patient oriented therapy non ste acs prof dr midhat nurkić fesc director clinic for cardiovascular...

Patient Oriented Therapy Patient Oriented Therapy Non Non STE STE ACSACS

Prof dr Midhat nurkić FESC

Director clinic for cardiovascular disease UKC Tuzla

Acute Coronary Syndrome Acute Coronary Syndrome (ACS)(ACS)

Definition:Definition: The spectrum of acute The spectrum of acute ischemia related syndromes ranging ischemia related syndromes ranging from UA to MI with or without ST from UA to MI with or without ST elevation elevation that are secondary to acute that are secondary to acute plaque rupture or plaque erosion.plaque rupture or plaque erosion.

[----[----UAUA------------------NSTEMINSTEMI--------------------STEMISTEMI----]----]

AntithromboticTherapy

Stable Angina

UnstableAngina

Non-Qwave MI

ThrombolysisPrimary PCI

Q wave MI

Mins-hours

Days-weeks

STEMIUA/NSTEMICAD

Cannon CP J Thromb Thrombolysis. 1995;2:205-218.

Spectrum of Chronic Coronary Spectrum of Chronic Coronary SyndromeSyndrome

Endstage Heart Disease

Congestive Heart Failure

Ventricular Dilation

Remodeling

Arrhythmia & Loss of Muscle

Myocardial Infarction

Myocardial Ischemia

IHD/Angina Pectoris

Atherosclerosis

Endothelial Dysfunction

Risk Factors + Hypertension

Coronary ThrombosisChronicCoronarySyndrome

AcuteCoronarySyndrome

Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004.

Acute Evaluation of ACSAcute Evaluation of ACS

ST-segment Elevation

Chest pain or Short of Breath

Unstable Angina

ST-segment Depression

– + +

Presentation

ECG

Diagnosis

Normal

Markers

Acute MI

–+

Rule-Out

Anderson JL. J Am Coll Cardiol 2007;50:e1-157

StableAngina

UnstableAngina

ST Elevation MI

Non ST Elevation MI

ECG – ST ↑

CK-MB

Troponin

CRP/BNP

ECG - ST ↓

<- + Markers Identify MI patients, who are High-Risk Patients ->

CHD MortalityCHD Mortality

Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Recent Trends CHD Recent Trends CHD MortalityMortality


Cardiovascular Procedure Cardiovascular Procedure TrendsTrends


What is a UA/NSTEMI Patients What is a UA/NSTEMI Patients Risk of inpatient Cardiac Risk of inpatient Cardiac

Mortality and ischemic events?Mortality and ischemic events?

Risk StratificationRisk Stratification

1.1. Integral prerequisite to decision makingIntegral prerequisite to decision makinga)a) Intensive initial assessmentIntensive initial assessmentb)b) Continuous clinical assessmentContinuous clinical assessmentc)c) Targeted ECG and marker dataTargeted ECG and marker data

2.2. Risk based on contingent probabilitiesRisk based on contingent probabilitiesa)a) Probability of obstructive CAD causing ischemiaProbability of obstructive CAD causing ischemiab)b) Risk Risk givengiven presence of obstructive CAD presence of obstructive CAD

3.3. Risk scores should be a routine part of Risk scores should be a routine part of assessment throughout the hospital course assessment throughout the hospital course and periodically after dischargeand periodically after discharge


• Age ≥ 65 years =1 point

• At least 3 risk factors for CAD =1 point

• Prior coronary stenosis of ≥ 50% =1 point

• ST-segment deviation on ECG presentation =1 point

• At least 2 anginal events in prior 24 hours =1 point

• Use of aspirin in prior 7 days =1 point

• Elevated serum cardiac biomarkers =1 point

Variables Used in the TIMI Risk Score

The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42.TIMI = Thrombolysis in Myocardial Infarction.

TIMI Risk ScoreDownloadable Apps available

Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.TIMI = Thrombolysis in Myocardial Infarction.

TIMI Risk

Score

All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent

Revascularization Through 14 Days After Randomization %

0-1 4.7

2 8.3

3 13.2

4 19.9

5 26.2

6-7 40.9

Initial Evaluation - Risk StratificationInitial Evaluation - Risk Stratification

12-lead ECG within 10 min for all patients 12-lead ECG within 10 min for all patients with chest pain or symptoms suggestive with chest pain or symptoms suggestive of ACSof ACS

Early risk stratification by symptoms, Early risk stratification by symptoms, physical findings, ECG, cardiac markersphysical findings, ECG, cardiac markers

Cardiac markers, Troponins and CK-MB, Cardiac markers, Troponins and CK-MB, for initial assessment for initial assessment

