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Mauritius Medical Association

Mauritius Medical Association. Percutaneous Coronary Interventions (PCI) In Acute Coronary Thrombosis June 2008. Dr U.S RAMJUTUN, Consultant Cardiologist, Victoria Hospital. Anterior heart showing coronary vessels. Aorta. Left Main Coronary Artery. Right Coronary Artery. Left

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Mauritius Medical Association

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  1. Mauritius Medical Association Percutaneous Coronary Interventions (PCI) In Acute Coronary Thrombosis June 2008 Dr U.S RAMJUTUN, Consultant Cardiologist, Victoria Hospital

  2. Anterior heart showing coronary vessels Aorta Left Main Coronary Artery Right Coronary Artery Left Circumflex Branch Posterior Interventricular Left Anterior Descending Marginal Branch

  3. Location of infarctions Septal AMI V1, V2 Anterior AMI V3, V4 Lateral AMI V5, V6 - ( I, AVL ) Inferior AMI II, III, AVF

  4. Acute Myocardial Infarction (Wavefront phenomenon) Occlusive thrombus on a plaque of atheroma 15 minutes 2 hours 6 hours % necrosis 0% 50% 90%

  5. Wavefront phenomenon of ischaemic cell death 15 Minutes 40 Minutes Nonischaemic Ischaemic (viable) Necrotic 3 Hours >6 Hours

  6. Acute Coronary Syndrome • Initiating Events • 1 Plaque rupture • 2 Thrombus formation • 3 Vasoconstriction

  7. Plaque Rupture Lipid pool Lipid-rich plaque Plaque disruption Fissure Unstableangina/ Non-Q-wave MI Acute MI, Q-wave Occlusive thrombus Subocclusive thrombus

  8. Thrombus Formation Platelet Adhesion

  9. ThrombusFormation Platelet Aggregation

  10. Thrombus Formation Fibrin Threads

  11. Acute Coronary Syndrome SUDDEN DEATH Unstable Angina Coronary Arterial Thrombosis Non-Q-Wave Myocardial Infarction Q-Wave Myocardial Infarction SUDDEN DEATH SUDDEN DEATH

  12. Acute Coronary Syndrome( ACS ) History NSTE ACS STE ACS ECG Unstable angina Non Q wave MI Q wave MI Outcome

  13. ECG changes indicative of an AMI. • Evolving myocardial infarction has been established as: • Patients with ST segment elevation, i.e. new ST segment elevation at the J point with the cut off points 0.2mV in V1 through V3 and 0.1mV in other leads • or New LBBB • Established myocardial infarction may be defined by: • Q wave in leads V1 through V3, OR • Q wave 0.03s in leads I, II, aVL, aVF, V4, V5, • or V6.

  14. Evolution of an acute myocardial infarction A. B. C. > 1 Hour Onset 15 Minutes F. D. E. Months later Days Later > 24 Hours

  15. Elevation of cardiac markers 7x upper limit of normal Total CK 6x 5x 4x 3x 2x Troponin I CK-MB 1x 0 20 40 60 80 100 120 140 160 Hours from onset of infarction

  16. Management of Patients with ST Elevation ST elevation Aspirin+ClopidogrelBeta-blocker etc.  12 h > 12 h Eligible forthrombolysis Thrombolysiscontraindicated Not a candidate forreperfusion therapy Persistent symptoms ? Thrombolyse PrimaryPTCA or CABG No Yes Other medical therapy:ACE inhibitors? NitratesAnticoagulants ConsiderReperfusionTherapy

  17. Thrombolysis • Perhaps the most significant advances in the early treatment of acute myocardial infarction (AMI) in the last decade are reperfusion therapy (thrombolysis) and angioplasty. • Many clinical trials have established early thrombolytic therapy as a recommended treatment for patients with ST-segment elevation or new Left Bundle Branch Block. • Although thrombolysis is not without risk, the benefits, in terms of lives saved, far outweigh these risks.

  18. Benefits for Early Diagnosis and Thrombolytic Treatment 80 0-1 hrs 65/1000 Absolute 35-day Mortality Reduction Versus Treatment Delay Per 1000 Patients Treated 60 1-2 hrs 37/1000 40 2-3 hrs 29/1000 Absolute benefit per 1000 Rx patients 3-6 hrs 26/1000 6-12 hrs 18/1000 12-24 hrs 9/1000 20 0 0 3 6 9 12 15 18 21 24 Treatment delay (h)

  19. Contraindications and Cautions for Fibrinolysis in STEMI • Any prior intracranial hemorrhage • Known structural cerebral vascular lesion (e.g., arteriovenous malformation) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours Absolute Contraindications NOTE: Age restriction for fibrinolysis has been removed compared with prior guidelines.

  20. Contraindications and Cautions for Fibrinolysis in STEMI Absolute Contraindications • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months

  21. Contraindications and Cautions for Fibrinolysis in STEMI Relative Contraindications • History of chronic, severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110 mm Hg) • History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications • Traumatic or prolonged (> 10 minutes) CPR or major surgery (< 3 weeks)

  22. Contraindications and Cautions for Fibrinolysis in STEMI Relative Contraindications • Recent (< 2 to 4 weeks) internal bleeding • Noncompressible vascular punctures • For streptokinase: prior exposure (> 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

  23. Reperfusion Options for STEMI PatientsStep 1: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. • Fibrinolysis generally preferred • Early presentation ( ≤ 3 hours from symptom onset and delay to invasive strategy) • Invasive strategy not an option •  Cath lab occupied or not available •  Vascular access difficulties No access to skilled PCI lab • Delay to invasive strategy •  Prolonged transport Door-to-balloon more than 90 minutes •  > 1 hour vs fibrinolysis (fibrin-specific agent) now

  24. Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. • Invasive strategy generally preferred • Skilled PCI lab available Door-to-balloon < 90 minutes • High Risk from STEMI Cardiogenic shock, Killip class ≥ 3 • Contraindications to fibrinolysis, including increased risk of bleeding and ICH • Late presentation > 3 hours from symptom onset • Diagnosis of STEMI is in doubt

  25. Percutaneous coronary interventionsPCI(balloon angioplasty, stenting, debulking, brachytherapy etc) • Primary PCI • Rescue PCI • Facilitated PCI • Ischaemia driven PCI • Late PCI • Etc.

  26. Primary PCI for AMI • 1977- first PCI (Gruntzig) • 1979- first primary PCI (Rentrop P et al.) • 2003-metaanalysis of 23 randomized trials: superiority of primacy PCI compared to thrombolysis • Pivotal studies: PAMI (1993), GUSTO IIb(1997), DANAMI 2 (1997) PRAGUE 1&2(2000,2003) etc.

  27. Thank you

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