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Heart Attacks: Killers in Disguise!

Heart Attacks: Killers in Disguise!. W. Frank Peacock, MD, FACEP Vice Chief, Emergency Department The Cleveland Clinic. Agenda. What is an Acute Coronary Syndrome? (a heart attack) Why do you care? CAD is the number one killer in Scotland Who gets ACS? What are the symptoms?. Agenda.

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Heart Attacks: Killers in Disguise!

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  1. Heart Attacks: Killers in Disguise! W. Frank Peacock, MD, FACEPVice Chief, Emergency DepartmentThe Cleveland Clinic

  2. Agenda • What is an Acute Coronary Syndrome? (a heart attack) • Why do you care? • CAD is the number one killer in Scotland • Who gets ACS? • What are the symptoms?

  3. Agenda • When should you go to the hospital? • why you should go to the hospital? • How do we diagnosis it? • What happens if your diagnosed with it? • What can be done to prevent getting this?

  4. How does the heart work? Its just a pump, right?

  5. Its also a gland Myocardial injury Fall in LV performance ANP BNP Activation of RAAS, SNS, ET, and others Peripheral vasoconstriction Hemodynamic alterations Myocardial toxicity Remodeling and progressive worsening of LV function Heart failure symptoms Morbidity and mortality

  6. Epidemiology of CHD in the US • Single most frequent cause of death • 656,000 deaths in 2002 • 1 of every 5 deaths • Incidence • Each year, 1.2 million Americans will have a new or recurrent coronary event, and >40% will die as a result • 700,000 events will be first attacks; 500,000 will be recurrences • Prevalence • 13 million Americans have a history of CHD (acute MI, other acute ischemic (coronary) heart disease, angina pectoris, atherosclerotic cardiovascular disease, and all other forms of heart disease) CHD = coronary heart disease; MI = myocardial infarction.American Heart Association. Heart Disease and Stroke Statistics—2005 Update; 2005.

  7. Epidemiology of CHD Scotland • Single most frequent cause of death • Incidence • Prevalence CHD = coronary heart disease; MI = myocardial infarction.American Heart Association. Heart Disease and Stroke Statistics—2005 Update; 2005.

  8. Smk (1) DM (2) HTN (3) ApoB/A1 (4) 1+2+3 All 4 +Obes +PS All RFs Risk for CHD Increases With Additional Risk Factors: INTERHEART Study 512 256 128 64 32 16 8 4 2 1 Odds ratio (99% Cl) PS = psychosocial Yusuf S, et al. Lancet. 2004;364:937-952.

  9. INTERHEART: Impact on CV Risk of Multiple Risk Factors (Smoking, Lipids, Hypertension, Diabetes, Abdominal Obesity, Diet, ↓Physical Activity, Alcohol, Psychosocial*) 512 –Large int’l case-control study– 15,152 cases– 14,820 controls– 52 countries– Follow-up: 4 years 256 128 64 32 Odds Ratio for 1st MI (99% CI) 16 Smk = smoking DM = diabetes HTN = hypertension Obes = abdominal obesity Ps = psychosocial factors 8 4 2 1 Smk(1) DM(2) HTN(3) ApoB-ApoA1(4) 1+2+3 All 4 All 4+ Obes All 4+ Ps All riskfactors *eg, stress, depression Note: odds ratio plotted on a doubling scale. . Yusuf S, et al. Lancet. 2004;364:937-952.

  10. What does an ACS feel like?

  11. Symptoms of CAD • NONE…….. • Sudden Cardiac Death • Chest Pain • Usually a pressure • Not seconds • Anginal equivalents • Jaw or shoulder pain • Nausea & vomiting • Shortness of breath • Weak & dizzy • Diaphoresis

  12. Classicpresentation Chest pressure Elephant Sweating Nausea/vomiting Radiation of pain Shortness of breath Anginal equivalents Jaw/shoulder pain Nausea & vomiting Shortness of breath Weak & dizzy Diaphoresis Symptoms of Heart Attack

  13. Who gets “Equivalents”? • Women • Diabetics • Elderly • Heart Transplant patients • Patients who can’t perceive/communicate well? • Drunk • Mentally ill

  14. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Hospital fibrinolysis: door-to-needle within 30 min Not PCI capable Call 9-1-1 Call fast • EMS on-scene • Encourage 12-lead ECGs • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min EMS triage plan Inter-hospital transfer Onset of symptoms of STEMI 9-1-1 EMS dispatch PCI capable GOALS 5 min 8 min EMS Transport Patient EMS Prehospital fibrinolysis EMS-to-needle within 30 min EMS transport EMS-to-balloon within 90 min Patient self-transport Hospital door-to-balloon within 90 min Dispatch 1 min Golden hr = 1st 60 min Total ischemic time: within 120 min Adapted with permission from Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed November 1, 2005.