Use of risk stratification models (TIMI, Use of risk stratification models (TIMI, PURSUIT, GRACE) can be useful to assist PURSUIT, GRACE) can be useful to assist in decision making for treatment optionsin decision making for treatment options

12-lead ECG within 10 min for all patients 12-lead ECG within 10 min for all patients with chest pain or symptoms suggestive with chest pain or symptoms suggestive of ACSof ACS

Early risk stratification by symptoms, Early risk stratification by symptoms, physical findings, ECG, cardiac markersphysical findings, ECG, cardiac markers

Cardiac markers, Troponins and CK-MB, Cardiac markers, Troponins and CK-MB, for initial assessment for initial assessment

Use of risk stratification models (TIMI, Use of risk stratification models (TIMI, PURSUIT, GRACE) can be useful to assist PURSUIT, GRACE) can be useful to assist in decision making for treatment optionsin decision making for treatment options

IIII IIaIIaIIaIIa IIbIIbIIbIIb IIIIIIIIIIII


UA/NSTEMI Hospital CareUA/NSTEMI Hospital Care

Let’s Start with the Basics! Assuming the NSTEMI has been ruled in or out

ACC/AHA GuidelinesACC/AHA GuidelinesACS Treatment Overview: UA/NSTEMIACS Treatment Overview: UA/NSTEMI

aIf possible, clopidogrel should be withheld for 5-7 days prior to the procedure.Anderson JL, et al. Circulation. 2007;116:803-877.

Initial invasive management

Initial conservative managemen

t

Diagnosis of UA or NSTEMI is likely or definite

Aspirin or clopidogrel (if patient is aspirin intolerant)

PCI or CABGa

Diagnostic angiograph

y

Medical therapy

Long-term medical management:Clopidogrel, aspirin, β-blocker,

ACEI, statin

Evaluation of LV Function in pt with ischemia

Selection of Initial Selection of Initial TreatmentTreatment

Wright RS et al. Circ 2011;123;2022-2060.

Early TreatmentEarly TreatmentClass I IndicationsClass I Indications

Bedrest/chair with continuous ECG MonitoringBedrest/chair with continuous ECG Monitoring O2 therapy with saturation <90%, respiratory distress, or O2 therapy with saturation <90%, respiratory distress, or

other high-risk features for hypoxemiaother high-risk features for hypoxemia SL NTG 0.4 mg q5min x3 then assessment of need for IV SL NTG 0.4 mg q5min x3 then assessment of need for IV

NTGNTG IV NTG indicated first 48 hours for treatment of IV NTG indicated first 48 hours for treatment of

persistent ischemia, CHF or HTN; should not preclude tx persistent ischemia, CHF or HTN; should not preclude tx with beta-blockers or ACEwith beta-blockers or ACE

Oral Beta-Blocker in first 24 hours for pt who do not haveOral Beta-Blocker in first 24 hours for pt who do not have Signs of CHFSigns of CHF Low out-put stateLow out-put state Increased risk of cardiogenic shockIncreased risk of cardiogenic shock Contraindication to Beta blockers/heart block/COPDContraindication to Beta blockers/heart block/COPD

If Beta-Blockers are contraindicated a If Beta-Blockers are contraindicated a nondihydropyridine calcium channel blocker may be nondihydropyridine calcium channel blocker may be used if no LV dysfunctionused if no LV dysfunction

Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment (Cont.)Early Treatment (Cont.) ACE inhibitor within 24 hours with pulmonary ACE inhibitor within 24 hours with pulmonary

congestion or LVEF < 40% in the absence of congestion or LVEF < 40% in the absence of hypotension or contraindicationhypotension or contraindication

Because of the increased risk of mortality, reinfarction, Because of the increased risk of mortality, reinfarction, HTN, CHF, and myocardial rupture NSAIDS except for HTN, CHF, and myocardial rupture NSAIDS except for ASA should be discontinued at presentationASA should be discontinued at presentation

Class II indications:Class II indications: It is reasonable to admin O2 to all UA/NSTEMI pts in It is reasonable to admin O2 to all UA/NSTEMI pts in

first 6 hours. IIafirst 6 hours. IIa Morphine (1-5 mg IV) remains Class I for STEMI Morphine (1-5 mg IV) remains Class I for STEMI

although may increase adverse events in although may increase adverse events in UA/NSTEMI1,2UA/NSTEMI1,2 It is reasonable to administer morphine sulfate IV if It is reasonable to administer morphine sulfate IV if

the is uncontrolled ischemic CP despite NTG. IIathe is uncontrolled ischemic CP despite NTG. IIa

1. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367. 2. Meine T el al. Am Heart J 2005;149:1043- 9

