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“Acute Coronary Syndrome”

“Acute Coronary Syndrome”. July 24, 2013. Item 72.

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“Acute Coronary Syndrome”

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  1. “Acute Coronary Syndrome” July 24, 2013

  2. Item 72 • A 78 year old man is evaluated in the ED with chest pain. The patient reports that the pain, which is present in the left substernal area, began at rest, and has been present for 12 hours. He reports no similar episodes of chest pain. Medical history is significant for hypertension and a 30-pack year history of ongoing tobacco use. His only medication is nifedipine. • On PE, temperature is 37.90C, BP 130/80 mm Hg, pulse rate is 72/minute and respiration rate is 12/min. BMI is 28. A normal carotid upstroke without carotid bruits is noted, jugular venous pulsations are normal and S1 and S2 are heard without murmurs. Lung fields are clear, distal pulses are normal and no peripheral edema is present.

  3. Item 72 (Con’t) • Serum creatinine kinase level is 500 units/L and troponin I level is 26 ng/mL. Lab findings are otherwise normal. • EKG shows sinus rhythm at 70/min; 2 mm ST-segment elevation in leads II, III and aVF; and 1 mm ST segment depression in leads V2 and V3. He is taken to the cardiac cath lab and found to have single vessel coronary disease with severe stenosis of the proximal left anterior descending coronary artery.

  4. Item 72 (Con’t) • Which of the following is the most appropriate treatment? • Coronary artery bypass surgery • Intracoronary thrombolytic therapy • Medical therapy • Primary percutaneous coronary intervention

  5. STEMI Care and Time to Treatment Goals • Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators. I IIa IIb III 2013 ACC/AHA Guideline A JACC 2013;61:e1-63

  6. STEMI Care and Time to Treatment Goals • Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours I IIa IIb III 2013 ACC/AHA Guideline A JACC 2013;61:e1-63

  7. STEMI Care and Time to Treatment Goals • Reperfusion therapy is reasonable for patients with STEMI within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population I IIa IIb III 2013 ACC/AHA Guideline B JACC 2013;61:e1-63

  8. Item 38: MKSAP • A 54 year old man is evaluated in the ED for acute coronary syndrome that began 30 minutes ago. He has type 2 diabetes mellitus and hypertension. He reports no history of bleeding or stroke. He has a remote history of peptic ulcer disease for which he takes no medications. Medications are lisinopril and glipizide. • On physical exam, he is afebrile, BP is 160/90 mm Hg, pulse rate is 80 and respiration 12/min. CV examination reveals a normal S1 and S2 without an S3 and no murmurs. Lung fields are clear.

  9. MKSAP: Item 38 • Serum troponin and creatinine kinase levels are pending. Hematocrit is 42% and platelet count is 220,000/L • EKG shows 3 mm ST segment elevation in leads V2 through V4 and a 1 mm ST segment depression in leads II, III and aVF. A chest radiograph is normal. • There is no cardiac cath lab present at the hospital and it would take approximately 1.5 hours to transfer the patient to the closest facility that performs PCI. -blockers, unfractionated heparin, clopidogrel and aspirin are initiated.

  10. MKSAP: Item 38 • Which of the following is the most appropriate management? • Abciximab and thrombolytic therapy • Await the results of troponin and CK • Thrombolytic therapy • Transfer for primary PCI

  11. STEMI Care and Time to Treatment Goals • If the symptom duration is within 3 hours and the expected door to balloon time minus the expected door to needle time is: • Within 1 hour, primary PCI is preferred • Greater than 1 hour, fibrinolytic therapy is generally preferred. I IIa IIb III 2004 ACC/AHA Guideline B Circulation 2004;110:588-636

  12. Door to Balloon Time for Transfer and Direct Arrival Patients, National CV Data Registry (NCDR) Am Heart J 2011;161:76-83 210 180 Transfer PCI 150 120 Target Door to Balloon Time Time (Minutes) Direct PCI 90 60 30 0 Year 2005 QI 2005 Q3 2006 Q1 2006 Q3 2007 Q1 2007 Q3

