managing acute coronary syndromes

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Managing Acute Coronary Syndromes Parul Bagri 3 rd yr PGT General Medicine Chairperson: Dr. Dipankar Ghosh Dastidar

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Page 1: Managing acute coronary syndromes

Managing Acute Coronary Syndromes

Parul Bagri3rd yr PGT

General MedicineChairperson: Dr. Dipankar Ghosh Dastidar

Page 2: Managing acute coronary syndromes

The talk…• UA, NSTEMI, and STEMI

• Risk stratification

• Management– PCI

– Fibrinolytic therapy

– Anti Platelet therapy

– Anti thrombotic

– Adjunctive therapy

– CABG

• Complications in MI

Page 3: Managing acute coronary syndromes

Clinical diagnosis of ACS

12 lead ECGNon diagnostic Diagnostic

serial ECGs at 15- to 30-min

intervals during the first hour

ST elevation or new LBBBor true post.

MI

ST segment depression or T waveinversion

STEMI

TROPONIN T

NSTEMI

+ -

UA

-Measure serial cardiac troponin T at presentation and 3–6 h after symptom onset (I)

-If high/intermediate risk, obtain lead V7 to V9 (IIa) or continuous ECG monitoring (IIb) - TTE

Page 4: Managing acute coronary syndromes

Risk Stratification: TIMI score• Parameters for NSTE-ACS:

1. Age ≥ 65 yrs

2. ≥ 3 CAD risk factors:

1. HTN, hyperlipidemia, diabetes, smoker, family hx of early MI

3. Documented CAD with ≥50% stenosis

4. ST segment deviation

5. ≥ 2 anginal episodes in past 24 hours

6. Aspirin use in the past 1 week (marker for more severe case)

7. Elevation of cardiac enzymes

• Risk: – 0-2: Low 3-4: Intermediate 5-

7: High risk

• GRACE scores, GUSTO score etc.

• Parameters for STEMI1. Age 65- 74 years (2)2. Age ≥ 75 years (3)3. h/o Angina or DM/HTN (1)4. HR >100 bpm (2)5. SBP< 100 mmHg (3)6. Killip class II to IV (2)7. Weight <67 kgs (1)8. Anterior ST elevation or

LBBB (1)9. Time to treatment > 4hrs (1)

• Total score- 14• >9: 30-day mortality 35%• 0-1 : 30-day mortality <2%

Page 5: Managing acute coronary syndromes
Page 6: Managing acute coronary syndromes

Indicationsof primary PCI in STEMI

• Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. (II a)

•Stent placement : either DES or BMS (Class I)

•DES or BMS: depends on bleeding risk and ability to comply with dual anti-platelet therapy (DAPT) for 1

year

Page 7: Managing acute coronary syndromes

Indications for Fibrinolytic Therapy When There Is a >120-Minute Delay From FMC to Primary PCI

Page 8: Managing acute coronary syndromes

Agent dose Fibrin specificity

Antigenicity Patency rate(90 min TIMI 2 0r 3 flow)

Fibrin specific:

1.Tenecteplase Single i.v bolus (weight based)*

++++ no 85%

2. Reteplase 10 U + 10 U i.v30mins apart

++ no 84%

3. Alteplase 90 min weight based infusion**

++ no 73% to 84%

Non fibrin specific:Streptokinase

1.5 million units i.v over 30 to 45 mins.

Non specific yes 60% to 68%

*30 mg for weight <60 kg; 35 mg for 60–69 kg; 40 mg for 70–79 kg; 45 mg for 80–89 kg;and 50 mg for =90 kg.

**Bolus 15 mg, infusion 0.75 mg/kg for 30 min (maximum 50 mg), then 0.5 mg/kg (maximum 35 mg) over the next 60 min; total dose not to exceed 100 mg.

Page 9: Managing acute coronary syndromes

Contraindications: Fibrinolytic agents• ABSOLUTE Any prior ICH

Known structural cerebral vascular lesion (eg, arteriovenousmalformation)

Known malignant intracranial neoplasm (primary or metastatic)

Ischemic stroke within 3 mo (except ischemic stroke within 4.5 hrs)

Suspected aortic dissection

Active bleeding or bleeding diathesis (excluding menses)

Significant closed-head or facial trauma within 3 months

Intracranial or intraspinal surgery within 2 months

Severe uncontrolled hypertension (unresponsive to emergency therapy)

For streptokinase, prior treatment within the previous 6 months

• RELATIVE History of chronic, severe, poorly

controlled hypertension Significant hypertension on

presentation (SBP >180 mm Hg or DBP >110 mm Hg)

History of prior ischemic stroke >3 months

Dementia Known intracranial pathology not

covered in absolute contraindications Traumatic or prolonged (>10 min)

CPR Major surgery (<3 wk) Recent (within 2 to 4 wk) internal

bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Oral anticoagulant therapy

Page 10: Managing acute coronary syndromes

Assessment of reperfusion after fibrinolysis

• The relatively sudden and complete relief of chest pain

• >70% ST resolution at 60 or 90 mins (in the index lead showing the greatest degree of elevation on presentation)

• The presence of reperfusion arrhythmias (eg, accelerated idioventricular rhythm).