Early Hospital CareEarly Hospital Care2011 Focused update Antiplatelet therapy2011 Focused update Antiplatelet therapy

ASA should be administered to ASA should be administered to USA/NSTEMI as soon as possible after USA/NSTEMI as soon as possible after hospital presentation and continued hospital presentation and continued indefinitely (LOE A)indefinitely (LOE A)

Clopidogrel (loading dose followed by Clopidogrel (loading dose followed by maintenance dose) should be administered maintenance dose) should be administered to USA/NSTEMI patients who are unable to to USA/NSTEMI patients who are unable to take ASA because of hypersensitivity or take ASA because of hypersensitivity or major gastrointestinal intolerance (LOE B)major gastrointestinal intolerance (LOE B)

Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367


Pt with definite USA/NSTEMI at Pt with definite USA/NSTEMI at medium or high risk and in whom an medium or high risk and in whom an initial invasive strategy is selected initial invasive strategy is selected should receive dual-antiplatelet should receive dual-antiplatelet therapy on presentation (LOE A)therapy on presentation (LOE A) ASA on presentationASA on presentation The second should be given before PCI The second should be given before PCI

as follows…..as follows…..



Before PCI:Before PCI: Clopidogrel LOE BClopidogrel LOE B An IV GP An IV GP IIIb/IIIa inhibitor (LOE A) eptifibatide Ib/IIIa inhibitor (LOE A) eptifibatide

or tirofiban are the preferred agentsor tirofiban are the preferred agents

At the time of PCI:At the time of PCI: Clopidogrel if not started before PCI LOE AClopidogrel if not started before PCI LOE A Prasugrel LOE BPrasugrel LOE B An IV GP IIb/IIIa inhibitor LOE AAn IV GP IIb/IIIa inhibitor LOE A


Hospital CareHospital Care2011 Focused update Antiplatelet therapy2011 Focused update Antiplatelet therapy

For USA/NSTEMI patients in whom an For USA/NSTEMI patients in whom an initial conservative strategy is selected initial conservative strategy is selected clopidogrel (loading dose followed by clopidogrel (loading dose followed by maintenance dose) should be added to maintenance dose) should be added to ASA and anticoagulant therapy as soon ASA and anticoagulant therapy as soon as possible after admission and as possible after admission and administered for at least 1 month and administered for at least 1 month and ideally up to 1 yearideally up to 1 year


Loading Doses of Loading Doses of Thienopyridine prior to PCIThienopyridine prior to PCI

Clopidogrel 300-600mg as early as Clopidogrel 300-600mg as early as possible before the time of PCI (LOE possible before the time of PCI (LOE A)A)

Prasugrel 60mg should be given Prasugrel 60mg should be given promptly and no later than 1 hour promptly and no later than 1 hour after PCI, Once coronary anatomy is after PCI, Once coronary anatomy is defined and a decision is made to defined and a decision is made to proceed with PCI (LOE B)proceed with PCI (LOE B)



For USA/NSTEMI patients in whom an For USA/NSTEMI patients in whom an initial conservative strategy is initial conservative strategy is selected if recurrent selected if recurrent symptoms/ischemia, CHF, or serious symptoms/ischemia, CHF, or serious arrhythmias subsequently appear, arrhythmias subsequently appear, then diagnostic angiography should then diagnostic angiography should be preformedbe preformed



For patients with USA/NSTEMI treated For patients with USA/NSTEMI treated conservatively without recurrent conservatively without recurrent symptoms, CHF or arrhythmia a stress test symptoms, CHF or arrhythmia a stress test should be performedshould be performed

If the pt is not classified as low risk after If the pt is not classified as low risk after the stress test then angiography should be the stress test then angiography should be performedperformed


Hospital CareHospital Care2011 Focused update2011 Focused update

If at low risk Post Stress Test:If at low risk Post Stress Test: Continue ASAContinue ASA Continue clopidogrel for at least 1 month Continue clopidogrel for at least 1 month

and ideally up to 1 yearand ideally up to 1 year Discontinue GP Iib/IIIa inhibitor if startedDiscontinue GP Iib/IIIa inhibitor if started Continue UFH for 48 hours or administer Continue UFH for 48 hours or administer

enoxaparin or fondaparinux for the enoxaparin or fondaparinux for the duration of hospitalization up to 8 days duration of hospitalization up to 8 days and then discontinueand then discontinue



For patients with USA/NSTEMI in whom For patients with USA/NSTEMI in whom CABG is selected post angiographyCABG is selected post angiography Continue ASAContinue ASA Discontinue IV GP Iib/IIIa inhibitor 4 hours before Discontinue IV GP Iib/IIIa inhibitor 4 hours before

CABGCABG Continue UFHContinue UFH Discontinue enoxaparin 12-24 hours before Discontinue enoxaparin 12-24 hours before