  13. Transfer and Direct PCI Door to Balloon Time Am Heart J 2011;161:76-83 50 90 minutes 40 Direct PCI = 79 min (n=86,382) 30 63.4% Percentage of Patients 20 Transfer PCI = 149 min 10 (n=29,248) 9.7% 0 2 3 4 5 6 1 Door to Balloon Time (hours)

  14. STEMI Care and Time to Treatment Goals • Immediate transfer to a PCI-capable hospital for primary PCI is recommended strategy for STEMI patients who initially arrive at or are transported to a non-PCI-capable hospital with a FMC-to-device time goal of 120 minutes or less. I IIa IIb III 2013 ACCF/AHA Guideline B

  15. STEMI Patient, First Medical Contact Non-PCI Capable Hospital PCI Capable Hospital Door In Door Out (DIDO) ≤30 mins FMC* to Device Time ≤120 min Anticipated FMC* to Device Time ≥120 min FMC* to Device Time ≤90 mins Transfer for Primary PCI Cath Lab for PCI Thrombolytic Therapy within 30 mins *FMC: First Medical Contact JACC 2013;61:e1-63

  16. Acute Coronary Syndrome Definition A constellation of clinical symptoms due to acute myocardial ischemia Circulation 2011,123:e426-e579

  17. Myocardial Infarction Definition Myocardial necrosis (or myocardial cell death) due to prolonged ischemia. Third Universal Definition of MI Circulation 2012,126:2020-2035

  18. Causes of Acute Coronary Syndrome • Atherosclerosis • Compression - Muscle bridges - Aortic aneurysm • Congenital - Anomalous origin - Anomalous course - Single artery • Drugs - Sumatriptan - Ergot alkaloids - Cocaine • Embolic - Vegetations - Tumor - Calcium • Aortic dissection • Intimal proliferation - Fibromuscular hyperplasia - Radiation • Vasospasm • Trauma • Arteritis

  19. 3 Major Causes of ACS • Atherosclerosis • Atherosclerosis • Atherosclerosis

  20. Types of Myocardial Infarction Type 1: Spontaneous MI due to plaque rupture, ulceration, fissuring, erosion, etc. Type 2: MI secondary to an ischemic imbalance Type 3: MI resulting in death and biomarkers are unavailable Type 4a: MI related to PCI Type 4b: MI related to stent thrombosis Type 5: MI related to CABG Circulation 2012;126:2020-2035

  21. MI Type 1

  22. Plaque Rupture

  23. Healed Plaque

  24. Erosion

  25. Vessel Lumen Progressive Narrowing of the Arterial Lumen Lipid Core Clot Atherosclerotic Vessel Progressive Narrowing (Time) Thrombotic Occlusion

  26. Plaque Rupture and Atherothrombosis Vessel Lumen Lipid Core Thrombus Atherosclerotic Vessel Plaque Rupture Platelet Adhesion Activation and Aggregation Thrombus Formation Thrombotic Occlusion MI Stroke Vascular Death Am J Med 1996;101:199-209

  27. Most MI’s Arise From Smaller Stenoses Baseline Study Circulation 1988;78:1157-1166

  28. Most MI’s Arise From Smaller Stenoses 13 Days Later Circulation 1988;78:1157-1166

  29. Most MI’s Arise From Smaller Stenoses Baseline Study Circulation 1988;78:1157-1166

  30. Most MI’s Arise From Smaller Stenoses 2 months later Circulation 1988;78:1157-1166

  31. Most MI’s Arise From Smaller Stenoses Circulation 1995;92:657-671 80 68% Asymptomatic 60 Symptomatic MI Patients (%) 40 18% 20 14% 0 > 70% < 50% 50-70% Percentage Stenosis

  32. Acute Coronary Syndrome Circulation 2002;105:2000-2004 PCI With Stent Systemic Medical Therapy to Stabilize Plaque • Aspirin • Clopidogrel/Prasugrel/Ticagrelor • Statins • ACE Inhibitors/ARBs • Beta Blockers • Smoking Cessation

  33. Multiple Plaques in ACS Circulation 2002;106:804-808 79% of patients had >1 plaque ruptured 40 29% 30 25% 21% MI Patients (%) 20 12.5% 10 7.5% 4.5% 0 3 4 5 Culprit Lesion 1 2 Number of Ruptured Plaques in Addition to Culprit Lesion Detected by IVUS

