Acute coronary syndrome

Warong Lapanun MD.Bhumibol Adulyadej Hospital

6/2/2011

Mr PM: 54-y-o presenting at a non-PCI hospital

• 12.00 Myalgia and fatigue Epigastric fullness for 2 hrs

• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferior wall+ RVMI BP 90/40 mmHg

•Nearest cath lab 40 min away

Transfer for primary PCI Lysis on Site Lysis with immediate transfer to cath lab

Which type of Lytic Rx will be selected?

McNamara et al. JACC. 2006;47:2180-6.

Door-to-Balloon Time (minutes)

3.04.2

5.7

7.4

0

5

10

15

20

90 91-120 121-150 150

p < 0.01

><

Mo

rtal

ity

%

n = 29,222

Pinto et al. Circulation. 2006;114:2019-2025

192, 509 pts at 645 NRMI hospitals

• 43801 pts STEMI PPCI• ACC registry 2005-2006• In hospital Mortality• Median D2B 83 min.• Overall MR 4.6%

Rathor SS,et al. BMJ2009:338;1807

•D2B Mortality( P<0.001)

• 30 min = 3.0%• 60 min = 3.5%• 90 min = 4.3%• 120 min = 5.6%• 180 min = 8.4%

Rathor SS,et al. BMJ2009:338;1807

Mortality Reduction(%)

8

4

6

2

0

1 3 6 12 24

10

A

D

E

C

B

Hr

Time to Rx is Critical Opening the artery is 1o Goal ( PCI>lysis)

Gersh BJ et al. JAMA 2005;293:979-986

Potential outcomes

A-B : No benefit

A-C : Benefit

B-C : Benefit

E-D : Harm

Francone M, et al.JACC2009;23:2145

Infarct size Myocardial Edema

Myocardial Salvage Microvascularobstruction

SK r-tPA TNK

TIMI flow gr 3 ~30% ~50% ~60%

Fribrinolytic Characteristic

Boden et al. JACC 2007,50;10. 923

Risk Factors Age > 75 yr Black race Female Hx of stroke SBP > 160 mmHg Wt <65(w),<80(m) INR>4 Use of rt-PA

Risk Score ICH(%)0-1 0.69

2 1.023 1.634 2.49>5 4.11

Bonnefoy, E. et al. Eur Heart J 2009 30:1598-1606

<2 hrs

>2 hrs

CAPTIM: 5 Year Survival

Prehospital Thrombolysis vs Primary PCI

Su

rviv

al o

f P

roab

ility

PPCI

Prehosp lysis

Prehosp lysis

PPCI

35.9

26.8

23.4

16.1

12.4

7.3

4.42.21.60.8

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 6 7 8 >8

Antman et al Circulation 2000;102:2031-7

Historical Points

Age > 75 3

65-74 2

DM or HT or 1

Angina

Exam.

SBP<100 3

HR >100 2

Killip II-IV 2

Wt < 67kg 1

Presentation

Ant. STE or LBBB 1

Time to Rx > 4 hr 1

Points

%

Benjamin M. Scirica JACC 2010;55;1403-1415

ST Resolution

Primary PCI Rescue PCI Facilitated PCI Pharmaco-invasive

without PCI capability who cannot be

transferred and PCI within 90 min of FMC

should be Rx with Lytic Rx within 30 min,

unless Lytic Rx is contraindicated.

with PCI capability should be Rx with p-

PCI within 90 min of FMC .

IIbI IIa III

A

B

Modified

Modified

FMC: First Medical Contact

STEMI within 12 h after onset of symptoms At centre without PCI facilities with

>1 high risk features:1. Cumulative ST-segment elevation of > 15 mm 2. New onset LBBB3. Previous MI4. Killip class of 2 or more or 5. LV ejection fraction of 35% or less.

Carlo Di Mario, Lancet 371 February 16, 2008

Carlo Di Mario, Lancet 371 February 16, 2008

Cantor WJ et al. N Engl J Med 2009;360:2705-2718

Pts with STEMI within 12 hrs after onset of symptoms At centers : No PCI capability Rx with Tenecteplase (TNK) ST-segment elevation of ≥ 2 mm in two anterior leads or ST-segment elevation of ≥ 1 mm in two inferior leads and

One high-risk characteristics:1. Systolic BP < 100 mm Hg,2. HR > 100 bpm,3. Killip class II or III, 4. ST- depression of ≥ 2 mm in the anterior leads, or 5. ST- elevation of ≥ 1 mm in V4R indicative of RV

involvement.

