ACS Pearl and Pitfall_handout

8/13/2019 ACS Pearl and Pitfall_handout

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W. Wiwatworapan MD.

Cardiologist, Maharat Nakorn Ratchasima Hospital

Acute Coronary syndromePearl & Pitfall

Outline STEMI ACC guideline 2013

Management algorithm

Pitfall in STEMI

NSTE-ACS Management algorithm

Pitfall in NSTE-ACS


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STEMI


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SymptomRecognition Call toMedical System ED

Cath LabPreHospital

Delay in Initiation of Reperfusion TherapyIncreasing Loss of Myocytes

Treatment Delayed is Treatment Denied

Management Guideline


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Reperfusion Therapy for STEMI Patients

STEMI who candidate for reperfusion

In PCI-capable

center

In non-PCI-capable

center

Primary PCI

FMC-device time

90 min

Transfer for primary PCI

if FMC-device time 120 min

Fibrinolyticwithin 30 minutes

if FMC-device time > 120 min

Urgent transferfor PCI

If fail reperfusion

or reocclusion

Transferfor CAGwithin 3-24 hr

(pharmacoinvasive

strategy)PCI

or CABG

or Medication

DIDO 30 minutes

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction




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In PCI-capable

center

Primary PCI

FMC-device time

90 min

PCI

or CABG

or Medication



In non-PCI-capable

center

Fibrinolyticwithin 30 minutesif FMC-device time > 120 min

DIDO 30 minutes

Transfer for primary PCIif FMC-device time 120 min

PCI

or CABG

or Medication


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In non-PCI-capable

center



DIDO 30 minutes

Except

Posterior wall MI

Suspected acute Leftmain stenosis

Fibrinolytic Agents

Anaphylaxis

Should repeat dosewithin 6 months

Need adjunctiveanticoagulant Higher patency rate More complication


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Fibrinolytic Agents - Contraindications

Adjunctive Antiplatelet to SupportReperfusion With Fibrinolytic Therapy

!


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Adjunctive Anticoagulant to SupportReperfusion With Fibrinolytic Therapy



In non-PCI-capable

center

Fibrinolyticwithin 30 minutesif FMC-device time > 120 min

Urgent transfer

for PCI

If fail reperfusion

or reocclusion

Transferfor CAG

within 3-24 hr

(pharmacoinvasive

strategy)PCI

or CABG

or Medication

DIDO 30 minutes


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In PCI-capable

center

In non-PCI-capable

center

Primary PCI

FMC-device time

90 min

Transfer for primary PCI

if FMC-device time 120 min



Urgent transferfor PCI

If fail reperfusion

or reocclusion

Transferfor CAGwithin 3-24 hr

(pharmacoinvasive

strategy)PCI

or CABG

or Medication

DIDO 30 minutes

< 12-24 hr

Cardiogenic shock

Contraindication for

fibrinolytic

Inconclusive

Loading 2

antiplatelet

Loading 2

antiplatelet

Loading 2

antiplatelet

anticoagulant

Pitfall in STEMI


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Female 50 y, chest pain 1 h

A. Repeat ECGB. Refer for primary PCI

C. Fibrinolytic agent

D. Work up other cause of chest pain

F/U ECG 10 min later

A. Repeat ECG

B. Refer for primary PCI

C. Fibrinolytic agent

D. Work up other cause of chest pain


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Post SK 30 min

Post SK 60 min

At ER


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Post SK 70 min

A. Urgency refer for PCI

B. Refer for CAG in 3-24 hr

C. Optimize medication &

refer next few days

D. Medication only

Pearl & Pitfall In inconclusive ECG

Look for reciprocal change

Serial ECG

Or.. Echocardiogram if you can


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Pearl & Pitfall In Acute inferior wall MI (esp. RV infarct)

Carefully exam pulse 4 extremities

Consider CXR

Wide mediastinum

Calcium sign

Female 50 y, chest pain 1 hA. Repeat ECG in 10 minutes

B. Repeat ECG with V3R, V4R

C. Repeat ECG with V7-V9

D. Rx as UA/NSTEMI


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Pearl & Pitfall In ACS with suspected Posterior wall MI

Tall R in V1-2 with ST depression

ECG V7-9

EKG .Male 70 y, chest pain 1 h

A. Prinzmetalsangina

B. Acute RV infarct

C. Tako tsubo cardiomyopathy

D. Left main stenosis


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EKG 2

ST elevation in aVR ST elevation greater 0.5 mm in aVR in

NSTEMI with often very significant ST

depression in many leads (8)favors the

diagnosis of occlusion of left main trunk.

The 12 lead ECG in ST elevation myocardial infarction :a practical approach for clinicians


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Female 50 y, chest pain 1 h

A. Anterior wall MIB. Inferior wall MI

C. Lateral wall MI

D. Not MI

Pearl & Pitfall In other causes of ST elevation (Not MI)

No Dynamic change

No progression to Q wave

Involve > 1 coronary territories


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NSTE-ACS

What should you know aboutNSTE-ACS

Assessment of Likelihood of ACS

Early Hospital care

Early Risk Stratification

Invasive vs. Conservative Strategy

Pharmacotherapy

Long-term secondary prevention


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Likelihood of ACS

ACC/AHA UA/NSTEMI Guideline 2007

High Intermediate Low

Symptoms Chest or left arm

discomfort

reproducing prior

documented angina

Chest or left arm

discomfort

Symptom in absence

of any intermediate

likelihood character

History Know history of CAD > 70 years

Male, DM

Recent Cocaine use

Physical

Examination

Transient MR

Hypotension

Rales

Manifestation of

extracardiac vascular

disease

Chest pain

reproduced by

palpation

ECG ST deviation 1 mm

T wave inversion in

multiple lead

Q wave

ST depression 0.5

1 mm

Normal

Cardiac Biomarkers Positive Normal Normal

Early Hospital CareClass I

Bed rest & Telemetry

Oxygen (maintain saturation > 90%)

