1 / 85

UA/NSTEMI Guidelines

UA/NSTEMI Guidelines. Dr. Sajeer K.T Senior Resident Dept. of Cardiology. Definition UA/NSTEMI. Electrocardiographic ST segment depression or prominent T wave inversion and/or Positive biomarkers of necrosis (troponin ) In the absence of ST segment elevation

brennan-lopez
Télécharger la présentation

UA/NSTEMI Guidelines

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. UA/NSTEMI Guidelines Dr. Sajeer K.T Senior Resident Dept. of Cardiology

  2. Definition UA/NSTEMI Electrocardiographic ST segment depression or prominent T wave inversion and/or Positive biomarkers of necrosis (troponin ) In the absence of ST segment elevation In an appropriate clinical setting ( chest discomfort or anginal equivalent)

  3. ACC/AHA Task force on practice guidelines • 2007 • 2011 focused updates

  4. Risk stratification • Early hospital care • Conservative management strategy • Invasive management strategy

  5. Risk stratification • Diagnostic evaluation: • Assesses the risk that a pt with UA/NSTEMI has for MI or death during next few weeks. • Focuses on history Physical findings ECG findings Biomarkers of cardiac injury (Cardiac specificTroponin) TIMI score

  6. 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.

  7. TIMI Risk Score

  8. Early Hospital care

  9. Anti ischemic therapy and analgesic therapy • Bed rest with continuous ECG monitoring • Supplemental oxygen ( if spo2<90% or respiratory distress). • sublingual nitrate every 5 min for a total of 3 doses . • IV NTG in first 48 hrs - persistent ischemia - HF - hypertension class 1

  10. Anti ischemic therapy contd.. class 1 - Oral beta-blocker therapy ( within the 1st 24 h) Contraindications: 1) signs of HF 2) low out put state( SBP<90,oliguria,HR<50) 3) other relative contraindications to beta blockade. (PR > 0.24 s, 2nd or 3rd degree AV block, active asthma or reactive airway disease). 4) increased risk for cardiogenic shock

  11. Risk factors for increased cardiogenic shock • Older age • Female sex • Time delay • Higher killip class • SBP<120 • HR>110 or <60

  12. If Beta blockers are contra indicated Nondihdropyridine calcium channel blockers - Verapamil - Diltiazem Contraindications for CCBs: Severe LV dysfunction

  13. COMMIT Trial • 45,852 patients within 24 h acute MI ― 93% STEMI or LBBB, 7% had NSTEMI • Up to 15 mg IV → 50 mg po metoprolol daily v/s placebo • composite primary outcomes ― death, reinfarction, or cardiac arrest • No decrease of com-primary outcome by metoprolol - modest reduction in reinfarctions and VF •  Risk cardiogenic shock especially with initial hemodynamic instability • Recommend: start -blocker po when hemodynamically stable

  14. ACEI & ARBs ACE inhibitor (orally within 1st 24 h) in patients with - pulmonary congestion - LVEF ≤ 40% contraindications: - hypotension (SBP < 100 mm Hg or < 30mm Hg below baseline) - known contraindications ACEIs ARBs: if intolerance to ACEI

  15. (class IIa) • IV morphine • IV beta blocker : in HTN with UA/NSTEMI ( with no CI for Beta Blocker) • Oral long acting non-DHP CCBs : for recurrent ischemia if no CI ( after nitrates and beta blockers) • Oral ACEI - in pts with out - pulmonary congestion - LVEF≤ 40%

  16. Intra aortic balloon counter pulsations (IABP) • For continuing severe ischemia • For hemodynamic unstability Class IIa

  17. Class III • Nitrates : - SBP<90 or ≥ 30mm Hg below the baseline. - with in 24 hr of PDEIs ( sildenafil& tadalafil) • IV ACEI : ↑ ed risk of hypotension • IV beta blockers : with CI to Beta blockade • NSAIDs ( except ASA): a/w ↑ mortality, reinfarction, HTN, HF, myocardial rupture

  18. Antiplatelet therapy

  19. Antiplatelet therapy class 1 Aspirin : as soon as possible (165-325 mg) - (non enteric formulation orally or chewed). -Continued indefinitely(75-162mg/d ) in pts who tolerate it. Clopidogrel : - loading dose -300mg - daily maintenance dose 75mg - Continued for at least 1 month and ideally up to 1 year.

