Acute Myocardial Infarction(Acute MI)

Prof. Arthur Pollak, M.D.

Director, Acute Cardiac Care Center

Director of Clinical Research

Heart Institute

Hadassah – Hebrew University Medical Center

Atherosclerosis is a Generalized Disease

Atherosclerosis is a Generalized Disease

REGION MEDIAN AGE, WOMEN MEDIAN AGE, MEN

Western Europe 68 (59-76) 61 (53-70)

Central and eastern Europe 68 (59-74) 59 (50-68)

North America 64 (52-75) 58 (49-68)

South America and Mexico 65 (56-73) 59 (50-68)

Australia and New Zealand 66 (59-74) 58 (50-67)

Middle East 57 (50-65) 50 (44-57)

Africa 56 (49-65) 52 (46-61)

South Asia 60 (50-66) 52 (45-60)

China and Hong Kong 67 (62-72) 60 (50-68)

Southeast Asia and Japan 63 (56-68) 55 (47-64)

Comparison of Age at First Myocardial Infarction Among Women and Men Across Geographic Regions

Yusuf S: The INTERHEART Study. Lancet 2004;364:937

Age distribution in Hadassah CCU

RISK FACTORS FOR CAD

0

40

80

Hypertension DiabetesMellitus

Obesity FamilyHistory

WOMENMEN

NUMBER OF CORONARY ARTERIES OCCLUDED > 80%

0

15

30

45

0 1 2 3 4

WOMEN

MEN

NUMBER OF CORONARY ARTERIES INVOLVED

The Effect of Race & Sex on Physicians’ Recommendations for Cardiac

Catheterization

Refer. Rate (%) OR P Value

Sex Men 90.6 1.0 0.02 Women 84.7 0.6

Race White 90.6 1.0 0.02 Black 84.7 0.6

Referral for Catheterization

Race & sex influence how physicians interpret & manage chest pain

Schulman KA, et al. NEJM 1999;340:618-616

Atheroma Morphology by Ultrasound

“Soft” Lipid-Laden Plaque “Hard” Fibrous Plaque

Plaque RupturePlaque Rupture

Acute coronary syndromesAcute coronary syndromes

AP/SB

Acute anterior wall MI The Normal Heart

AP/SB

Recent large Antero-Septal

Myocardial Infarction

Ebers Papyrus

• Typical Chest Painpressure, heaviness, burning irradiation to arms, neck, jaw, upper abdomen,

sometimes to the back• Shortness of breath

pulmonary congestion → pulmonary edema• Nausea, Vomiting• Cold sweating• Dizziness → look for arrhythmias• Anxiety, fear of death (!)

Obtain ECG as quickly as possible (< 10 min) !

• Typical Chest Painpressure, heaviness, burning irradiation to arms, neck, jaw, upper abdomen,

sometimes to the back• Shortness of breath

pulmonary congestion → pulmonary edema• Nausea, Vomiting• Cold sweating• Dizziness → look for arrhythmias• Anxiety, fear of death (!)

Obtain ECG as quickly as possible (< 10 min) !

Clinical PresentationClinical Presentation

Physical examinationPhysical examination

• Pallor• Cold and clammy extremities• Cold sweat on forehead and palms• Bilateral crackles / crepitations / rales

on lung auscultation (mostly basal)• Muffled heart sounds, sometimes S4• Apical systolic murmur → look for

mitral regurgitation• Pulse: tachycardia , bradycardia• Blood pressure: high , low

• Pallor• Cold and clammy extremities• Cold sweat on forehead and palms• Bilateral crackles / crepitations / rales

on lung auscultation (mostly basal)• Muffled heart sounds, sometimes S4• Apical systolic murmur → look for

mitral regurgitation• Pulse: tachycardia , bradycardia• Blood pressure: high , low

ECG on admission:Anterior ST segment elevation

Thrombolysis

Importance of time to reperfusionin patients undergoing PPCI for STEMI

Importance of time to reperfusionin patients undergoing PPCI for STEMI

NCDR - National Cardiovascular Data Registry (USA)

Cannon CP. JAMA 2000;283:2941 ;; Rathore SS. BMJ 2009;338:b1807

Importance of time to reperfusionin patients given fibrinolysis for STEMI

Importance of time to reperfusionin patients given fibrinolysis for STEMI

NCDR - National Cardiovascular Data Registry (USA)