CABG and dose with UFH per institution practiceCABG and dose with UFH per institution practice Discontinue fondaparinux 24 hours before CABG Discontinue fondaparinux 24 hours before CABG

and dose with UFH per institution practiceand dose with UFH per institution practice Discontinue bivalirudin 3 hours before CABG and Discontinue bivalirudin 3 hours before CABG and

dose with UFH per institution practicedose with UFH per institution practice



In patients taking thienopyridine in whom In patients taking thienopyridine in whom CABG is planned and can be delayed…CABG is planned and can be delayed…

Discontinue clopidogrel for at least 5 daysDiscontinue clopidogrel for at least 5 days Discontinue prasugrel for at least 7 daysDiscontinue prasugrel for at least 7 days

Unless the need for revascularization and or Unless the need for revascularization and or the net benefit of the thienopyridine the net benefit of the thienopyridine outweighs the potential risks of excess outweighs the potential risks of excess bleeding… LOE Cbleeding… LOE C


ACC/AHA Guidelines update 2011ACC/AHA Guidelines update 2011UA/NSTEMI: Long-Term Medical Management UA/NSTEMI: Long-Term Medical Management

UA or NSTEMI at hospital discharge

Inhospital management with medical therapy

(without stenting)

Inhospital therapy with bare-metal stent

implantation

Inhospital therapy with drug-eluting stent

implantation

Aspirina 75-162 mg/d indefinitely plus

clopidogrelb 75 mg/d for at least 1 mo, ideally up

to 1 yr

Aspirina 162-325 mg/d for at least 1 mo, then

75-162 mg/d indefinitely plus

clopidogrelb 75 mg/d or prasugrel 10 mg/d for at

least12 months*

Aspirina 162-325 mg/d for at least 3 mo with

Sirolimus and 6 mo paclitaxel, then

75-162 mg/d indefinitely plus

clopidogrelb 75 mg/d or prasugrel 10 mg/d for at

least 12 mo

Is an indication for anticoagulation present?

If yes: add warfarinc,d

If no: continue dual antiplatelet

therapy

aIf patient is allergicto aspirin, useclopidogrel alone (indefinitely) or try aspirin desensitization.

cContinue aspirin indefinitely and warfarin long term, if indicated for specific conditions.dIf warfarin is added to aspirin and clopidogrel, the recommended INR is 2.0-2.5.

bIf patient is allergic to clopidogrel, use ticlodipine 250 mg PO bid.


Evaluating Recurrent RiskEvaluating Recurrent RiskSecondary Prevention Secondary Prevention

StrategiesStrategiesBroad Goals during Hospital discharge Broad Goals during Hospital discharge

phasephase Prepare the patient for normal Prepare the patient for normal

activitiesactivities Use the acute event as an Use the acute event as an

opportunity to reevaluate the plan of opportunity to reevaluate the plan of care - lifestyle and risk factor care - lifestyle and risk factor modificationmodification


Reperfusion is the Issue but Reperfusion is the Issue but once stabilized…..once stabilized…..

ASAASA Anti-platelet TherapyAnti-platelet Therapy Cholesterol goalCholesterol goal Blood Pressure goalBlood Pressure goal Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone)Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone) Discharged with sublingual NTG and instructed in its useDischarged with sublingual NTG and instructed in its use Diabetes management: HbA1c < 7%Diabetes management: HbA1c < 7% Warfarin for Afib/flutter or LV thrombus or other Warfarin for Afib/flutter or LV thrombus or other

indication indication Daily physical activity 30 min 7 d/wk, minimum 5 d/wkDaily physical activity 30 min 7 d/wk, minimum 5 d/wk Ask, advise, assess, and assist patients to stop smokingAsk, advise, assess, and assist patients to stop smoking Cardiac Rehabilitation recommended esp. for those with Cardiac Rehabilitation recommended esp. for those with

mult. Risk factors or mod/high risk mult. Risk factors or mod/high risk Annual influenza immunization Annual influenza immunization


For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription.

For all patients, encouraging 30 to 60 min of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work).

Advising medical supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, HF) is recommended.

Encouraging resistance training 2 d per week may be reasonable (Class IIb; LOE: C)

Physical activity:2007 Goal:30 min 7 d per wk; minimum 5 d per wk

Goals Class I Recommendations

Secondary Prevention and Long Term Secondary Prevention and Long Term ManagementManagement

patient oriented therapy non ste acs prof dr midhat nurkić fesc director clinic for cardiovascular...

Documents

risk scores

timi risk calculator

ischemia b risk

e18e209 slide

ecg presentation

lead ecg

point stsegment deviation

recurrent mi