Acute Coronary Syndrome

Rich Derby, Lt Col, USAF MGMC Family Practice Program

Objectives

Define & delineate acute coronary syndrome Review Management Guidelines

Unstable Angina / NSTEMI STEMI

Review secondary prevention initiatives

Scope of Problem
(2004 stats)

CHD single leading cause of death in United States

452,327 deaths in the U.S. in 2004

1,200,000 new & recurrent coronary attacks per year 38% of those who with coronary attack die within a year of having it Annual cost > $300 billion

Expanding Risk Factors

Smoking Hypertension Diabetes Mellitus Dyslipidemia

Low HDL < 40 Elevated LDL / TG

Family Historyevent in first degree relative >55 male/65 female

Age-- > 45 for male/55 for female Chronic Kidney Disease Lack of regular physical activity Obesity Lack of Etoh intake Lack of diet rich in fruit, veggies, fiber

Acute Coronary Syndromes

Unstable Angina
Similar pathophysiology

Non-ST-Segment Elevation MI (NSTEMI)

Similar presentation and early management rules STEMI requires evaluation for acute reperfusion intervention

ST-Segment Elevation MI (STEMI)

Diagnosis of Acute MI STEMI / NSTEMI

At least 2 of the following

Ischemic

symptoms Diagnostic ECG changes Serum cardiac marker elevations

Diagnosis of Angina

Typical anginaAll three of the following

Substernal chest discomfort Onset with exertion or emotional stress Relief with rest or nitroglycerin

Atypical angina

2 of the above criteria

Noncardiac chest pain

1 of the above

Diagnosis of Unstable Angina

Patients with typical angina - An episode of angina

Increased in severity or duration Has onset at rest or at a low level of exertion Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain

Patients not known to have typical angina

First episode with usual activity or at rest within the previous two weeks Prolonged pain at rest

Unstable Angina
Non occlusive thrombus

NSTEMI
Occluding thrombus sufficient to cause tissue damage & mild myocardial necrosis ST depression +/T wave inversion on ECG Elevated cardiac enzymes

STEMI
Complete thrombus occlusion ST elevations on ECG or new LBBB Elevated cardiac enzymes More severe symptoms

Non specific ECG

Normal cardiac enzymes

Acute Management

Initial evaluation & stabilization Efficient risk stratification

Focused cardiac care

Evaluation

Efficient & direct history Initiate stabilization interventions

Occurs simultaneously

Plan for moving rapidly to indicated cardiac care

Directed Therapies are Time Sensitive!

Chest pain suggestive of ischemia

Immediate assessment within 10 Minutes
Initial labs and tests
12 lead ECG Obtain initial cardiac enzymes electrolytes, cbc lipids, bun/cr, glucose, coags CXR

Emergent care IV access Cardiac monitoring Oxygen Aspirin Nitrates

History & Physical Establish diagnosis Read ECG Identify complications Assess for reperfusion

Focused History

Aid in diagnosis and rule out other causes

Reperfusion questions

Palliative/Provocative factors Quality of discomfort Radiation Symptoms associated with discomfort Cardiac risk factors Past medical history especially cardiac

Timing of presentation ECG c/w STEMI Contraindication to fibrinolysis Degree of STEMI risk

Targeted Physical

Examination
Vitals Cardiovascular system Respiratory system Abdomen Neurological status

Recognize factors that increase risk

Hypotension Tachycardia Pulmonary rales, JVD, pulmonary edema, New murmurs/heart sounds Diminished peripheral pulses Signs of stroke

ECG assessment
ST Elevation or new LBBB STEMI
ST Depression or dynamic T wave inversions

NSTEMI
Non-specific ECG

Unstable Angina

Normal or non-diagnostic EKG

ST Depression or Dynamic T wave Inversions

ST-Segment Elevation MI

New LBBB

QRS > 0.12 sec L Axis deviation Prominent R wave V1-V3 Prominent S wave 1, aVL, V5-V6 with t-wave inversion

Cardiac markers

Troponin ( T, I)

CK-MB isoenzyme

Very specific and more sensitive than CK Rises 4-8 hours after injury May remain elevated for up to two weeks Can provide prognostic information Troponin T may be elevated with renal dz, poly/dermatomyositis

Rises 4-6 hours after injury and peaks at 24 hours Remains elevated 36-48 hours Positive if CK/MB > 5% of total CK and 2 times normal Elevation can be predictive of mortality False positives with exercise, trauma, muscle dz, DM, PE

Prognosis with Troponin

8
Mortality at 42 Days

7.5 % 6.0 % 3.7 %

7 6 5 4 3 2 1 0

3.4 % 1.0 %
831

1.7 %
174 148 134 50 67
9.0

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 Cardiac troponin I (ng/ml)

Risk Stratification
STEMI Patient?
Based on initial Evaluation, ECG, and Cardiac markers

YES

NO

- Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy

UA or NSTEMI
- Evaluate for Invasive vs. conservative treatment - Directed medical therapy

Cardiac Care Goals

Decrease

amount of myocardial necrosis Preserve LV function Prevent major adverse cardiac events Treat life threatening complications

STEMI cardiac care

STEP 1: Assessment

Time since onset of symptoms

90 min for PCI / 12 hours for fibrinolysis

Is this high risk STEMI?