Cannon CP. JAMA 2000;283:2941 ;; Rathore SS. BMJ 2009;338:b1807

Time to thrombolysis and 35-day mortality

STEMI – time is muscleSTEMI – time is muscle

Reperfusion TherapyReperfusion Therapy

• Primary Percutaneous Coronary Intervention (PPCI) – preferred! (especially in cardiogenic shock, heart failure, arrhythmia, late presentation)

• Thrombolytic Therapy – Fibrinolysis – if early!Tissue Plasminogen Activator (tPA)Streptokinase Risk of Bleeding → Contraindications:

History of Intracranial Hemorrhage History of Ischemic Stroke within 3 months Cerebral vascular malformation or intracranial malignancy Suspected Aortic Dissection Active bleeding or known bleeding diathesis Significant closed-head or facial trauma within 3 months Traumatic or prolonged (>10 min) cardiac resuscitation

Coronary Angiogram

12

5

6

7

9

10

3

4

8

LAD

LCXRCA

11

12

13

14

15

Thrombolysis

Angioplasty

Isolated LAD Lesion

Reperfusion TherapyReperfusion Therapy

• Primary Percutaneous Coronary Intervention (PPCI) – preferred! (especially in cardiogenic shock, heart failure, arrhythmia, late presentation)

• Thrombolytic Therapy – Fibrinolysis – if early!Tissue Plasminogen Activator (tPA)Streptokinase Risk of Bleeding → Contraindications:

History of Intracranial Hemorrhage History of Ischemic Stroke within 3 months Cerebral vascular malformation or intracranial malignancy Suspected Aortic Dissection Active bleeding or known bleeding diathesis Significant closed-head or facial trauma within 3 months Traumatic or prolonged (>10 min) cardiac resuscitation

TIMI grade 3 coronary flow isassociated with improved survival

Medical therapy (initial)Medical therapy (initial)

• Oxygen (if O2 saturation < 95%)• Aspirin (300-325 mg) to be chewed• Sublingual Nitroglycerine (tablets or spray)• Morphine sulfate (2-4 mg) I.V. (intravenous)• Furosemide (40 mg) if pulmonary congestion• Beta blocker (5 mg metoprolol I.V., repeat X3)• High-dose statin (atorvastatin 80 mg orally)• Treat ventricular arrhythmia promptly (!)

Obtain blood for cardiac biomarkers (Troponin-T, CPK, hemoglobin, electrolytes, coagulation, kidney and liver function)

• Oxygen (if O2 saturation < 95%)• Aspirin (300-325 mg) to be chewed• Sublingual Nitroglycerine (tablets or spray)• Morphine sulfate (2-4 mg) I.V. (intravenous)• Furosemide (40 mg) if pulmonary congestion• Beta blocker (5 mg metoprolol I.V., repeat X3)• High-dose statin (atorvastatin 80 mg orally)• Treat ventricular arrhythmia promptly (!)

Obtain blood for cardiac biomarkers (Troponin-T, CPK, hemoglobin, electrolytes, coagulation, kidney and liver function)

Adding Clopidogrel to Aspirinin STEMI (COMMIT trial)

Adding Clopidogrel to Aspirinin STEMI (COMMIT trial)

TRITON – TIMI 38:patients with ACS undergoing PCI

TRITON – TIMI 38:patients with ACS undergoing PCI

Wiviott SD. TRITON – TIMI 38. N Engl J Med 2007;357:2001

13,608 patients (10,074 UA/NSTEMI ; 3,534 STEMI)

TRITON – TIMI 38:patients with STEMI undergoing PCI

TRITON – TIMI 38:patients with STEMI undergoing PCI

K-M estimate of time to first primary efficacy event (composite of CV death, MI or stroke)

No. at risk

Clopidogrel

Ticagrelor

9,291

9,333

8,521

8,628

8,362

8,460

8,124

Days after randomisation

6,743

6,743

5,096

5,161

4,047

4,147

0 60 120 180 240 300 360

121110

9876543210

13

Cu

mu

lati

ve in

cid

ence

(%

)

9.8

11.7

8,219

HR 0.84 (95% CI 0.77–0.92), p=0.0003

Clopidogrel

Ticagrelor

K-M = Kaplan-Meier; HR = hazard ratio; CI = confidence interval

Wallentin et al. NEJM 2009;361:1045-57

NNT = 54

18,624 patients (10,174 UA/NSTEMI ; 8,430 STEMI)

15% RRR

Medical therapy (advanced)Medical therapy (advanced)

• 2nd antiplatelet (ADP-receptor antagonist)Prasugrel, Clopidogrel, Ticagrelor

• Anticoagulant therapyUnfractionated heparin (4000-5000 units) I.V.

