Treatment of acute - PowerPoint Presentation

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Treatment of acute coronary syndrome

MUDr. Denisa JahnlováDepartment of CardiologyFN Motol and 2nd Medical Faculty of the Charles University

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Acute coronary syndromes

Pathophysiologic mechanismvulnerabile plaque disruption with superimposed thrombus and subsequent coronary blood flow cessation

with reduced myocardial

supply

→ acute ischemia → necrosisLeading symptom - chest pain2 groups according to ECGPatients with acute chest pain and persistent (20 min) ST-segment elevationThis condition is termed ST-elevation ACS and generally reflects an acute total coronary occlusionMost patients will ultimately develop an ST-elevation myocardial infarction (STEMI)Immediate reperfusion by primary angioplasty or fibrinolytic therapyPatients with acute chest pain but no persistent ST-segment elevationECG changes may include transient ST-segment elevation, persistent or transient ST-segment depression, T-wave inversion, flat T waves or pseudo-normalization of T waves or the ECG may be normalNSTEMI - myocardial necrosisNAP - myocardial ischemia without cell loss, lower risk of death

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EpidemiologyIncidence of NSTEMI higher than incidence of STEMI

In-hospital mortalityHigher in STEMI patients vs. NSTEMI (7 vs. 5%)STEMI - mortality 25-30% (1960s) → 10% (nowadays)6 month mortalitySimilar in both groups (12 vs. 13%)Long-term follow-up Higher in NSTEMI patientsOlder

patientsComorbidities (diabetes mellitus, renal insuficiency)

Generalized

atherosclerosis including multivessel

coronary diseaseSex differences men account for more than 90% of patients with AMI at the age under 40y (a hormonal profile of woman has a protective effect)Age differences in patients aged under 40 years only one coronary artery is affected

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ACS with ST-segment elevationPre-hospital management

Relief of BreathlessnessO2 only to breathless, hypoxic (SaO2<95%), heart failure patient

Relief of painh

uman

reasons, sympathetic activation-vasoconstiction, increases workload of the hearttitrated i.v. opioids (Morphine, Fentanyl) + antiemeticsRelief of anxietyexplain the situation to the patient, tranquillizerBBhypertensive and tachycardic patient metoprolol, bisoprolol, esmololCAVE contraindication: acute cardiac failure, bradycardia

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ACS with ST-segment elevationPre-hospital management

Nitrate pain, hypertesion, heart failuresublingual, intravenous

(isosorbide dinitrate

1-5 mg i.v.

in hypertensive

patients) CAVE! Contraindications: hypotense, sildenafil → resistent hypotension Monitoring vital function and ECGCardiac arrest due to ventricular fibrillation!!!Terminated by defibrillationTheapeutic hypothermia after resuscitation is indicatedImmediate angiography in patients with CA whose ECG shows STEMI/high suspicion on ongoing infarction

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ACS with ST-segment elevation Reperfusion therapy: time is muscle!!!

Indication within 12 h of symptom onset with persistent STE or new LBBB (later → necrosis)in patients

with ongoing ischemia

→

laterwithin 120 minutes of first contact with doctorTypes of RTmechanical (PCI)preferred reperfusion strategy randomized clinical trials → superior to fibrinolysispharmacological (fibrinolysis)

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Prehospital and in-hospital management

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Reperfusion Strategy in Europe

Reperfusion therapy 37-93%pPCI rate varies

between 5 and 92%;

Thrombolysis

0-55%

EUROPE IS VERY HETEROGENOUS!!!

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≥600 p-PCI /

million

/

year

400-599 p-PCI /

million

/

year

200-399 p-PCI /

million

/

year

<

200 p-PCI /

million

/

year

Data not

known

Annual

I

ncidence

of

P

rimary

PCIs

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The distribution of the 22

interventional centers working (24/7) in the Czech RepublicPopulation of the Czech Republic is 10 million

people

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ACS with ST-segment elevation Mechanical

reperfusion therapy - PCIPrimary PCI (pPCI) is reccomended over fibrinolysis within 120 minutes of FMC In unstable patients (acute heart failure/cadiogenic shock) unless related delayStenting (new generation of DES) + tromboaspiration is recommended balloon angiopasty alone

Radial access should be prefered over femoral

access

reduces

incidence of acute bleeding events (RIVAL trial)pPCI should be limited to the culprit vessel except of patients in cardiogenic shock and persistent ischemia after PCI

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Process

of the implantation of stent

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Aspiration trombectomy

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ACS with ST-segment elevationIn-hospital care

– periprocedural pharmacotheraphyDAPT -combination of aspirin + ATP inhibitorsAspirin For all patients without contraindicationsInitial oral loading dose 150-300 mg, 75-100 mg daily

ATP inhibitorsIn addition to Aspirin for 12 months unless contraindications3-6 months afted DES implantation in case of high bleeding risk

