Updates in Acute Coronary Syndromes Management Mohammad Zubaid, MB, ChB, FRCPC, FACC

1. Updates in Acute Coronary Syndromes Management Mohammad Zubaid, MB, ChB, FRCPC, FACC Professor of Medicine, Kuwait University Head, Division of Cardiology Mubarak Alkabeer Hospital Kuwait The 1st Kuwait-North American update in Internal Medicine 4th Medical Scientific Conference – Mubarak Alkabeer Hospital February 7, 2014 – Jumeirah hotel, Kuwait

2. From plaque formation to progression to clinical manifestations Plaque formation Clinical manifestations • STABLE • No symptoms • Silent ischemia • Stable angina Slow Risk factor Atherosclerosis progression • UNSTABLE • Unstable angina • NSTEMI • STEMI • Sudden cardiac death Accelerated Progression Atherothrombosis

3. Distribution of ACS type in KuwaitDischarge diagnosis 2534 patients

5. Gulf COAST 2012 Kuwait population

6. Pooled analysis of the short-term results from 23 randomized trials comparing primary PCI and fibrinolytic therapy in 7739 patients Stone G. Circulation 2008;118:538-551

7. Primary PCI Steg et al, EHJ 2012;33:2569-2619

8. Periprocedural antithrombotic medicationsin primary PCI Steg et al, EHJ 2012;33:2569-2619

9. Fibrinolytic therapy Steg et al, EHJ 2012;33:2569-2619

10. PCI post lysis Steg et al, EHJ 2012;33:2569-2619

11. Prehospital and in-hospital managementReperfusion stratergies within 24 h of FMC STEMI diagnosis Primary PCI capable center EMS or non primary-PCI capable center Preferably < 60 min PCI possible <120 min? Immediate transfer to PCI center Primary - PCI Yes No Preferably ≤ 90 min (≤ 60 min in early presenters) Preferably ≤ 30 min Rescue PCI Immediate transfer to PCI center Immediately No Successful fibrinolysis Immediate fibrinolysis Yes Preferably 3-24 h Coronary angiography Steg et al, EHJ 2012;33:2569-2619

12. Important treatment goals in the management of STEMI Steg et al, EHJ 2012;33:2569-2619

13. Components of delay in STEMI Reperfusion therapy Symptom onset Diagnosis FMC ≤ 10 min Patient delay ………..……………….... ………..………………......... ………..………………... System delay ………..………………................. Time to reperfusion therapy Wire passage in culprit artery (primary PCI) Start of lysis Steg et al, EHJ 2012;33:2569-2619

14. Reperfusion in eligible patientsPer country

15. Reperfusion in eligible patientsKuwait

16. Was reperfusion administered in time?

17. Reperfusion TimelineThrombolysis in Kuwait

18. Primary PCI experience Adan Hospital November 13 – December 30, 2013 Distribution of timeline

19. Primary PCI experience Adan Hospital November 13 – December 30, 2013 Distribution of timeline during and after normal working hours

20. Primary PCI experience Mubarak Alkabeer Hospital November 13 – December 30, 2013 Held off for two weeks in the middle Distribution of timeline

21. Primary PCI experience MKH vs. Adan Hospital November 13 – December 30, 2013 Distribution of timeline (values in mean)

22. Components of delay in STEMI Reperfusion therapy Symptom onset Diagnosis FMC ≤ 10 min Patient delay ………..……………….... ………..………………......... ………..………………... System delay ………..………………................. Time to reperfusion therapy Wire passage in culprit artery (primary PCI) Start of lysis Steg et al, EHJ 2012;33:2569-2619

23. Door to balloon in hospitals with and without cath labs in Kuwait Cardiology response time ECG to Cardiology Door to ECG Door to balloon Adan Hospital 9 64 7 4 Cardiology response time ECG to Cardiology Door to balloon Door to ECG Mubarak AlKabeer Hospital Ambulance trip time Ambulance notification Ambulance response 30 13 18 5 111 20 3

24. In-hospital cardiac catheterization

25. Prehospital and in-hospital managementReperfusion stratergies within 24 h of FMC STEMI diagnosis Primary- PCI capable center EMS or non primary-PCI capable center Preferably < 60 min PCI possible <120 min? Immediate transfer to PCI center Primary - PCI Yes No Preferably ≤ 90 min (≤ 60 min in early presenters) Preferably ≤ 30 min Rescue PCI Immediate transfer to PCI center Immediately No Successful fibrinolysis Immediate fibrinolysis Yes Preferably 3-24 h Coronary angiography Steg et al, EHJ 2012;33:2569-2619

26. PCI post lysis Steg et al, EHJ 2012;33:2569-2619

27. Kuwait Gulf COAST population Rates of inhospital cath for STEMI patients

28. Management of hyperglycemia in the acute phase of STEMI Steg et al, EHJ 2012;33:2569-2619

29. Routine therapies in the acute, subacute and long term phase of STEMI Steg et al, EHJ 2012;33:2569-2619

30. Routine therapies in the acute, subacute and long term phase of STEMI Steg et al, EHJ 2012;33:2569-2619

31. Adherence to medical therapy

32. Gulf COASTSTEMI/NSTEMI

33. From plaque formation to progression to clinical manifestations Plaque formation Clinical manifestations • STABLE • No symptoms • Silent ischemia • Stable angina Slow Risk factor Atherosclerosis progression • UNSTABLE • Unstable angina • NSTEMI • STEMI • Sudden cardiac death Accelerated Progression Atherothrombosis

35. Work up of ischemic chest pain Chest Pain Admission Working diagnosis Acute Coronary Syndrome normal or undetermined ECG Persistent ST-elevation ST/T– abnormalities ECG troponin rise/fall troponin normal Bio-chemistry Diagnosis STEMI NSTEMI Unstable Angina Hamm et al, EHJ 2011;32:2999-3054

37. Criteria for high risk with indicationfor invasive management Hamm et al, EHJ 2011;32:2999-3054

38. Gulf COAST Kuwait population

39. Decision – making algorithm in ACS 1.Clinical Evaluation 2. Diagnosis/Risk Assessment 3. Coronary angiography STEMI reperfusion urgent < 120 min ACS possible No CAD no/elective Hamm et al, EHJ 2011;32:2999-3054

40. Antithrombotic treatment in NSTE ACS Targets for antithrombics Antiplatelet Anticoagulation Tissue Factor Collagen Aspirin Plasma clotting cascade Fondaparinux ADP Clopidogrel Prasugrel Ticagrelor Thromboxane A2 Prothrombin AT LMWH Heparin Factor Xa Conformational activation of GPIIb/IIIa AT GPIIb/IIIa inhibitors Thrombin Platelet aggregation Bivalirudin Fibrinogen Fibrin Thrombus Hamm et al, EHJ 2011;32:2999-3054

42. Conclusions • Management of ACS has evolved rapidly over the past few years. • Early risk stratification and cardiac catheterization is a cornerstone in ACS management. • If we want to benefit our patients, it is important that we examine what we do. • Our ACS patients receive good medical therapy at discharge from hospital. • However, we rely heavily on lytic therapy for reperfusion in STEMI and it is not administered in efficient timing to get the most benefit from it. • In both STEMI and NSTE ACS, our use of cardiac catheterization falls short of guidelines recommendations.