  20. CURE trial • 12,562 patients with UA/NSTEMI presenting with in 24 hrs • Clopidogrel 300mg loading >>>75mg/d v/s placebo • All patients received ASA • Significant reductions in the rate of in-hospital severe ischemia and revascularization and need for IV GPIIb/IIIa inhibitors. • Strong evidence for addition of clopidogrel to ASA on admission in management of patients in whom a non-interventional approach is intended. • Useful approach in hospitals that do not have a routine policy about early invasive procedures

  21. Use of Proton pump inhibitors Interfere with the metabolism of clopidogrel - - Lansoprazole inhibits CYP450 2C19 - Rabeprazole Omeprazole : significantly decrease the inhibitory effect of clopidogrel on platelet aggregation. Pantoprazole lacks inhibition of CYP450 2C19 Omeprazole -- Deleted recommendation 2011

  22. Anti coagulant therapy recommendations Class I Invasive strategy: - UFH - Enoxaparin - Bivalirudin Conservative strategy: - UFH or Enoxaparin - Fondaparinux ( preferable in pts with increased risk of bleeding) Enoxaparin or fondaparinux preferable to UFH unless CABG is planned with in 24 hrs Class IIa

  23. UFH dosage • ACC/AHA Guidelinesrecommend weight-adjusted dose of UFH : 60 units/kg bolus and : 12 units/kg/hr infusion.

  24. Select Management Strategy: Initial Conservative Strategy Versus Initial Invasive strategy

  25. UA/NSTEMI ASA ( Clopidogrel if ASA intolerance) Invasive strategy Conservative strategy Anticoagulant therapy: Enoxaparin or UFH Bivalirudin Anticoagulant therapy: Enoxaparin or UFH Fondaparinux Pre cath: Add second antiplatelet agent: -Clopidogrel -GPIIb/IIIA inhibtor (IV eptifibatide or tirofiban) Initiate clopidogrel

  26. Next step per triage decision at angiography PCI: Clopidogrel (if not begun precath) Or Prasugrel Or GPIIB/IIIA inhibitor (if not begun precath CABG: Maintenance ASA Medical therapy: -D/C GPIIb/IIIainhibitor and give clopidogrel as per conservative strategy

  27. Initial Conservative management Strategy

  28. UA/NSTEMI Conservative strategy ASA + Anticoagulant therapy Enoxaparin, UFH, Bivalirudin, Fondaparinux Clpidogrel (30-600 mg→→ 75mg) -ASA continued indefinitely -Clpidogrel continued for at least 1 month and ideally up to 1 year

  29. UA/NSTEMI- conservative strategy Class 1 No subsequent features that necessitates CAG LV EF EF<40% EF>40% Stress testing Low risk High Risk • -ASA indefinitely • -Clopidogrel – 1 month (ideally up to 1 year) • -Discontinue IV GPIIb/IIIa inhibitor if started previously • Continue UFH for 48 hrs or administer • enoxaparin or fondaparinux max up to 8days or • duration of hospitalization CAG

  30. ACC/AHA noninvasive risk stratfication: high risk (>3% annual mortality rate) • severe resting LV dysfunction (LVEF<35%) • High risk TMT score (score≤ -11) • Severe exercise LV dysfunction (LVEF<35%) • Stress induced large perfusion defect (if ant.) • Stress induced multiple perfusion defects • Large fixed perfusion defect with LV dialatation or increased lung uptake (thallium 201) • Stress induced moderate perfusion defect with LV dialatation or increased lung uptake (thallium 201) • Echo wall motion abn.at low dose dobutamine • Stress echo evidence of extensive ischemia

  31. UA/NSTEMI- Conservative Strategy Class IIa Recurrent ischemic discomfort with ASA+ Clopidogrel+Anticoagulant treatment Add a GPIIb/IIIa inhibitor before diagnostic CAG Omit GPIIB/IIIa inhibitors if bivalirudin is selected as the anticoagulant & 300-600 mg clopidogrel was administered 6 hours earlier than planned CAG or PCI

  32. Management after Diagnostic Angiography in Patients with UA/NSTEMI Dx Angiography Select Post Angiography Management Strategy CABG PCI Medical therapy CAD on angiography No significant obstructive CAD on angiography • Cont ASA . • DC clopidogrel 5 to 7 d prior to elective CABG. • DC IV GP IIb/IIIa 4 h prior to CABG • Cont UFH • DC enoxaparin 12 to 24 h prior to CABG; • DC fondaparinux 24 h prior to CABG; • DC bivalirudin 3 h prior to CABG. Dose with UFH per institutional practice • Cont ASA • LD of clopidogrel if not given pre angio • & • IV GP IIb/IIIa if not started pre angio • DC ACT after PCI for uncomplicated cases • Cont ASA • LD of clopidogrel if not given pre angio • DC IV GP IIb/IIIa after at least 12 h if started pre angio • Cont IV UFH for at least 48 h or enoxaparin or fondaparinux for dur of hosp ; • either DC bivalirudin or cont at a dose of 0.25 mg/kg/hr for up to 72 h at physician‘s discretion . Antiplatelet and ACT at physician’s discretion (Class I, LOE: C)

  33. UA/NSTEMI- CABG selected as post angiography management Class 1 • - • Continue ASA • Discontinue clopidogrel - 5 days prior to CABG • (discontinue prasugrel - 7 days prior to CABG) • -Discontinue IV GPIIb/IIIa inhibitor (eptifibatide or tirofiban) 4 hrs before CABG. • Continue UFH • Discontinue enoxaparin & fondaparinux 12-24 hrs bfore CABG and dose with UFH per institutional practice • Discontinue bivalirudin 3 hours before CABG and dose with UFH as per institutional practice