Ticagrelor

180 mg loading dose, 90 mg twice daily in all patients with high or intermmidiate ischemic risk

Prasugrel 60 mg loaging dose, 10 mg daily dosecontraindicated in patients with prior stroke and older > 75y. and body weight <60 kgClopidogrel300-600 mg loaging dose,75 mg daly doseOnly in patients who cannot recieve ticagrelor or prasugrel or who require oral antikoagulationPPI inhibitors in patients in risk of gastrointestinal bleeding

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ACS with ST-segment elevationIn-hospital

care – periproceduralpharmacotheraphyUnfractionated heparin (UFH) in patients undergoing PCI70-100 IU/Kg i.v. (max.5000 IU bolus before

PCI)APTT 1,5-2,5xLMWH (low

molecular

weight heparin)0,5 mg/kg i.v. followed by 1 mg/kg s.c.Fondaparinux is not recommended!Glykoprotein IIb/IIIa inhibitorsBailout therapy - only in no-reflow, massive trombus, trombotic complicationsOnly periprocedural!!!

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ACS with ST-segment elevation Pharmacological

reperfusion therapy: FibrinolysisFibrinolysis is an important in those settings where primary PCI cannot be offered to STEMI patients within the recommended timelinesHigher risk of

bleeding, sucesfull

only

in 70-80%

Within 12 h of symptom onset if primary PCI cannot be performed within 120 minPrehospital startA fibrin-specific agent (tenecteplase, alteplase, reteplase) is recommendedAnticoagulation (UFH/enoxaparin) is recommended until revascularization and for the duration of hospital stayDAPT (aspirin + clopidogrel)Transfer to a PCI-capable centre is indicated for all patients following fibrinolysis

Unstable

patients

-

rescue

/

emergency

PCI

Stable

patients

– PCI in 3-24 hod

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Fibrinolysis x PCIMeta-analysis of

23 trials (n=7739 pts.)

Keeley

EC. Lancet 2003

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ACS with ST-segment elevation Management during

hospitalizationThe Coronary Care Unit Management of arrhythmias, heart failure, mechanical circulatory support and complex (non)invasive and haemodynamic monitoring

Patients should stay on coronary care unit

for

2-3 days (at least 24 hours)Standard cardiology departmentEven after leaving the CCU patients are able to move around the room and in the following days rehabilitate and before discharge they are able to walk up the stairsThe total length of hospitalization is around 1 weekReturn to job possible approximately one month after the onset of the symptoms

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ACS with ST-segment elevation Management at discharge

Low-risk patients with successful pPCI could safely be discharged from hospital at day 3 age <70 yearsLVEF > 45% 1 or 2 VDsuccessful PCIno persistent arrhythmias

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ACS with ST-segment elevation Long-term therapies

CAD is a chronic condition and patients who have recovered from a STEMI are at high risk for new events and premature death !!!Most patients with STEMI who die do so after discharge from the index event!

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ACS with ST-segment elevation Long-term therapies- l

ifestyle interventions and risk factor controlcessation of smokingtight blood pressure controldiet and weight controlthe encouragement of physical activity

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ACS with ST-segment elevation Long-term therapies-

pharmacotherapyAntithrombotic therapy DAPT (combination of aspirin + ADP-receptor blocker) for up to 12 months

Aspirin indefinitely (75-100mg)

Tigagrelor

/

prasugrel is reccomended over clopidogrel for 12 monthsBeta-blockers In all patients without contraindications, especially in patients with heart failure and systolic dysfunctionMetoprolol up to 200 mg daily, Carvediol up to 25 mg daily, Bisoprolol up to 10 mg dailyContraindication: in patients in acute phase and heart failure, cardiogenic shock, bradycardiaStatins Lipid-lowering therapyAtorvastatin 40-80 daily, Rosuvastatin 20-40 mg dailyACE inhibitors In all patients without contraindications, especially in heart failure, left ventricular systolic dysfunction, diabetes mellitusRamipril 1,25 mg, Lisinopril 2,5 mg, Enalapril 2,5 mgIn case of intolerance : Valsartan 20 mg twice daily, Losartan, Candesartan is an alternative

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ACS without ST-segment elevation

Patients with acute chest pain but no persistent ST-segment elevationECG changes may include transient ST-segment elevationpersistent or transient ST-segment depressionT-wave inversionflat T waves pseudo-normalization of T waves ECG may be normalThe clinical spectrum of non-ST-elevation ACS (NSTE-ACS) may range from patients free

of symptoms at presentation individuals with ongoing ischaemia

electrical

or haemodynamic instability

cardiac arrestThe pathological correlate at the myocardial level isNSTE-myocardial infarction (NSTEMI)- positive hsTnI, cardiomyocyte necrosisunstable angina –myocardial ischaemia without cell loss, negative hsTnI

