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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
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Atherosclerosis is a Generalized Disease
Atherosclerosis is a Generalized Disease
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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
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Age distribution in Hadassah CCU
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RISK FACTORS FOR CAD
0
40
80
Hypertension DiabetesMellitus
Obesity FamilyHistory
WOMENMEN
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NUMBER OF CORONARY ARTERIES OCCLUDED > 80%
0
15
30
45
0 1 2 3 4
WOMEN
MEN
NUMBER OF CORONARY ARTERIES INVOLVED
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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
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Atheroma Morphology by Ultrasound
“Soft” Lipid-Laden Plaque “Hard” Fibrous Plaque
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Plaque RupturePlaque Rupture
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Acute coronary syndromesAcute coronary syndromes
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AP/SB
Acute anterior wall MI The Normal Heart
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AP/SB
Recent large Antero-Septal
Myocardial Infarction
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Ebers Papyrus
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• 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
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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
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ECG on admission:Anterior ST segment elevation
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Thrombolysis
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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
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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
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Time to thrombolysis and 35-day mortality
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STEMI – time is muscleSTEMI – time is muscle
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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
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Coronary Angiogram
12
5
6
7
9
10
3
4
8
LAD
LCXRCA
11
12
13
14
15
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Thrombolysis
Angioplasty
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Isolated LAD Lesion
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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
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TIMI grade 3 coronary flow isassociated with improved survival
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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)
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Adding Clopidogrel to Aspirinin STEMI (COMMIT trial)
Adding Clopidogrel to Aspirinin STEMI (COMMIT trial)
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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)
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TRITON – TIMI 38:patients with STEMI undergoing PCI
TRITON – TIMI 38:patients with STEMI undergoing PCI
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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)
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15% RRR
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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
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TIMI risk score for STEMITIMI risk score for STEMI
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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
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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
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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
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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
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Cardiac Rupture Syndrmes Complicating STEMI
FreeWallRupture –Tamponadewith Shock
VentricularSeptalRupture –VSD withRt. To Lt.Shunt
PapillaryMuscleRupture –withSevereMitralRegurgitation
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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
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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.)
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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
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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
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Thank youThank you
View of the Hadassah – Hebrew University Medical Center