• Glycoprotein IIb/IIIa inhibitors, I.V. (provisional)Tirofiban (Aggrastat)Eptifibatide (Integrilin)

• Bivalirudin (in patients undergoing PPCI)• Low-molecular weight heparin (LMWH) – for

patients not managed by PPCI / thrombolysisEnoxaparin, Fondaparinux

• 2nd antiplatelet (ADP-receptor antagonist)Prasugrel, Clopidogrel, Ticagrelor

• Anticoagulant therapyUnfractionated heparin (4000-5000 units) I.V.

• Glycoprotein IIb/IIIa inhibitors, I.V. (provisional)Tirofiban (Aggrastat)Eptifibatide (Integrilin)

• Bivalirudin (in patients undergoing PPCI)• Low-molecular weight heparin (LMWH) – for

patients not managed by PPCI / thrombolysisEnoxaparin, Fondaparinux

TIMI risk score for STEMITIMI risk score for STEMI

MI complications: Heart FailureMI complications: Heart Failure

• Dilation of the ventricle – “remodeling”• Increased wall stress• Reduced ejection fraction• Reduced functional capacity• Fluid overload (pulmonary congestion,

peripheral edema, pleural effusion)• Look for Mitral Regurgitation (MR)• Therapy: ACE inhibitors, Beta blockers,

spironolactone, diuretics, digoxin

• Dilation of the ventricle – “remodeling”• Increased wall stress• Reduced ejection fraction• Reduced functional capacity• Fluid overload (pulmonary congestion,

peripheral edema, pleural effusion)• Look for Mitral Regurgitation (MR)• Therapy: ACE inhibitors, Beta blockers,

spironolactone, diuretics, digoxin

Impact of left ventricular functionon survival following MI

Impact of left ventricular functionon survival following MI

Volpi A. GISSI-2 database. Circulation 1993;88:416

MI complications: ArrhythmiasMI complications: Arrhythmias

• Ventricular tachycardia / fibrillationPrompt DC shock

• Bradycardia:Sinus bradycardia , AV block – inferior MIAtropin, Dopamine, Pacemaker

• Tachycardia:Sinus tachycardiaAtrial fibrillationTreat heart failure

• Ventricular tachycardia / fibrillationPrompt DC shock

• Bradycardia:Sinus bradycardia , AV block – inferior MIAtropin, Dopamine, Pacemaker

• Tachycardia:Sinus tachycardiaAtrial fibrillationTreat heart failure

MI complications: PericarditisMI complications: Pericarditis

• Acute post MI pericarditisAnti-inflammatory drugs, NSAID

• Dressler syndromeAnti-inflammatory drugs, steroids

• Acute post MI pericarditisAnti-inflammatory drugs, NSAID

• Dressler syndromeAnti-inflammatory drugs, steroids

Cardiac Rupture Syndrmes Complicating STEMI

FreeWallRupture –Tamponadewith Shock

VentricularSeptalRupture –VSD withRt. To Lt.Shunt

PapillaryMuscleRupture –withSevereMitralRegurgitation

MI complications: RuptureMI complications: Rupture

• Intra-aortic balloon pump (IABP)• If tamponade – prompt pericardiocentesis• Urgent surgery

• Intra-aortic balloon pump (IABP)• If tamponade – prompt pericardiocentesis• Urgent surgery

Therapy on dischargeTherapy on discharge

• Healthy life-style• Aspirin• 2nd antiplatelet• ACE-inhibitor• Beta-blocker• Statin (high dose)• Cardiac rehabilitation• Risk factor control (smoking, diabetes,

hypertension, obesity, hyperlipidemia, etc.)

• Healthy life-style• Aspirin• 2nd antiplatelet• ACE-inhibitor• Beta-blocker• Statin (high dose)• Cardiac rehabilitation• Risk factor control (smoking, diabetes,

hypertension, obesity, hyperlipidemia, etc.)

Trends in in-hospital drug therapy over 10 years: following the guidlines

Trends in in-hospital drug therapy over 10 years: following the guidlines

Data from ACSIS: Acute Coronary Syndrome Israeli Survey

Trends in outcome over 10 years:Mortality and MACE

Trends in outcome over 10 years:Mortality and MACE

Data from ACSIS: Acute Coronary Syndrome Israeli Survey

Thank youThank you

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