coronary syndromes

Coronary syndromesGiuseppe Biondi-Zoccai, MD

Sapienza University of Rome, Italygiuseppe.biondizoccai@uniroma1.it

Learning goals

• Preamble• Definitions• Impact• Approach• Management

Learning goals

• Preamble• Definitions• Impact• Approach• Management

Time machine

Teixera et al, Int J Cardiol 2013

Myocardial infarction in the 60’s

Myocardial infarction today

Learning goals

• Preamble• Definitions• Impact• Approach• Management

Differential diagnosis of coronary syndromes

• Asymptomatic CAD• Chronic stable angina• Unstable angina• Acute myocardial infarction

In addition:• Ischemic cardiomyopathy• Sudden ischemic cardiac death• Myocardial ischemia due to spasm or mismatch

Wijns et al, Eur Heart J 2010

From diagnosis to risk stratification

http://en.wikipedia.org/wiki/Acute_coronary_syndrome

Third universal definition of myocardial infarction

• Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following:– Symptoms of ischemia.– New or presumed new significant ST-segment–T wave (ST–T)

changes or new left bundle branch block (LBBB).– Development of pathological Q waves in the ECG.– Imaging evidence of new loss of viable myocardium or new

regional wall motion abnormality.– Identification of an intracoronary thrombus by angiography or

autopsy.

Thygesen et al, Eur Heart J 2012

Third universal definition of myocardial infarction: subtypes

Thygesen et al, Eur Heart J 2012

Third universal definition of myocardial infarction: subtypes

• 1 - Spontaneous MI: related to plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in one or more of the coronary arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis.

• 2 - Secondary MI: In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. spasm, anemia, etc.

• 3 - Fatal MI: Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB.

Thygesen et al, Eur Heart J 2012

Third universal definition of myocardial infarction: subtypes

• 4a – Related to PCI: >5 x 99th percentile URL in patients with normal baseline values (>99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, symptoms, new ischemic ECG changes, angiographic loss of patency, or imaging demonstration of MI.

• 4b – Related to stent thrombosis: angiography or autopsy evidence and cardiac biomarkers values with at least one value above the 99th percentile URL.

• 5 – Related to CABG: cardiac biomarker values >10 x 99th percentile URL. In addition, new pathological Q waves or new LBBB, or angiographic documented new graft or new native coronary artery occlusion, or imaging evidence of MI.

Thygesen et al, Eur Heart J 2012

Learning goals

• Preamble• Definitions• Impact• Approach• Management

Stable CAD in diabetics

Farkouh et al, New Engl J Med 2012

Stable CAD

Farkouh et al, New Engl J Med 2012

MAC

CE (%

)

Stable CAD in diabetics

Farkouh et al, New Engl J Med 2012

Medically managed ACS

Roe et al, New Engl J Med 2012

Invasively managed ACS

Wallentin et al, New Engl J Med 2009

Card

iova

scua

lr de

ath,

M

I, or

stro

ke (

%)

STEMI

Montalescot et al, Lancet 2012

Card

iova

scua

lr de

ath,

M

I, or

stro

ke (

%)

Learning goals

• Preamble• Definitions• Impact• Approach• Management

High-sensitivity troponins

Thygesen et al, Eur Heart J 2012

Ischemic scores

Discrimination (c statistic)

D’Ascenzo et al, Contemp Clin Trials 2012

Bleeding scores

www.crusadebleedingscore.com

SYNTAX score

www.syntaxscore.com

SYNTAX score

www.syntaxscore.com

SYNTAX score

Farooq et al, Lancet 2013

Learning goals

• Preamble• Definitions• Impact• Approach• Management

Radial access

Romagnoli et al, J Am Coll Cardiol 2012

Prehospital thrombolysisDe

ath,

shoc

k, C

HF, o

r rei

nfar

ction

(%)

Armstrong et al, New Engl J Med 2013

Bivalirudin

NAC

E (%

)M

ACE

(%)

Kastrati et al, New Engl J Med 2008

Prasugrel

Wiviott et al, New Engl J Med 2008

Cardiovascular death, MI or stroke

Non-CABG-related TIMI major bleeding

TicagrelorVascular death, MI or stroke Major bleeding

Months Months

Wallentin et al, New Engl J Med 2009

Adjusted indirect comparison

Biondi-Zoccai et al, Int J Cardiol 2011

CangrelorSt

ent t

hrom

bosis

(%)

Bhatt et al, New Engl J Med 2013 (57% CSA, 25% NSTEACS, 18% STEMI)

Rivaroxaban

Mega et al, New Engl J Med 2012

Beta-blockers

Bangalore et al, JAMA 2012

Card

iova

scul

ar d

eath

, M

I or s

trok

e (%

)

Statins

Patti et al, Circulation 2011

Fractional flow reserve

De Bruyne et al, New Engl J Med 2012

CABG or PCI?

Mohr et al, Lancet 2013

Off-pump vs on-pump CABG

Palmerini et al, J Am Coll Cardiol 2012; Palmerini et al, Am Heart J 2013

Drug-eluting stents

Palmerini et al, Lancet 2012

Drug-eluting stents

Palmerini et al, Lancet 2012

Drug-eluting balloons

Byrne et al, Lancet 2013

Bioresorbable stents

Palmerini et al, Lancet 2012

Bioresorbable stents

Serruys et al, Lancet 2009

Take home messages• Developments in the field of coronary syndromes

represent an outstanding example of the successful combination of pathophysiologic, diagnostic, prognostic, pharmacologic and device research.

• Despite the dramatic prognostic improvement, several issues remain unsettled.

• In addition, the worsening plethora of management options will make the treatment of individual patients more and more complex, unless risk-beneficial and cost-beneficial tailoring tools are developed.

Many thanks for your attention

For these slides and further ones on similar topics feel free to visit:

www.metcardio.org/slides.html

For additional details or queries feel free to contact me directly:

giuseppe.biondizoccai@uniroma1.it