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Coronary syndromes

Coronary syndromes. Giuseppe Biondi-Zoccai , MD Sapienza University of Rome , Italy giuseppe.biondizoccai@uniroma1.it. Learning goals. Preamble Definitions Impact Approach Management. Learning goals. Preamble Definitions Impact Approach Management. Time machine.

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Coronary syndromes

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  1. Coronary syndromes Giuseppe Biondi-Zoccai, MD Sapienza University ofRome, Italy giuseppe.biondizoccai@uniroma1.it

  2. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  3. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  4. Timemachine Teixeraet al, Int J Cardiol 2013

  5. Myocardialinfarction in the 60’s

  6. Myocardialinfarctiontoday

  7. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  8. Differentialdiagnosisofcoronarysyndromes • Asymptomatic CAD • Chronicstable angina • Unstable angina • Acute myocardialinfarction In addition: • Ischemiccardiomyopathy • Suddenischemiccardiacdeath • Myocardial ischemia due tospasm or mismatch Wijnset al, Eur Heart J 2010

  9. Fromdiagnosistoriskstratification http://en.wikipedia.org/wiki/Acute_coronary_syndrome

  10. Thirduniversaldefinitionofmyocardialinfarction • Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: • Symptomsof ischemia. • New or presumed new significant ST-segment–T wave (ST–T) changes or new left bundle branch block (LBBB). • Development of pathological Q waves in the ECG. • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. • Identification of an intracoronary thrombus by angiography or autopsy. Thygesenet al, Eur Heart J 2012

  11. Thirduniversaldefinitionofmyocardialinfarction: subtypes Thygesenet al, Eur Heart J 2012

  12. Thirduniversaldefinitionofmyocardialinfarction: subtypes • 1 - Spontaneous MI: related to plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in one or more of the coronary arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis. • 2 - SecondaryMI: In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. spasm, anemia, etc. • 3 - FatalMI: Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB. Thygesenet al, Eur Heart J 2012

  13. Thirduniversaldefinitionofmyocardialinfarction: subtypes • 4a – Relatedto PCI: >5 x 99th percentile URL in patients with normal baseline values (>99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, symptoms, new ischemic ECG changes, angiographic loss of patency, or imaging demonstration of MI. • 4b – Relatedtostentthrombosis: angiography or autopsyevidence and cardiac biomarkers values with at least one value above the 99th percentile URL. • 5 – Relatedto CABG: cardiac biomarker values >10 x 99th percentile URL. In addition, new pathological Q waves or new LBBB, or angiographic documented new graft or new native coronary artery occlusion, or imaging evidence of MI. Thygesenet al, Eur Heart J 2012

  14. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  15. Stable CAD in diabetics Farkouhet al, New Engl J Med 2012

  16. Stable CAD MACCE (%) Farkouhet al, New Engl J Med 2012

  17. Stable CAD in diabetics Farkouhet al, New Engl J Med 2012

  18. Medicallymanaged ACS Roeet al, New Engl J Med 2012

  19. Invasivelymanaged ACS Cardiovascualrdeath, MI, or stroke (%) Wallentinet al, New Engl J Med 2009

  20. STEMI Cardiovascualrdeath, MI, or stroke (%) Montalescotet al, Lancet 2012

  21. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  22. High-sensitivitytroponins Thygesenet al, Eur Heart J 2012

  23. Ischemicscores Discrimination (c statistic) D’Ascenzoet al, ContempClinTrials 2012

  24. Bleedingscores www.crusadebleedingscore.com

  25. SYNTAX score www.syntaxscore.com

  26. SYNTAX score www.syntaxscore.com

  27. SYNTAX score Farooqet al, Lancet 2013

  28. Learninggoals • Preamble • Definitions • Impact • Approach • Management

  29. Radialaccess Romagnoli et al, J Am CollCardiol 2012

  30. Prehospitalthrombolysis Death, shock, CHF, or reinfarction (%) Armstrong et al, New Engl J Med 2013

  31. Bivalirudin NACE (%) MACE (%) Kastrati et al, New Engl J Med 2008

  32. Prasugrel Cardiovasculardeath, MI or stroke Non-CABG-related TIMI major bleeding Wiviottet al, New Engl J Med 2008

  33. Ticagrelor Vasculardeath, MI or stroke Major bleeding Months Months Wallentinet al, New Engl J Med 2009

  34. Adjustedindirectcomparison Biondi-Zoccaiet al, Int J Cardiol 2011

  35. Cangrelor Stentthrombosis (%) Bhattet al, New Engl J Med 2013 (57% CSA, 25% NSTEACS, 18% STEMI)

  36. Rivaroxaban Mega et al, New Engl J Med 2012

  37. Beta-blockers Cardiovasculardeath, MI or stroke (%) Bangalore et al, JAMA 2012

  38. Statins Patti et al, Circulation 2011

  39. Fractional flow reserve De Bruyneet al, New Engl J Med 2012

  40. CABG or PCI? Mohret al, Lancet 2013

  41. Off-pump vs on-pump CABG Palmerini et al, J Am CollCardiol 2012; Palmerini et al, Am Heart J 2013

  42. Drug-elutingstents Palmerini et al, Lancet 2012

  43. Drug-elutingstents Palmerini et al, Lancet 2012

  44. Drug-elutingballoons Byrne et al, Lancet 2013

  45. Bioresorbablestents Palmerini et al, Lancet 2012

  46. Bioresorbablestents Serruyset al, Lancet 2009

  47. Take home messages • Developments in the fieldofcoronarysyndromesrepresentanoutstandingexampleof the successfulcombinationofpathophysiologic, diagnostic, prognostic, pharmacologic and deviceresearch. • Despite the dramaticprognosticimprovement, severalissuesremainunsettled. • In addition, the worseningplethoraof management optionswillmake the treatment ofindividualpatients more and more complex, unlessrisk-beneficial and cost-beneficialtailoringtools are developed.

  48. Manythanksforyourattention Fortheseslides and furtherones on similartopicsfeel free tovisit: www.metcardio.org/slides.html Foradditionaldetails or queriesfeel free tocontact me directly: giuseppe.biondizoccai@uniroma1.it

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