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ACS without ST-segment elevationOngoing ischemia

Patients may present with ongoing myocardial ischaemia, characterized by one or more of the following:recurrent or ongoing chest painmarked ST depression on 12-lead ECGheart failure haemodynamic or electrical instabilityImmediate PCI is indicateddue to the amount of myocardium in danger and the risk of malignant ventricular arrhythmias

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ACS without ST-segment elevation- Risk score

and bleeding risk assesmentGrace risk scoreEstimenate the

in-hospital mortality,

mortality

at 6 months, at 1 year and at 3 years

The combined risk of death or MI at 1 yearVariables :ageSystolic blood pressurepulse rateserum creatinine Killip class at presentationcardiac arrest at admissionelevated cardiac biomarkers and ST deviationCrusade bleeding riskEstimate the patient’s likelihood of an in-hospital major bleeding eventbaseline patient characteristicsfemale genderhistory of diabeteshistory of peripheral vascular disease or strokeadmission clinical variables heart ratesystolic blood pressuresigns of heart failureadmission laboratory values haematocritcalculated creatinine clearance

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ACS without ST-segment elevation Pharmacological treatment of ischaemia

Decrease myocardial oxygen demand or increase myocardial oxygen supplyO2only in patients with saturtion less than 90%/in respiratory distressBeta-blockers in patients

with ongoing ischaemic symptoms and without contraindications

N

itrates

i.v. or sublingual to relieve angina, uncontrolled hypertension or signs of heart failureCAVE! Avoid in patients with recent intake of sildenafilOpiatesonly in patients with symtoms despite the theraphy with BB and NitratesIf the patient is not free of signs and symptoms after this treament, immediate PCI is recommended!!!

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ACS without ST-segment elevation Platelet

inhibition DAPT -combination of aspirin + ATP inhibitorsAspirin For all patients without contraindicationsInitial oral loading dose 150-300 mg, 75-100 mg dailyATP inhibitorsIn addition to Aspirin for 12 months unless contraindications3-6 months afted DES implantation in case of high bleeding risk

Ticagrelor 180 mg loading dose, 90 mg twice daily in all patients with high or intermmidiate ischemic risk

Prasugrel

60 mg loaging dose, 10 mg daily dose

contraindicated in patients with prior stroke and older > 75y. and body weight <60 kgClopidogrel300-600 mg loaging dose,75 mg daly doseOnly in patients who cannot recieve ticagrelor or prasugrel or who require oral antikoagulationPPI inhibitors in patients in risk of gastrointestinal bleeding

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ACS without ST-segment elevation Anticoagulation

Unfractionated heparin (UFH) in patients undergoing PCI70-100 IU/kg i.v. (max. 5000 IU bolus berore PCI), APTT 1,5-2,5xFondaparinux The most favourable efficacy – safety profile in NSTEMIInhibition of Xa2.5 mg s.c. daily (CAVE renal insufficiency)OASIS-5 study – less bleeding eventsBolus UFH 70-85 IU/kg during the

procedure (to avoid formation of trombus on cathether) Low molecular weight heparin (LMWH)

In patients pretreated with LMWH

1 mg/kg twice daly (CAVE renal

insufficiency)Continuation after sucesfull PCI for 24 hin conservative treatment during hospital stay

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ACS without ST-segment elevationR

eperfusion strategyPCI + implantation of stent (2nd generation DES) is the method of choiseTiming of PCI according to the risk stratificationFibrinolysis is not reccomended at NSTEMI

CABG (surgical revascularization) More frequently multivessel disease

with no culprit

lesion

Diabetic patientsHigher proportion of surgical high risk charakteristics (x elective CABG)Older ageFemale genderLeft main coronary diseaseLV dysfunctionHigher bleeding and ischemic risk (timing of surgery x DAPT)

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ACS without ST-segment elevationTiming of reperfusion strategy

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ACS without ST-segment elevation Long-term therapies

- pharmacotherapyAntithrombotic therapy DAPT (combination of aspirin + ADP-receptor blocker)

for up to 12 monthsAspirin indefinitely

(75-100mg

)

Tigagrelor/prasugrel is reccomended over clopidogrel for 12 monthsBeta-blockers In patients wih heart failure and systolic dysfunctionMetoprolol up to 200 mg daily, carvediol up to 25 mg daily, bisoprolol up to 10 mg dailyContraindication: in patients in acute phase and heart failureStatins Lipid-lowering therapyAtorvastatin 40-80 daily, Rosuvastatin 20-40 mg dailyACE inhibitors Heart failure, left ventricular systolic dysfunction, diabetes mellitusRamipril 1,25 mg, Lisinopril 2,5 mg, Enalapril 2,5 mg, Valsartan 20 mg twice daily, Losartan, Candesartan is an alternative when intolerance of ACEi is present