Nitrate

Oral Beta-blockers in 1st

24-hours if nocontraindications (IV Beta-blockers class IIa)

ACE-I in 1st24-hours for heart failure ofLVEF < 40% (Class IIa for all other patients)

Statin


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Early Hospital CareClass III

Nitrates if SBP < 90 mmHg or RV infarction

Nitrates within 24-hrs of Sildenafil or 48-hrs of

Tadalafil use

IR-CCB in absence of Beta-blockers

NSAIDs & COX-2 inhibitors

Early Risk Stratification Rapid clinical determination

Troponin is the preferred biomarker

If normal, repeat biomarker at 6-12 hours

after onset of symptoms


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Antman EM, et al. N Engl J Med. 1996;335:1342-1349.

TIMI III B Trial

N=1,404

Troponin I Levels to Predict the Riskof Mortality in ACS

4.78.3

13.2

19.926.2

40.9

0

1020

30

40

50

0/1 2 3 4 5 6/7Number of Risk Factors

14-d Death, MI, or UrgentRevascularization (%) 10 times

Antman EM, et al. JAMA.2000;284:835-842.

TIMI risk score

Age 65 years

3 risk factors for CAD

Prior stenosis > 50%

ST-segment deviation

2 anginal in 24 hours

Use of aspirin in 7 days

cardiac biomarkers


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JAMA 2004;291:2727-33

Management Strategies forNon ST elevation ACS

Definite/Possible ACSInitiate ASA, Beta-blockers, Nitrates, ECG monitor

Early Invasive Strategy

TIMI Risk Score 3

New ST segment deviation

Positive biomarkersHemodynamic instability

Refractory angina

PCI in past 6 months

CABG

LVEF < 40%

Conservative

TIMI Risk Score < 3

No ST segment deviation

Negative biomarkers

Recurrent symptoms

Heart failure

Serious arrhythmia

Stable

Assessment of EF

Stress TestCoronary angiography

LVEF < 40%Stress test +ve


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Antithrombotic in ACSAt least

2 Antiplatelet

1 Anticoagulant

Antiplatelet (At least 2)Clopidogrel Prasugrel Ticagrelor

Conservative X PCI Thrombolytic X XDose OD OD b.i.dVariability of

Response

++ + +Risk of Bleeding + ++ +Genotyping CYP 2C19 Not establish Not establishTransition toelective Sx 5 d 7 d 3-5 dAntiplatelet effect Slowwer Faster Faster

ASA +


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Anticoagulant (Indirect)Heparin LMWH Fondaparinux

Molecular Wt 15,000 5,000 1,728Target Xa and IIa Xa > IIa XaBioavailability 30% 90% 100%(hr) 1 4 17Renal excretion No Yes YesAntidote Complete Partial NoHIT


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Early Invasive Strategy

Initiate Anticoagulant (I A)

UFH (I A)

Enoxaparin (I A)

Bivalirudin (I B)

Fondaparinux* (I B)

Clopidrogrel (I A)

Prasugrel (I B)

Ticagrelor (I B)

IV GP IIb/IIIa inh (I A)

ASA (I A)

Clopidogrel if ASA intolerant (I B)

UFH if CAG

Bleeding ?

Should not switch from

UFH

Clopidogrel + GP IIb/IIIa

inh (IIa) : Favor if

Delay CAG

High risk feature

MACEBleeding

Use in PCI case only

NSTE-ACS

ASA intolerantClopidogrel 75 mg OD

Indefinite Therapy (IIa B)

ASA 75-162 mg OD

Indefinite Therapy (I A)

Medication

Clopidogrel 75 mg OD(I A) or

Ticagrelor 90 mg BID (I B)

At least 1 mo (I A) & up to 12 mo in

the absence of risk of bleeding (I B)

PCI

Clopidogrel 75 mg OD (I A) or

Ticagrelor 90 mg BID(I B) for 12 mo

Continuation > 12 months may be

considered in pt with a high risk of

thrombosis and a low risk of bleeding (IIb C)

Prasugrel 10 mg daily may be

Considered (12 mo) in the absence of :

Increased bleeding risk

Likely to undergo CABG within 7 days

History of stroke or TIA

Age > 75 years

Weight < 60 kg

(Class IIa, Level B) (I B for ACC)

Risk of stent

thrombosis

Canadian Journal of Cardiology 27 (2011) S1S59

ASA 162-325 mg LD(I A)

Clopidogrel 300-

600 mg LD before

or at time of PCI(I B)

Plasugrel at timeof PCI (I B)


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Secondary PreventionClass I Indications

Aspirin

Beta-blockers

ACE-I : CHF, LVEF


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Likelihood of ACS

2 antiplatelet +

1 anticoagulant +

Other medication

Reperfusion

Risk stratification Revascularization

1

2

3

4

5

W. Wiwatworapan MD.

Cardiologist, Maharat Nakorn Ratchasima Hospital

Acute Coronary syndromePearl & Pitfall

Documents

ACS Pearl and Pitfall_handout