KILLIP classification If higher risk may manage with more invasive rx

Determine if fibrinolysis candidate

Meets criteria with no contraindications Based on availability and time to balloon rx

Determine if PCI candidate

Fibrinolysis indications

ST segment elevation >1mm in two contiguous leads New LBBB Symptoms consistent with ischemia Symptom onset less than 12 hrs prior to presentation

Absolute contraindications for fibrinolysis therapy in patients with acute STEMI

Any prior ICH Known structural cerebral vascular lesion (e.g., AVM) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months

Relative contraindications for fibrinolysis therapy in patients with acute STEMI

History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg) History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks) Recent (within 2-4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase/anistreplase: prior exposure (more than 5 days ago) or prior allergic reaction to these agents Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding

STEMI cardiac care

STEP 2: Determine preferred reperfusion strategy

Fibrinolysis preferred if:

PCI preferred if:

<3 hours from onset PCI not available/delayed door to balloon > 90min door to balloon minus door to needle > 1hr Door to needle goal <30min No contraindications

PCI available Door to balloon < 90min Door to balloon minus door to needle < 1hr Fibrinolysis contraindications Late Presentation > 3 hr High risk STEMI

Killup 3 or higher

STEMI dx in doubt

Comparing outcomes

Comparing outcomes

Medical Therapy MONA + BAH

Morphine (class I, level C)

Analgesia Reduce pain/anxietydecrease sympathetic tone, systemic vascular resistance and oxygen demand Careful with hypotension, hypovolemia, respiratory depression

Oxygen (2-4 liters/minute) (class I, level C)

Up to 70% of ACS patient demonstrate hypoxemia May limit ischemic myocardial damage by increasing oxygen delivery/reduce ST elevation

Nitroglycerin (class I, level B)

Analgesiatitrate infusion to keep patient pain free Dilates coronary vesselsincrease blood flow Reduces systemic vascular resistance and preload Careful with recent ED meds, hypotension, bradycardia, tachycardia, RV infarction

Aspirin (160-325mg chewed & swallowed) (class I, level A)

Irreversible inhibition of platelet aggregation Stabilize plaque and arrest thrombus Reduce mortality in patients with STEMI Careful with active PUD, hypersensitivity, bleeding disorders

Beta-Blockers (class I, level A)

14% reduction in mortality risk at 7 days at 23% long term mortality reduction in STEMI Approximate 13% reduction in risk of progression to MI in patients with threatening or evolving MI symptoms Be aware of contraindications (CHF, Heart block, Hypotension) Reassess for therapy as contraindications resolve

ACE-Inhibitors / ARB (class I, level A)

Start in patients with anterior MI, pulmonary congestion, LVEF < 40% in absence of contraindication/hypotension Start in first 24 hours ARB as substitute for patients unable to use ACE-I

Heparin (class I, level C to class IIa, level C)

LMWH or UFH (max 4000u bolus, 1000u/hr)

Indirect inhibitor of thrombin less supporting evidence of benefit in era of reperfusion Adjunct to surgical revascularization and thrombolytic / PCI reperfusion 24-48 hours of treatment Coordinate with PCI team (UFH preferred) Used in combo with aspirin and/or other platelet inhibitors Changing from one to the other not recommended

Additional medication therapy

Clopidodrel (class I, level B)

Irreversible inhibition of platelet aggregation Used in support of cath / PCI intervention or if unable to take aspirin 3 to 12 month duration depending on scenario

Glycoprotein IIb/IIIa inhibitors

(class IIa, level B) Inhibition of platelet aggregation at final common pathway In support of PCI intervention as early as possible prior to PCI

Additional medication therapy

Aldosterone blockers (class I, level A)

Post-STEMI patients
no significant renal failure (cr < 2.5 men or 2.0 for women) No hyperkalemis > 5.0 LVEF < 40% Symptomatic CHF or DM

STEMI care CCU

Monitor for complications:

recurrent ischemia, cardiogenic shock, ICH, arrhythmias

Review guidelines for specific management of complications & other specific clinical scenarios

