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DISC TWO – CINEANGIOGRAM-BASED CASE STUDIES

DISC TWO – CINEANGIOGRAM-BASED CASE STUDIES. GO. Table of Contents – Disc Two. Please insert Disc One for Access to: CATH Panel Report 2003 Enoxaparin Dosing Guidelines for ACS Clinical Trials – Data and Summaries Clinical Presentations Animated Clinical Pathways

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DISC TWO – CINEANGIOGRAM-BASED CASE STUDIES

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  1. DISC TWO – CINEANGIOGRAM-BASED CASE STUDIES

  2. GO Table of Contents – Disc Two Please insert Disc One for Access to: CATH Panel Report 2003 Enoxaparin Dosing Guidelines for ACS Clinical Trials – Data and Summaries Clinical Presentations Animated Clinical Pathways Clinical CME-Accredited Symposia Videocast Clinical Cardiology CME-Accredited Monographs Quick Consult Clinical Trials Guide Clinical Pathways – PDF Files Cineangiogram-Based Clinical Case Studies Note: Click on the “GO” hearts to access individual listings for a category. You must be online with an Internet connection to utilize the “Free CME” links on the CATH Panel Report, the clinical monographs, and the Symposia Videocast (located on Disc One)

  3. ACS Problem Based Learning Case Studies Edward T. A. Fry, MD, FACC, FSCAI Director, Interventional Cardiology St.Vincent Hospital, Indianapolis, IN The Indiana Heart Center The Care Group, LLC Indiana Heart Institute

  4. ACS PBL Case #1

  5. ACS PBL: Case #1 J.B. 65 y/o female, retired pathologist Presents to ER at 9 PM with 2 hrs SSCP and dyspnea, at rest. Better after TNG SL x 3 at home. Some DOE x 2 wks. PMHx: Stent in LAD 8/00, hyperlipidemia, smokes, HTN, bilateral mastectomies for breast cancer, TAH (no HRT), NKA Meds: ASA, Lisinopril, Atorvastatin, Metoprolol, Fluoxetine, Raloxifene

  6. Case 1: EKG #1

  7. ACS PBL: Case #1 BP 160/90 HR 64 RR 16 135 lbs. Sat.=93% on 2 lit. PE: Chest – clear, bilat. mastectomies Cor – RRR, S4, I/IV systolic murmur at the apex, no S3 Abd – Soft, nontender, no HSM Ext – No edema. Pulses normal. Left carotid bruit

  8. ACS PBL: Case #1 Labs (ER): WBC=7.1 Hgb=13.0 Plts=315K K+=3.4 Lytes otherwise WNL Cr=1.1 BUN=22 Gluc=101 CK=77 MB=2.8 TnI<0.3 CXR: NAD Monitor: NSR, BBB. No ectopy.

  9. ACS PBL: Case #1 Issues upon presentation: • Initial diagnostic impression / differential • Initial treatment(s) • Additional labs, work-up • Disposition • Risk assessment

  10. ACS PBL: Case #1 Admitted to Critical Care Unit NPO except meds ASA 325 mg q AM O2 4 lit/min IV-NTG at 20 ug/min Eptifibatide 180 ug/kg bolus, 2 ug/kg/min Enoxaparin 30 mg IV x 1 in ER and 60 mg sc q 12 hr (1st dose at 10 PM) Home meds continued

  11. ACS PBL: Case #1 3:20 AM: More CP (5/10), treated with SL NTG x 2, MSO4 4 mg IV, Pain is “improving”. ECG: T-wave inversion, ST dep. V5-6 4 hr TnI <0.3 5:00 AM: Recurrent CP (8/10). ECG – No change. Rx’d with TNG SL, MSO4

  12. Case 1: EKG #2 v

  13. ACS PBL: Case #1 6:00 AM: Emergent Cath (8 hrs after last enoxaparin given)

  14. Press Space Bar or Enter to Advance Cines to next image Left Coronary angiogram – significant ruptured plaque visible Right coronary angiogram – moderate disease visible Case #1 Stent successfully placed

  15. ACS PBL: Case #1 Emergent PCI: Eptifibatide continued at 2 ug/kg/min for 12 hrs post PCI. Heparin? Enoxaparin: 0.3 mg/kg IV at PCI 3.5 x 18 mm stent deployed, post- dilated to 4.0 mm. Sheath removal?