• Lack of resolution of ST elevation by at least 50% in the worst lead at 60 to 90 minutes should prompt strong consideration of a decision to proceed with immediate coronary angiography and “rescue” PCI.

Page 11: Managing acute coronary syndromes

When to do angiography after fibrinolysis?

Rescue PCI

Pharmaco-invasive strategy

Delayed PCI of a totally occluded infarct artery >24hrs in a stable patient without any demonstrable ischemia is not recommended

Page 12: Managing acute coronary syndromes

Early invasive vs ischemia guided therapy in NTSE- ACS

• The invasive strategy triages patients to an invasive diagnostic evaluation (i.e., coronary angiography).

• In contrast, the initial ischemia-guided strategy calls for an invasive evaluation in patients who 1) fail medical therapy (refractory angina or angina at rest or with minimal activity despite vigorous medical therapy), 2) have objective evidence of ischemia (dynamic ECG changes, myocardial perfusion defect) as identified on a non-invasive stress test, or 3) have clinical indicators of very high prognostic risk (e.g., high TIMI or GRACE scores).

Page 13: Managing acute coronary syndromes
Page 14: Managing acute coronary syndromes

Antiplatelet TherapyNTSE-ACS STEMI

Aspirin 162 mg to 325 mg loading81 mg to 162 mg/ day indefinitely

same

P2Y12 inhibitors•Clopidogrel

•Ticagrelor

•Prasugrel

300 to 600 mg loading f/b maintainence 75 mg/ day. Reload if PCI is done

180 mg loading f/b 90 mg BD

60mg loading f/b 10mg dailyContraindicated in TIA and stroke.All are continued for atleast 12 months if stents are used.

same300mg for fibrinolysis.These may be used for more than 1 year if DES is placed.

If only fibrinolysis is done, then clopidogrel is used and should be continued for atleast 14 days uptil 1 year in absence of bleeding.

GP IIb/IIIaInhibitorAbciximab,Tirofiban,Eptifibatide.

Used only if early invasive strategy is planned in high risk patients, only along with UFH.

Same (esp in patients with high thrombus burden)Role of intracoronaryAbciximab

Page 15: Managing acute coronary syndromes

Initial Parenteral AnticoagulantsNSTE- ACS STEMI with primary

PCISTEMI with fibrinolysis

Un-fractionated heparin UFH

i.v loading 60 IU/kg (max. 4000 IU) with 12 IU/kg/hr (max. 1000 IU) continued uptil 48 hrs or until PCI.(apTt: approx 50 to 70 s)

-50 to 70 U/kg IV bolus if GP IIb/IIIainhibitor is used-70 to 100 U/kg if GPIIb/IIIa is not used.

same as in NSTE-ACS

Bivalrudin Only in patients with early invasive strategy0.10 mg/kg loading f/b 0.25 mg/kg/ hrSame as STEMI for PCI

0.75-mg/kg IV bolus, then 1.75-mg/kg/h infusion.(preferred)Dose adjusment in CKD

Used in patients who develop HIT

Enoxaparin Loading: 30mg i.v f/b 1mg/kg 12 hourly, dose reduced to 1mg/kg in 24 hrs if CrCl <30 ml/min. additional 0.3mg/kg if PCI is planned.

Less studied for this setting.

Same as in NSTE-ACSbut for pts >75 years0.75 mg/kg bw.

Fondapariux 2.5 mg s.c daily, not to be used alone in patients planned for PCI, use UFH 85 U/kg alongwith

Class III indication if used alone; less studied in this setting

Same as NTSE-ACSDose reduction in CKD

Page 16: Managing acute coronary syndromes

Adjunctive therapy. Class

• Oxygen: when oxygen saturation is <90%, respiratory distress,

or other high-risk features for hypoxemia

I

•Nitrates: sublingual NTG 0.4mg every 5 min × 3 for continuing

ischemic pain-IV NTG 10 mcg/min for persistent ischemia, HF, or hypertension-contraindicated if PDE inhibitors have been used.

IIIII

•Analgesic therapy : IV morphine sulfate may be reasonable

for continued ischemic chest pain despite maximally tolerated anti-ischemic medications ( 4 to 8 mg iv initially)-NSAIDs should not be used

IIb

III

•Beta adrenergic blockers: oral beta blockers within the first

24 h in the absence of HF, low output state, risk for cardiogenicshock, or other contraindications-Use of metoprolol succinate, bisoprolol, carvedilol-reasonable to continue beta-blocker therapy in patients with normal LV function -contraindicated in presence of risk factors for shock

I

IIIa

III

Page 17: Managing acute coronary syndromes

• Calcium channel blockers• Non dihydropyridine CCBs is recommended with recurrent

ischemia and contraindications to beta blockers in the absence of LV dysfunction, increased risk for cardiogenic shock, PR interval >0.24 s, or 2nd or 3rd degree AV block without a cardiac pacemaker (I)

