her ECHO showed EF 30% & small pericardial effusion. Which of the following drugs should be discontinued? a. Metoprolol b. Diltiazem c. Hydralazine d. Lisinopril

Time to use your grey matter  Oral beta blockers should be initiated within first 24 hrs for those pts who do not have      1) 2) 3) 4) Signs of heart failure Evidence of low output state Increased risk of cardiogenic shock other contraindications to beta blockers Risk Factors for Cardiogenic Shock     Age > 70yrs BP <120 Heart rate >110 or < 60 Increased time since onset of symptoms

Time to use your grey matter

Time to use your grey matter    An 65 year-old woman presented to the ED at 6 AM with a history of intermittent chest pain x 1 week. She has long-standing hypertension and chronic kidney disease, and started hemodialysis recently. Her anti-hypertensive medications are: metoprolol, diltiazem, hydralazine, and lisinopril. She has been taking aspirin 325 mg daily since having a TIA one year ago. Her ECHO showed EF 30% & small pericardial effusion. Which of the following is indicated? a. Transe-esophageal echo b. Biventricular pacing c. Implantable cardioverter defibrillator d. Cardiac catheterization

Initial Conservative strategy Additional Management considerations

Conservative Rx  Hospital Care 2011 Focused update For USA/NSTEMI patients in whom an initial conservative strategy is selected if recurrent symptoms/ischemia, CHF, or serious arrhythmias subsequently appear, then diagnostic angiography should be preformed Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Conservative Rx Hospital Care 2011 Focused update   For patients with USA/NSTEMI treated conservatively without recurrent symptoms, CHF or arrhythmia a stress test should be performed If the pt is not classified as low risk after the stress test then angiography should be performed Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Conservative Rx Hospital Care 2011 Focused update  If at low risk Post Stress Test:     Continue ASA Continue clopidogrel for at least 1 month and ideally up to 1 year Discontinue GP IIb/IIIa inhibitor if started Continue UFH for 48 hours or administer enoxaparin or fondaparinux for the duration of hospitalization up to 8 days and then discontinue Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Pharao gets prescription

Time to use your grey matter   An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine. Physical exam is normal , ECG is below What would you recommend? a. A resting sistamibi scan b. A nuclear stress test c. Intravenous fibrinolytic drug d. Cardiac Cath

Selection of Initial Treatment Wright RS et al. Circ 2011;123;2022-2060.

Time to use your grey matter     An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine. Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9 Which of the following therapies are most appropriate? a. ASA 325 mg daily b. ASA 325 mg daily and clopidogrel 75 mg daily c. ASA 325 mg daily and prasugrel 10 mg OD e. Clopidogrel 75mg OD & IV eptifabatide

Medium to High Risk patients….. Early Hospital Care 2011 Focused update Antiplatelet therapy  Pt with definite USA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dualantiplatelet therapy on presentation (LOE A)   ASA on presentation The second should be given before PCI as follows….. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Medium to High Risk patients….. Early Hospital Care 2011 Focused update Antiplatelet therapy Before PCI:  Clopidogrel (LOE B)  An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide or tirofiban are the preferred agents At the time of PCI:  Clopidogrel if not started before PCI (LOE A)  Prasugrel (LOE B)  An IV GP IIb/IIIa inhibitor (LOE A) Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Time to use your grey matter     An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine. Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin Normal, CTn 2.9 Which of the following therapies are not appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin

Initial Invasive Strategy Anticoagulation

Continue Smiling

Time to use your grey matter     An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine. Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, Creatinin clearance is <30 ml/min, CTn 2.9 Which of the following therapies are not appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin

Time to use your grey matter     An 80 year-old man presented to the ED at 2 AM with a history of intermittent chest pain x 2 days. He is not taking any medicine. Physical exam is normal. Labs: RBS 150 mg%, CBC Normal, BUN & Creatinin normal but there is history of heparin induced thrombocytopenia Which of the following therapies is appropriate? a. IV unfractionated heparin b. Enoxaparin c. Foundaparinux e. Bivalirudin

Hospital Care 2011 Focused update  For patients with USA/NSTEMI in whom CABG is selected post angiography       Continue ASA Discontinue IV GP IIb/IIIa inhibitor 4 hours before CABG Continue UFH Discontinue enoxaparin 12-24 hours before CABG and dose with UFH per institution practice Discontinue fondaparinux 24 hours before CABG and dose with UFH per institution practice Discontinue bivalirudin 3 hours before CABG and dose with UFH per institution practice Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update    In patients taking thienopyridine in whom CABG is planned and can be delayed… Discontinue clopidogrel for at least 5 days Discontinue prasugrel for at least 7 days Unless the need for revascularization and or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding… (LOE C) Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

ACC/AHA Guidelines update 2011 UA/NSTEMI: Long-Term Medical Management UA or NSTEMI at hospital discharge Inhospital management with medical therapy (without stenting) Aspirina 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d for at least 1 mo, ideally up to 1 yr aIf patient is allergic to aspirin, use clopidogrel alone (indefinitely) or try aspirin desensitization. bIf patient is allergic to clopidogrel, use ticlodipine 250 mg PO bid. Inhospital therapy with drug-eluting stent implantation Inhospital therapy with baremetal stent implantation Aspirina 162-325 mg/d for at least 1 mo, then 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d or prasugrel 10 mg/d for at least12 months* Aspirina 162-325 mg/d for at least 3 mo with Sirolimus and 6 mo paclitaxel, then 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d or prasugrel 10 mg/d for at least 12 mo Is an indication for anticoagulation present? If yes: add warfarinc,d Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367 If no: continue dual antiplatelet therapy cContinue aspirin indefinitely and warfarin long term, if indicated for specific conditions. dIf warfarin is added to aspirin and clopidogrel, the recommended INR is 2.0-2.5.

Dear Doctor!

Evaluating Recurrent Risk Secondary Prevention Strategies Broad Goals during Hospital discharge phase   Prepare the patient for normal activities Use the acute event as an opportunity to reevaluate the plan of care - lifestyle and risk factor modification Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Can U Revise

Evidence based medicine Take all these pills daily until a new clinical trial is published

Questions? No questions? Good! Then let’s go home & try some herbal Rx

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