* ST segment resolution < 50% & persistent chest pain, or hemodynamic instability

Failed Reperfusion* Successful Reperfusion

Cath / PCI within 6 hrs regardless of reperfusion

status

Cath and Rescue

PCI GP IIb/IIIa

Inhibitor

Elective Cath

PCI

> 24 hrs later

Community

Hospital

Emergency

Department

TNK + ASA + Clopidogrel +

Heparin or Enoxaparin

Pharmacoinvasive :

Urgent PCI Centre

Standard Strategy:

Assess chest pain, ST resolution

at 60-90 min after randomization

Randomization

PCI Centre

High Risk STEMI 12 hrs, 1059 Pts

TRANSFER AMI

Cantor WJ et al. N Engl J Med 2009;360:2705-2718

Kaplan-Meier Curves

Cantor WJ et al. N Engl J Med 2009;360:2705-2718

*Primary endpoint was death, reinfarction, recurrent ischemia,

new or worsening heart failure, or cardiogenic shock at 30 days

Primary Endpoint* at 30 Days Re-infarction at 6 MonthsStd Rx

Early PCIEarly PCI

Std Rx

Verheugt, NEJM 2009; 360, 26: 2779-2781

Pharmacoinvasive

Facilitated PCI

No Class III

ER physician activate the Cath Lab One call activate the cath lab Cath lab team ready in 20-30 min Prompt data feed back Senior management commitment Team-based approach

รอบัตร รอแพทย์ตรวจ

ท ำ EKGใน 10 นำที

แพทย์เวร ER

ปรึกษำ staff cardio ผ่ำน single

call operator, rtafheart@gmail.com

ส่งท ำ PCI

ผู้ป่วยเจ็บหน้ำอก

แพทย์เวร Med

Fellow cardio

ตำมเจำ้หน้ำที่ Cath Lab

Time to Lab

PCI-Center

Fast Track MI

EKG ด่วนแพทย์ดูใน 10 นำที

ST elevation ตำม staff cardio ทันที

No ST elevation ………………. MD.

European Heart Journal (2008) 29, 2909–2945

ESC GUIDELINES

ESC PCI Guidelines 2O10

Mr PM: 54-y-o presenting at a non-PCI hospital

• 12.00 Myalgia and fatigue Epigastric fullness for 2 hrs

• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferior wall+ RVMI BP 90/40 mmHg

•Nearest cath lab 30 min away

Transfer for PPCI 14.30 Lab 100% Prox. RCA Clot aspiration 14.50 Balloon Stent 4.0x20 mm Final TIMI III flow

Oxygen,NTG, Morphine ASA / Clopidrogrel /Prasugrel/Ticangrelor Heparin/ LMWH/ Fonda GP IIb IIIa antagonist Lab Echo IABP CAG / PCI : Early or Late

Benjamin M. Scirica JACC 2010;55;1403-1415

Thygesen et al,Circulation November 27, 2007

Universal Definition of MI

Spontaneous AMI

Secondary AMI

Sudden cardiac death

Post PCI : 3x 99%URL

Post CABG : 5x 99%URL URL: upper reference limit

Thygesen et al,Circulation November 27, 2007

Benjamin M. Scirica JACC 2010;55;1403-1415

Goncalves PA, et al. Eu Heart J 2005;26:865

Equally Effective

Prevalence increased RFs:▪ Older age,

▪ Predominance of females

▪ high rate of DM

▪ Smoking and obesity

Use of preventive medications Increasing sensitive Troponin Assay

Robert P, et al. Circulation 2009; 54: 1544

NSTE-ACS

63%

CASPAR: Coronary Artery Spasm in Patients With ACSOng P, et al. JACC 2008; 52:523

Plaque rupture: 80% Plaque erosion/spasm CASPAR study : 448 ACS

pts

~ 25% of ACS: no culprit lesion

~ 50% of no culprit

IC Ach spasm

CCBs / nitrates : may benefit

Endothelial function

OCT Thin-Capped fibroatheromatous ( TCFA)Positive remodeling

Plaque rupture : Rest-onset, Exertion-trigger

Tanaka A. et al. Circulation 2008;118;2368

Thin-capped Thick-capped

Plaque shoulder

Lipid coreLipid core

OCT: Optical Coherence Tomography

Everyone should be on anti-plt and anti-coag Choose Rx Consevative vs Invasive Choose antithrombotic regimen

The strategy selected

Bleeding risk of patients

Strategy selected Pt risk stratification Bleeding vs Ischemic risk Equally

important

Antman. Circulation 2001;103:2310-4

57

Inf. epigastric

artery

89-y-o lady with severe Lt. RAS and TVD

Assess/document bleeding risk in every pt. Avoid crossover : UFH and LMWH Proper doseWt. and renal function Use radial access in pts at high risk of

bleeding Stop anticoag after PCI/ indication? Selective “downstream” use of GPI