PCI after fibrinolysis, emergent CABG, etc

Decision making for risk stratification at hospital discharge and/or need for CABG

Unstable angina/NSTEMI cardiac care

Evaluate for conservative vs. invasive therapy based upon:

Risk

of actual ACS TIMI risk score ACS risk categories per AHA guidelines

Low
Intermediate

High

Risk Stratification to Determine the Likelihood of Acute Coronary Syndrome

Assessment
Findings indicating HIGH likelihood of ACS Findings indicating

INTERMEDIATE
likelihood of ACS in absence of highlikelihood findings

Findings indicating LOW likelihood of ACS in absence of high- or intermediate-likelihood findings

Probable ischemic symptoms Recent cocaine use

History

Chest or left arm pain or discomfort as chief symptom Reproduction of previous documented angina Known history of coronary artery disease, including myocardial infarction New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales

Chest or left arm pain or discomfort as chief symptom Age > 50 years

Physical examination

Extracardiac vascular disease

Chest discomfort reproduced by palpation

ECG

New or presumably new transient ST-segment deviation (> 0.05 mV) or Twave inversion (> 0.2 mV) with symptoms Elevated cardiac troponin T or I, or elevated CK-MB

Fixed Q waves Abnormal ST segments or T waves not documented to be new

T-wave flattening or inversion of T waves in leads with dominant R waves Normal ECG Normal

Serum cardiac markers

Normal

TIMI Risk Score

Predicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days

ACS risk criteria

Low Risk ACS
No intermediate or high risk factors <10 minutes rest pain

Intermediate Risk ACS

Moderate to high likelihood of CAD >10 minutes rest pain, now resolved T-wave inversion > 2mm Slightly elevated cardiac markers

Non-diagnositic ECG
Non-elevated cardiac markers Age < 70 years

High Risk ACS

Elevated cardiac markers New or presumed new ST depression Recurrent ischemia despite therapy Recurrent ischemia with heart failure High risk findings on non-invasive stress test Depressed systolic left ventricular function Hemodynamic instability Sustained Ventricular tachycardia PCI with 6 months Prior Bypass surgery

Low risk

Intermediate

risk

High risk

Chest Pain center

Conservative therapy

Invasive therapy

Invasive therapy option UA/NSTEMI

Coronary angiography and revascularization within 12 to 48 hours after presentation to ED For high risk ACS (class I, level A) MONA + BAH (UFH) Clopidogrel

20% reduction death/MI/Stroke CURE trial 1 month minimum duration and possibly up to 9 months

Glycoprotein IIb/IIIa inhibitors

Conservative Therapy for UA/NSTEMI

Early revascularization or PCI not planned MONA + BAH (LMW or UFH) Clopidogrel Glycoprotein IIb/IIIa inhibitors

Only in certain circumstances (planning PCI, elevated TnI/T)

Surveillence in hospital

Serial ECGs Serial Markers

Secondary Prevention

Disease

HTN, DM, HLP smoking, diet, physical activity, weight

Education, cardiac rehab program

Behavioral

Cognitive

Secondary Prevention disease management

Blood Pressure
Goals < 140/90 or <130/80 in DM /CKD Maximize use of beta-blockers & ACE-I

Lipids
LDL < 100 (70) ; TG < 200 Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids

Diabetes

A1c < 7%

Secondary prevention behavioral intervention

Smoking cessation

Cessation-class, meds, counseling

Physical Activity
Goal 30 - 60 minutes daily Risk assessment prior to initiation

Diet
DASH diet, fiber, omega-3 fatty acids <7% total calories from saturated fats

Thinking outside the box

Or maybe just move.

Secondary prevention cognitive

Patient education

In-hospital discharge outpatient clinic/rehab

Monitor psychosocial impact

Depression/anxiety assessment & treatment Social support system

Medication Checklist after ACS

Antiplatelet agent

Aspirin* and/or Clopidorgrel

Lipid lowering agent

Statin* Fibrate / Niacin / Omega-3

Antihypertensive agent
Beta blocker* ACE-I*/ARB Aldactone (as appropriate)

Prevention news
From 1994 to 2004 the death rate from coronary heart disease declined 33%... But the actual number of deaths declined only 18% Getting better with treatment But more patients developing disease need for primary prevention focus

Summary

ACS includes UA, NSTEMI, and STEMI Management guideline focus

Immediate assessment/intervention (MONA+BAH) Risk stratification (UA/NSTEMI vs. STEMI) RAPID reperfusion for STEMI (PCI vs. Thrombolytics) Conservative vs Invasive therapy for UA/NSTEMI

Aggressive attention to secondary prevention initiatives for ACS patients

Beta blocker, ASA, ACE-I, Statin