  15. What happens in the Ambulance? • Paramedics take your history and perform a brief exam • IV • Oxygen • Put on the monitor • May receive nitroglycerin under the tongue. (tingle, get a H/A) • Maybe: ECG, thrombolytic (clot dissolver)

  16. What happens when you get to the hospital?

  17. ED Visits - US 130,000,000 annually 10.4 M chest pain (8.0%) 6.24 M suspected or actual cardiac 4.1 M sent home non-cardiac 50,000 MIs 3.1 M non-cardiac (50%) 1.2 M AMI (20%) 1.5 M UA (24%) 374,400 sudden death (6%)

  18. Spectrum of Acute Coronary Syndromes Ischemic Discomfort at Rest Presentation No ST-segment Elevation ST-segment Elevation Emergency Department Cardiac Markers + – + + In-hospital 6-24 hours Unstable Angina (UA) Non-Q-wave MI (NSTEMI) Q-wave MI (STEMI) Adapted from Braunwald E, et al. Available at: http://www.acc.org/clinical/guidelines/unstable/unstable.pdf

  19. STEMI: Brief Physical Exam in the Emergency Department • Airway, Breathing, Circulation (ABC) • Vital signs, general observation • Presence or absence of jugular venous distension • Pulmonary auscultation for rales • Cardiac auscultation for murmurs or gallops • Presence or absence of stroke • Presence or absence of pulses • Presence or absence of systemic hypoperfusion (cool, clammy, pale/ashen) Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed November 1, 2005.

  20. General treatment measures STEMI: Acute Medical Therapy • Analgesics • Nitrates • Oxygen • β-blockers (decrease heart rate) • Primary PCI or coronary thrombolysis(primary PCI preferred after 3 hours) • Aspirin (162-325 mg, acute dose) • Heparin • If PCI: – Clopidogrel – GP IIb/IIIa inhibitors Infarct size limitation Reperfusion Antithrombotic and antiplatelet therapy Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed November 1, 2005.

  21. Chest Pain on a Saturday morning • While the physician was examining the ECG, the patient became unconscious and the rhythm on the monitor changed…

  22. Chest Pain on a Saturday morning • 12:01 100J DC cardioversion, patient immediately in NSR • 12:03 Clot box brought to room and catheterization lab team notified • 12:04 IV line started, 325 mg aspirin chewed and metoprolol given • 12:10 Open cath table and staff available, heparin iv and clopidogrel po given • 12:19 Patient’s stretcher rolls

  23. Goals of Reperfusion Therapy Patient Transport In-hospital Reperfusion D-N ≤30 min 5 min < 30 min D-B ≤90 min Methods of Speeding Time to Reperfusion • Media campaign • Patient education • Greater use of 9-1-1 • MI protocol • Critical pathway • Quality improvement program • Bolus lytics • Dedicated PCI team • Prehospital ECG and Prehospital Rx, if possible Adapted with permission from: Antman EM, et al. Available at: http://www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed November 1, 2005.

  24. Time from Symptom Onset to Treatment Predicts 1 Year Mortality—Primary PCI The relative risk of 1 year mortality increases by 7.5% for each 30 minute delay. Roughly 1% every 3 minutes Y=2.86 (± 1.45) + 0.0045X1 + 0.000043X2P<.001 De Luca G, et al. Circulation. 2004;109:1223-1225.

  25. 80 60 Absolute benefit per 1000 treated patients 40 20 0 0 3 6 9 12 15 18 21 24 Time to Treatment Meta-analysis of 50,246 Patients in Lytic Trials(Juice to squeeze) Boersma E, et al. Lancet.1996;348:771

  26. Primary PCI vs Thrombolysis in STEMI: Meta-analysis (23 RCTs, N=7739) 25 Short-term Outcomes (4-6 weeks) P<.0001 Bonferroni correction 6 variables: p <0.0083 20 P<.0001 15 P<.0001 P=.0002 PCI Frequency (%) P=.032 10 Thrombolytictherapy 5 P<.0001 0 Death Nonfatal MI Recurrent Ischemia Hemor- rhagic Stroke Major Bleed Death, Nonfatal Reinfarction, or Stroke Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.

  27. What if the ECG is not diagnostic? (As it is in >95%)

  28. Blood Markers • Necrosis • Something has to die • Strain • Natriuretic peptides • Other • Inflammation • Plaque rupture • Ischemia changes the blood

  29. ED Presentation Plaque Rupture Onset of Pain Discharge 12 to24 hrs -12 to0 hrs 0 IMA Ischemia Muscle death cTn Ventricular Overload BNP ACS Sequence and Timing All Ischemia Some Ischemia,Some Necrosis All Necrosis Amount of Tissue Time BNP

  30. 80 CKMB 70 60 Myoglobin 50 TnI 40 30 20 10 0 0 2 4 6 8 12 18 24 32 48 72 Hours After Onset of MI Appearance of necrosis markers Hospital arrival

  31. Oxygen Oxygen supply diminishes with disease progression Oxygen demand changesdaily and during life Time Ischemia occurs when O2 demand exceeds supply Disease vs Events?