  34. The Asymptomatic Progression of CAD Initial Presentation 62% MEN (65.8 years) 46% ACS or Sudden Cardiac Death WOMEN (70.4 years) 0 10 20 30 40 60 70 50 Levy D, Textbook of CV Medicine 1998 AHA: Heart Disease and Stroke Statistics-2006 Update

  35. Ventricular Fibrillation

  36. Ventricular Fibrillation and Survival 1.0 0.8 0.6 Proportion Surviving 0.4 0.2 0 2 3 4 5 6 7 8 9 10 1 Minutes

  37. Ventricular Fibrillation

  38. Deaths due to Acute MI • In-hospital mortality had improved significantly • 1960’s – prior to introduction of CCUs, in-hospital mortality averaged ~25-30%. • 1980’s – CCU, pre-reperfusion era ~16% • 1990 - 2000’s – era of fibrinolysis, coronary interventions, those who participated in clinical trials, one month mortality is ~4-6% Eur HJ 2208;29:2909-2945

  39. Mortality in Acute MI Pre-Hospital 21% 24 Hours In-Hospital 8% 52% 48 Hours In-Hospital 30 Days 19% One-half of all deaths occur “in the field” within one hour after symptom onset

  40. Acute Coronary Syndrome • ST elevation myocardial infarction • Non-ST elevation myocardial infarction • Unstable Angina

  41. Hospitalizations in the US due to ACS UA/NSTEMI Acute Coronary Syndromes 1.57 Million Hospital Admissions 79% 21% STEMI 0.33 million admissions 1.24 million admissions 0.67 million UA 0.57 million NSTEMI Heart Disease and Stroke Statistics 2007 Update Circulation 2007;115:69-171 ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

  42. Rates of Acute MI, 1999 - 2008 JACC 2013;61e7 300 MI 250 200 Non-STEMI 150 Incidence Rate (No. of cases/100,000 per person-year) 100 STEMI 50 0 2006 2007 2008 1999 2000 2001 2002 2003 2004 2005 Year

  43. Call 911 Acute Coronary Syndrome • Typical Symptoms: • Central chest pain • Chest discomfort • Chest pressure • Chest tightness • Heaviness • Cramping or burning sensation • Indigestion or heartburn

  44. Acute Coronary Syndrome Symptoms of Acute MI Hospitalized Recommended Discouraged Self Transport Call 911 Ambulance Transport JACC 2008;51:210-247

  45. Percentage of Patients with ACS Calling 911 • National Registry of MI -2 Emergency Medical System 53% • Survey of confirmed ACS patients in 20 US communities Emergency Medical System 10-48% (23%) Driven by someone else 60% 16% Drove themselves Circulation May, 2011 e440

  46. Acute Coronary Syndrome • Physical signs: • No physical signs diagnostic of Acute MI • Activation of autonomic nervous system • Pallor • Sweating • Hypotension or narrow pulse pressure • Irregularities in heart rate, bradycardia, tachycardia • Third heart sound • Basal rales

  47. Acute Coronary Syndrome Symptoms of Acute MI Ambulance Self Transport 12-Lead ECG Hospital/ED Obtained and Interpreted <10 mins 12 Lead-ECG JACC 2008;51:210-247

  48. Hospitalizations in the US due to ACS STEMI Acute Coronary Syndrome 1.57 Million Hospital Admissions 21% 79% UA/NSTEMI 1.24 million Admissions per year 0.33 million Admissions per year Heart Disease and Stroke Statistics 2007 Update Circulation 2007;115:69-171 ACC/AHA 2009 Joint STEMI/PCI Guidelines Focused Update

  49. Occlusive thrombus(ST Elevation MI) LargeFissure SmallFissure Mural thrombus(unstable angina/non-ST elevation MI) Thrombus Acute Coronary Syndromes Pathophysiology Lipid Pool Macrophages Stress, tensile,internal Shear forces,external Fissure Atheroscleroticplaque Plaquerupture Fuster V et al. NEJM. 1992; 326: 310-318. Davies MJ et al. Circulation. 1990; 82 (Suppl II): II-38, II-46.

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