  34. UA/NSTEMI- PCI has been selected as post angiography management Class 1A • - • Continue ASA • loading dose of thienopyridines if not given before CAG – • - clopidogrel 300-600 mg • - prasugrel 60 mg • IV GPIIa/IIIa inhibitor (abciximab, eptifibatide, tirofiban ) if not started before CAG (in troponin-positive and /or high risk patients) • Discontinue anticoagulant therapy after PCI for uncomplicated cases - Class IIa

  35. UA/NSTEMI –medical therapy is selected as management strategy + obstructive CAD -ASA -clopidogrel -discontinue IV GPIIb/IIIa inhibitor if started previously Anti coagulant therapy • Continue intravenous UFH for at least 48 h or until discharge if given • before diagnostic angiography • Continue enoxaparin or fondaparinux for duration of hospitalization or • up to 8 days. • Discontinue Bivalirudin

  36. UA/NSTEMI –medical therapy is selected as management strategy -No significant obstructive CAD- Antiplatelet and anticoagulant therapy at the discretion of physician Luminal irregularities with out flow limiting lesions –long term ASA

  37. UA/NSTEMI – conservative strategy -who do not undergo CAG or stress testing • ASA indefinitely • Clopidogrel for at least 1 month ( ideally up to 1 year) • Discontinue GPIIb/IIIa inhibitor if started previously • Continue UFH for 48 hrs • or • Enoxaparin or fondaparinux ( 8 days or dur.hosp.)

  38. Initial Invasive management strategy

  39. Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y Bavry AA, et al. J Am Coll Cardiol 2006;48:1319–1325. Reprinted with permission from Elsevier.CI = confidence interval; RR = relative risk.

  40. Relative Risk of Recurrent Nonfatal MI for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 2 y Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. CI = confidence interval; RR = relative risk. Reprinted with permission from Elsevier.

  41. Relative Risk of Recurrent UA Resulting in Rehospitalisation for Early Invasive Therapy Compared With Conservative Therapy at a Mean Follow-Up of 13 Months Bavry AA, et al. J Am Coll Cardiol 2006; 48:1319–1325. Reprinted with permission from Elsevier. CI = confidence interval; RR = relative risk; UA = unstable angina.

  42. - refractory angina - hemodynamic instability - arrhythmias - Elevated risk of clinical events Recommendations for initial invasive strategies Class I Initially stabilized high risk patients –reasonable to choose early invasive strategy (With in 12-12 hrs) Class IIa

  43. High risk clinical events • Recurrent angina/ischemia at rest • with low-level activities despite • intensive medical therapy • Elevated cardiac TnT or TnI • New/presumably new ST- • segment depression • Signs/symptoms of heart failure or new/worsening mitral regurgitation • High-risk findings from noninvasive testing • Hemodynamic instability • Sustained ventricular tachycardia • PCI within 6 months • Prior CABG • High risk score (e.g., TIMI, GRACE) • - LVEF < 40%)

  44. UA/NSTEMI Invasive strategy Dual –antiplatelet on presentation Initiate anticoagulant therapy : Enoxaparin or UFH Bivalirudin Before PCI- clopidogrel or IV GpIIb/IIIainhibitor-tirofiban or eptifibatide At the time of PCI- clopidogrel (if not started) or Prasugrel IV GpIIb/IIIa-tirofiban or eptifibatide (if not begun pre catheterization)

  45. Recommendations in whom PCI is planned (2011) Class 1 Clopidogrel loading 300-600 mg should be given as early as possible before or at the time of PCI Or Prasugrel 60 mg should be given promptly and not later than 1 hour after PCI once coronary artery anatomy is defined.

  46. Class III • No Abciximab to patients in whom PCI is • not planned. • Upstream GPIIa/IIIa inhibitors are not • recommended in • -TIMI score ≤ 2( low risk for ischemic events) • - at high risk of bleeding Prasugrel contraindicated in -Prior h/o TIA or stroke

  47. Duration and maintenance of thienopyridine therapy (2011) Class 1 Clopidogrel 75 mg daily or Prasugrel 10 mg daily Duration : Up to 12 months If the risk of morbidity because of bleeding outweighs the benefit by thienopyridine therapy earlier discontinuation can be considered

  48. Long term Antiplatelet therapy Class I Medical therapy BMS group DES group ASA 75-162 mg/d indefinitely & Clopidogrel 75 mg/d for at least 1 month and ideally up to 1 year ASA 162-325 mg/d (1 month) ↓ 75-162 mg/d (indefinitely) & Clopidogrel 75 mg/d or Prasugrel 10 mg/d (for at least 1 year) ASA 162-325 mg/d (SES-3months) (PES-6months) ↓ 75-162 mg/d (indefinitely) & Clopidogrel 75 mg/d Or prasugrel 10mg for at least 1 year

More Related