• Administer oral nondihydropyridine CCBs with recurrent ischemia after use of beta blocker and nitrates in the absence of contraindications (I)

• CCBs are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects. (I)

• Long-acting CCBs and nitrates are recommended for patients with coronary artery spasm (I)

• Immediate-release nifedipine is contraindicated in the absence of a beta blocker (III)

Page 18: Managing acute coronary syndromes

Statins•To initiate high intensity statins in all patients without contraindications(I). ( atorvastatin, rosuvastatin- 80mg)•To obtain a fasting lipid profile within 24 hrs (IIa)

ACE inhibitors/ARBs

•ACE inhibitors should be started and continued indefinitely in all patients with LVEF < 40% and in those with hypertension, diabetes mellitus, or stable CKD , unless contraindicated (I)•If intolerant, ARBS can be used.(I)* An ACE inhibitor should be used cautiously in the first 24 hours of AMI, because it may result in hypotension or renal dysfunction .

Aldosterone receptor blocker•Aldosterone blockade in patients post–MI without significant renal dysfunction(Cr >2.5 mg/dL in men or >2.0 mg/dL in women) or hyperkalemia (K >5.0 mEq/L) who are already receiving ACE inhibitors or b-blockers, with EF <40% and either symptomatic HF or DM within 3 to 14 days.

Page 19: Managing acute coronary syndromes

When to go for CABG?

• Coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features or if the patient is undergoing surgery for mechanical repair defects

• CABG - continue Aspirin (Class I)» Discontinue clopidogrel and ticagrelor for 5

days : prasugrel 7 days.

• In case of emergency, surgery can be performed if > 24 hrs have elapsed since last dose of clopidogrel.

• Abciximab to be discontinued atleast 12 hrs. Stop eptifibatide/tirofiban 2 to 4h

Page 20: Managing acute coronary syndromes

Complications of MI

• Cardiogenic shock

a. Emergency revascularization with either PCI or CABG is recommended in suitable patients irrespective of the time delay from MI onset.

b. If not suitable, then use fibrinolytic agents.

c. The use of intra-aortic balloon pump (IABP) counterpulsation can be useful after STEMI who do not quickly stabilize with pharmacological therapy.

d. Alternative LV assist devices in refractory cases.

• Mechanical complications

a. Mitral regurgitation

b. Ventricular septal rupture

c. Ventricular free wall rupture

d. LV aneursym

Page 21: Managing acute coronary syndromes

Electrical complications

• VT/VFa. immediate defibrillation or cardioversion for VF or

pulseless sustained VT, prophylactic use of lidocaine is not recommended.

b. In the absence of a reversible cause, late (>48 hours) in-hospital sustained VT/VF is an indication for ICD therapy.

c. If LVEF remains ≤0.35 and the patient has NYHA class II or III HF symptoms, or if the LVEF is ≤0.30 independent of symptoms, then ICD implantation is recommended.

• Temporary pacing is indicated for symptomatic bradyarrhythmias unresponsive to medical treatment.

• Atrial fibrillation: rate control vs rhythm control and anticoagulation

Page 22: Managing acute coronary syndromes

Pericarditis

• High dose Aspirin(650 mg every 4 to 6 hrs) is recommended for treatment of pericarditisafter STEMI.

• Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective.

• NSAIDs and glucocorticoids: contraindicated

• Anticoagulation should be discontinued in the presence of a significant (≥ 1cm) or enlarging pericardial effusion.

Page 23: Managing acute coronary syndromes

Thromboembolic complications• Anticoagulant therapy with a vitamin K antagonist

should be provided to patients with STEMI and AF with CHADS2 score# greater than or equal to 2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder.

• Targeting vitamin K antagonist therapy to a lower INR (eg, 2.0 to 2.5) might be considered in patients with STEMI who are receiving DAPT.

Blood sugar • Blood glucose levels should be maintained

around 180 mg/dL if possible while avoiding hypoglycemia.

Page 24: Managing acute coronary syndromes

Non invasive test for ischemia post-MI

• The presence of residual ischemia in patients who have not undergone cardiac catheterization

• In assessing the functional significance of a non-infarct artery stenosis identified at angiography. Here, stress imaging to localize ischemia would be appropriatein 3 to 6 weeks.

• Low-level exercise testing after MI: safe if no symptoms of angina or HF; and a stable baseline ECG 48 to 72 hours before the test.

• Pharmacological stress myocardial perfusionimaging for patients who can’t exercise

Page 25: Managing acute coronary syndromes

For low risk patients

• Treadmill ECG, stress myocardial perfusion imaging or stress echocardiography (before or within 72 hours of discharge).

• Perform coronary CT angiography to assess coronary artery anatomy or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia (without serial ECGs or Troponinlevels)

• To give daily aspirin, short-acting nitroglycerin, and other medication if appropriate (e.g., beta blockers), with instructions about activity level and clinician follow-up.

Patients with “possible ACS” (normal serial ECGs and cardiac troponins)

Page 26: Managing acute coronary syndromes

THANK YOU!!