  16. PEPCI: Enoxaparin SC and IV Pharmacokinetics

  17. Dosing of Enoxaparin in PCI Enox. dose At PCI (iv) Last dose of Enoxaparin Pre-PCI Abcix. Trial (none) PEPCI 0.3 mg/kg 0.3 mg/kg NICE-3 (none) (none) Collet (none) NICE-3 1.0 mg/kg (none) NICE-1 (none) (none) 0.75 mg/kg NICE-4 -12 hr -8 hr PCI 12 hr

  18. ACS PBL: Case #1 • CP resolved. ECG – NSR, LBBB, no change • Sheath removed 4 hrs after start of PCI (10:00 AM) • Subsequent enzymes were negative for MI • Transferred to telemetry floor • Clopidogrel 300 mg x 1, then 75 mg daily. • Continued on ACE-I, Beta-Blocker, Statin, ASA • Released home next AM

  19. ACS PBL Case #2

  20. PBL Case #2: Acute MI • S.S. 47 y/o male, Indianapolis Airport Security Guard, new onset severe CP at 4:00 AM • Presents to ER at 5:00 AM. BP=150/85, HR=84 (NSR), 220 lbs, diaphoretic, Sat=94% RA, Chest-clear, S4, RRR, No murmur, No edema • No hx of PUD, CVA, TIA, HTN, DM, MI • Strong family hx. Smokes 1 ½ packs/day

  21. Case 2: EKG #1

  22. PBL Case #2: AMI – Rx Options • Thrombolysis • Agent: TNK vs r-PA vs t-PA • Combination therapy? • Heparin: UFH vs enoxaparin • Transfer for Primary PCI (30 miles)? • Facilitated PCI

  23. PBL Case #2: AMI • ASA 81 mg chewable x4, IV TNG • Enoxaparin 30 mg IV bolus x 1 followed immediately by 100 mg SC and then q 12 hrs.* • TNK 50 mg IV bolus x 1 at 5:30 AM • Metoprolol 25 mg PO BID • 7:00 AM CP better, ST elevation nearly gone • Arrangements for transfer to St. Vincent made at 7:30 AM

  24. PBL Case #2: AMI • Patient arrives at St. Vincent at 9:00 AM initially pain free. • At 9:30 AM, he has recurrent CP and inferior ST elevation • Emergency cath and possible PCI recommended

  25. Press Space Bar or Enter to Advance Cines to next image Right coronary angiogram – significant occlusion Stent is placed. Balloon is inflated at thrombis location Left coronary angiogram – No disease visible Catheterization successful Case #2

  26. PBL Case#2: AMI • Rescue PCI: • Heparin / Enoxaparin dosing? • GP IIb/IIIa inhibitor therapy? • Sheath management? • Reheparinization / LMWH?

  27. PCI Following Enoxaparin Time from last dose of Enoxaparin Time after PCI 12 hr 8 hr 0 4-8 hr Sheath Pull* 0.3 mg/kg IV None * And >12 hr after TNK given,

  28. Case 2: EKG #2

  29. PCI Following Enoxaparin Time from last dose of Enoxaparin Time after PCI 12 hr 8 hr 0 4-8 hr Sheath Pull* 0.3 mg/kg IV None ENOX < 260 ENOX > 260 ENOX < 200-250 * And >12 hr if TNK given,

  30. LMWH in the Invasive Treatment of ACS and MI: Take Home Message • Enoxaparin is superior to UFH in ACS’s and in thrombolysis with TNK • Enoxaparin has favorable interactions with platelets that enhance use of GP IIb/IIIa inhibitors. • Enoxaparin can be used safely and effectively in PCI with or without a GP IIb/IIIa inhibitor.

  31. LMWH in the Invasive Treatment of ACS and MI: Take Home Message • Patients can be easily transitioned from medical stabilization with enoxaparin to an early invasive strategy of care including PCI in ACS’s and AMI. • Use of enoxaparin should not be an obstacle to cath or PCI. An early invasive strategy of care should not be an obstacle to use of enoxaparin.

  32. LMWH in the Invasive Treatment of ACS and MI: Take Home Message • Use of UFH in PCI is historical and emperic, founded on broad experience, but little data. • Growing body of data supports the use of LMWH in PCI in multiple clinical settings. • LMWH may be superior to UFH in PCI.

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