  32. What is in the future? New better markers

  33. Human Serum Albumin (HSA) isa circulating protein in blood with a metal binding site at the N-terminus. The N-terminus is altered during an ischemic event, resulting in Ischemia Modified Albumin (IMA™). IMA is unable to bind metals at the N-terminus. What is IMA? Bar Or et al, European Journal of Biochemistry, 2001

  34. Current EP Protocol 35% Rule Out 13% Rule Out 40% Grey Zone 75% Grey Zone 25% ACS 12% ACS Chest Pain at Presentation EP Protocol with good NPV ischemia marker

  35. What if the markers are all negative? (And they are in >90%)

  36. If It Moves, Even Below Your Hospital’s Cutpoint, It Is Bad N=2,188 Logistic regression models showing the odds ratios for predicting ACS MACE: MI, revascularization (PCI or CABG), or positive testing (>70% stenosis at catheterization, [+] MPI or non-invasive stress testing) within 30 days of index visit.

  37. All this testing… What’s the end result? • Most (88%) of the time, its negative • You go home • 18% of the time, something is positive • ECG  IMMEDIATE Cath lab • Marker  URGENT Cath lab • Stress test  Semi-elective Cath lab

  38. What happens in the Cath Lab? • Define the anatomy • Acutely closed vessel  fix it • Chronically closed vessel  nothing • Stenotic vessel: have options • ~50%; either medicine or angioplasty works • >70%; most get angioplasty

  39. Scotland Epidemiology

  40. Prevalence of coronary heart disease in Scotland: Scottish Heart Health Study. • 10,359 men and women aged 40-59 years from 22 districts in the Scottish Heart Health Study • Described the prevalence rates of coronary heart disease in Scotland in 1984-1986 and their relation to the geographical variation in mortality in these districts. • Coronary heart disease in Scotland was the highest reported to the WHO from 1984-86 • Angina was more common in men (5.5%) than in women (3.9%) • A history of MI was 3 times more common in men than women • Angina correlated well with mortality from coronary heart disease Br Heart J. 1990 Nov;64(5):295-8

  41. 2001: The good news • The Cardiovascular Epidemiology Unit at the University of Dundee celebrated its 20th anniversary with a 40 % decline in coronary mortality rate • The steep decline in coronary mortality in Scotland mirrors the pattern in the rest of Britain. • Improvement is a combination of: • Heightened awareness of health issues • Improved diet and more exercise • Improvement in treatments. • Scotland's record on heart disease is much improved • Russia now has the highest coronary mortality rate.

  42. 2003 British Women's Heart and Health Study • 4286 Women • 20% MI, angina, HF, CVA, PVD. • 50% HTN, 12% smoked, 25% obese • 50% w/ total cholesterol > 6.5 mmol/l, only 3% had low HDL • Age adjusted CVD prevalence • highest in Scotland: 25.0% (21.5% to 28.8%) • lowest in S. England: 15.4% (13.5% to 17.6%). • Woman in Scotland are 1.53 times more likely to have CVD • Of women with CVD • 12% are smokers, 1/3 had uncontrolled HTN, 1/3 were obese • 90% had a cholesterol > 5 mmol/l. • Only 41% were taking antiplatelet drugs and 22% were taking a statin. Journal of Epidemiology and Community Health 2003;57:134-140

  43. In Scotland • Coronary Heart Disease • one of the leading causes of death • 10,331 deaths in 2005 • Scotland has one of the highest death rates from CHD in the western world • Due to • high rates of smoking • poor diet • deprivation

  44. In the year ending March 31 2006 Scottish hospitals 48,962 hospital discharges for CHD 16,320 were for AMI(heart attack) CHD discharges represented around 4% of all acute hospital discharges. NHSScotland carried out 2,319 Coronary Artery Bypass Grafts 5,803 angioplasties 17,065 angiographies

  45. http://www.isdscotland • CHD mortality is strongly related to age. • 0-44 year olds is 4.1 per 100,000 • 75+, the rate is 1682.1 per 100,000 • The incidence of CHD is higher in men, elderly and deprived areas of Scotland • Smoking • being overweight • raised blood pressure • raised level of cholesterol

  46. Cost of Cardiovascular Disease in the UK • CVD cost the UK £29.1 billion in 2004 • (exceeds the GDP of Kuwait) • 29% (£8.5 billion) was due to Coronary Heart Disease • 27% (£8.0 billion) Cerebrovascular Disease • CVD Cost break down • 60% health care • 23% productivity losses • 17% informal care-related costs • Conclusions: CVD is a leading public health problem in the UK measured by the economic burden of disease. Heart 2006;92:1384-1389

  47. Small changes in UK cardiovascular risk factors could halve CHD mortality • The UK called for a 40% reduction in CVD mortality by 2010. • Potential reductions from the year 2000, were calculated for: • Continuation of recent risk factor trends • ~10,685 fewer CAD deaths in 2010 than in 2000 • Modest additional reductions in cholesterol and smoking • ~51,270 fewer deaths • Optimistic changes in obesity, DM, and physical activity, would have relatively small effects. Journal of Clinical Epidemiology 58 (2005) 733–740

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