Dione Nordby MSN, RNInterim Nurse Educator, St. Paul’s Hospital, Cardiac Intensive Care Unitdnordby@providencehealth.bc.ca

Acute Coronary Syndrome (ACS): Survival of the Species

ACS: Objectives

* The basics: coronary anatomy, ischemia, MI

* Pathophysiology of ACS

* Unpack ACS – What does it all mean?

U/A, NSTEMI, STEMI

* Discuss risk stratification methods for ACS

* Identify drugs used to treat and manage ACS

ACS: Coronary anatomy

RCA“inferior” RA/RVSA node (55%)AV node (90%)Tricuspid valveLV (posterior)

LCx“lateral”LASA node (45%)LV (posterior)MV

LAD“anterior”

Left/Right bundle LV (anterior)

APEX Septum

ACS basics: Ischemia

Critical ischemia

This deprives the heart muscle (myocardium) of blood and oxygen.

Irreversible cell death

Myocardial tissue dies and necroses

ACS basics: Myocardial infarction

Acute MI: Pathogenesis

ACS : atherosclerosis and CAD

The vulnerable plaque concept!

Plaque erosion OR Plaque rupture

ACS : atherosclerosis

ACS: What does it all mean?

A spectrum…

Non-ST Elevation MI (NSTEMI)

Unstable angina

ST Elevation MI (STEMI)

ACS : Unstable angina

* Symptoms of myocardial ischemia

* Typical versus Atypical

* Angina at rest or with minimal exertion, or increasing frequency

* Usually no ECG changes/ or transient

* Negative troponin

* Lower risk for complications/mortality

ACS: NSTEMI* Symptoms of myocardial ischemia- may be worse than UA

* Non-specific ECG changes or ST depression

* Positive troponin

* Intermediate/high/higher risk of complications/death

ACS : STEMI* Symptoms of myocardial ischemia – usually significant

* ST elevation on ECG

* Positive troponin

* Highest risk of complications/death

ACS : A spectrum

UA NSTEMI STEMI

ACS : Survival of the Species

78 yr old women c/o sudden central chest pain and nausea…What do we do?

Morphine?Oxygen?Nitrates?Aspirin

ACS : STEMI Treatment* RAPID REPERFUSION!!!* Monitor in critical care* Medical therapy: anticoagulation! + others…* Risk factor counseling

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.

ACS : STEMI 2013 ACCF/AHA STEMI guidelines

ACS : PCI vs Lytic

Which would you rather receive?

ACS : PCI vc Lytic

It depends…

* PCI has better short and long term outcomes (most of the time)

< 120 mins from first medical contact

2013 ACCF/AHA STEMI guidelines

ACS : UA & NSTEMI - Treatment

* Risk stratification- Who needs what?

-TIMI risk score

-Grace risk model

* Continuous ECG monitoring

* Observe for complications

* Appropriate medical therapy

* Referral for risk factor counseling

ACS : Risk stratification scores

* Age ≥65 years* Presence of at least three risk factors for coronary heart disease (CHD)* Prior coronary stenosis of ≥50 percent* Presence of ST segment deviation on admission ECG* At least two anginal episodes in prior 24 hours* Elevated serum cardiac biomarkers* Use of aspirin in prior seven days

* Age

* Killip class

* Systolic blood pressure

* Presence of ST segment deviation

* Cardiac arrest at presentation

* Serum creatinine concentration

* Presence of elevated cardiac biomarkers

* Heart rate

TIMI SCORE GRACE RISK SCORE

ACS : TIMI what?

Antman EM, Cohen M, Bernink PJ, et. al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835-42.

ACS : UA & NSTEMI – Treatment strategies

* Urgent Invasive (< 2 h)VERY HIGH RISK!!!

* Early Invasive (within 24 h)HIGH RISK!!

* Delayed Invasive (24-72h)INTERMEDIATE RISK!

* Conservative/Ischemia-guidedLOW RISK

…then continuous risk stratification!!!

ACS: Medical Therapy

General principles:

* Similar NSTEMI/STEMITHE BIG FIVE !

* The higher risk the patient, the the greater the overall benefit derived

ACS : Medical therapy

Antiplatelet therapy:

*ASA 162- 325mg… then 81-325 mg daily

*P2Y12 inhibitor

LOAD: Plavix 300 - 600mg as early as possible (less or none if lytic and older)

OR Ticagrelor 180mg…

MAINTENANCE: for at least a year!Plavix 75 mg dailyTicagrelor 90 mg BID

PLATO TRIAL: N Engl J Med 2009; 361:1045-1057 September 10, 2009 DOI: 10.1056/NEJMoa0904327

ACS : Medical therapy

Anticoagulation:

NSTEMI

*enoxaparin s/c until d/c or PCI*UFH for 48h or PCI*Bivalirudin until PCI (early invasive)

STEMI & Fibrinolysis

*enoxaprin s/c min. 48h or d/c*UFH

STEMI & PCI

*UFH until PCI

* Bivalirudin (esp. if high bleeding risk)

GP IIa/IIIb may be considered in some patients

ACS : Medical therapy

Beta blockers (eg. metoprolol, bisoprolol)

heart ratespeed of AV conductionforce of contraction

Decreased MVO2 demand and increased supply!

* Within 24 hour of admission* PO daily, BID, TID (Unless contraindicated)

ACEI (eg. ramipril, perindopril)

Angiotensin I Angiotensin II Decreased afterload + decreased preload

mortalitymajor eventventricular remodeling

* Within 24 hours of admission * PO BID, TID

*ARB if contraindicated or intolerant

ACS : Medical therapy RAAS Inhibitors

ACS : Medical therapy

Statins: FOR EVERYONE! (eg. atorvastatin) Block production of cholesterol in liver

recurrent MICAD mortalityneed for revascularizationstroke

* On admission to hospital* PO daily

ACS : Secondary Prevention – YOU!!!

* Cardiac Rehab!

* Risk factor counseling(ie: defining patient specific risk factors )

* Ensuring patients are aware revascularization does not mean CURE!

ACS : Recovery

ACS : Survival of the Species

QUESTIONS?

ACS : Survival of the Species

Do all patients presenting with ischemia have chest pain?

You said aspirin significantly reduces mortality, why is it a risk factor for the TIMI risk score?

Is there a preferred choice of medication for fibrinolytic administration?

Additional recommended resources

Amsterdam, E. A. et al. (2014). 2014 AHA/ACC guideline forthe management of patients with Non-ST-Elevation acute coronary syndromes. Circulation, 1(30), e344-e426. doi:10.1161/CIR.00000000000001 34

O’Gara, P. T. et al. (2013). 2013 ACCF/AHA guideline for the management of ST-Elevation myocardial infarction. Circulation, 1(27). e362-e425.doi:1016/CIR.0601 3e3182742cf6