Acute Myocardial Infarction (Acute MI)

1. Acute Myocardial Infarction(Acute MI) Prof. Arthur Pollak, M.D. Director, Acute Cardiac Care Center Director of Clinical Research Heart Institute Hadassah – Hebrew University Medical Center

3. Atherosclerosis is a Generalized Disease

4. Comparison of Age at First Myocardial Infarction Among Women and Men Across Geographic Regions Yusuf S: The INTERHEART Study. Lancet 2004;364:937

5. Age distribution in Hadassah CCU

6. RISK FACTORS FOR CAD %

7. NUMBER OF CORONARY ARTERIES OCCLUDED > 80% NUMBER OF CORONARY ARTERIES INVOLVED

8. The Effect of Race & Sex on Physicians’ Recommendations for Cardiac Catheterization Referral for Catheterization Race & sex influence how physicians interpret & managechest pain Schulman KA, et al. NEJM 1999;340:618-616

10. Atheroma Morphology by Ultrasound “Soft” Lipid-Laden Plaque “Hard” Fibrous Plaque

11. Plaque Rupture

12. Acute coronary syndromes

13. The Normal Heart Acute anterior wall MI

14. Recent large Antero-Septal Myocardial Infarction

15. Ebers Papyrus

16. Clinical Presentation • Typical Chest Pain • pressure, heaviness, burning • irradiation to arms, neck, jaw, upper abdomen, sometimes to the back • Shortness of breath • pulmonary congestion → pulmonary edema • Nausea, Vomiting • Cold sweating • Dizziness → look for arrhythmias • Anxiety, fear of death (!) • Obtain ECG as quickly as possible (< 10 min) !

17. Physical examination • Pallor • Cold and clammy extremities • Cold sweat on forehead and palms • Bilateral crackles / crepitations / rales on lung auscultation (mostly basal) • Muffled heart sounds, sometimes S4 • Apical systolic murmur → look for mitral regurgitation • Pulse: tachycardia , bradycardia • Blood pressure: high , low

20. ECG on admission: Anterior ST segment elevation

23. Thrombolysis

24. Importance of time to reperfusionin patients undergoing PPCI for STEMI NCDR - National Cardiovascular Data Registry (USA) Cannon CP. JAMA 2000;283:2941 ;; Rathore SS. BMJ 2009;338:b1807

25. Importance of time to reperfusionin patients given fibrinolysis for STEMI NCDR - National Cardiovascular Data Registry (USA) Cannon CP. JAMA 2000;283:2941 ;; Rathore SS. BMJ 2009;338:b1807

26. Time to thrombolysis and 35-day mortality

27. STEMI – time is muscle

28. Reperfusion Therapy • Primary Percutaneous Coronary Intervention (PPCI) – preferred! (especially in cardiogenic shock, heart failure, arrhythmia, late presentation) • Thrombolytic Therapy – Fibrinolysis – if early! • Tissue Plasminogen Activator (tPA) • Streptokinase • Risk of Bleeding → Contraindications: • History of Intracranial Hemorrhage • History of Ischemic Stroke within 3 months • Cerebral vascular malformation or intracranial malignancy • Suspected Aortic Dissection • Active bleeding or known bleeding diathesis • Significant closed-head or facial trauma within 3 months • Traumatic or prolonged (>10 min) cardiac resuscitation

29. Coronary Angiogram 1 5 LAD 2 7 LCX 11 RCA 6 3 12 8 9 4 13 15 10 14

30. Thrombolysis Angioplasty

31. Isolated LAD Lesion

32. Reperfusion Therapy • Primary Percutaneous Coronary Intervention (PPCI) – preferred! (especially in cardiogenic shock, heart failure, arrhythmia, late presentation) • Thrombolytic Therapy – Fibrinolysis – if early! • Tissue Plasminogen Activator (tPA) • Streptokinase • Risk of Bleeding → Contraindications: • History of Intracranial Hemorrhage • History of Ischemic Stroke within 3 months • Cerebral vascular malformation or intracranial malignancy • Suspected Aortic Dissection • Active bleeding or known bleeding diathesis • Significant closed-head or facial trauma within 3 months • Traumatic or prolonged (>10 min) cardiac resuscitation

33. TIMI grade 3 coronary flow is associated with improved survival

34. Medical therapy (initial) • Oxygen (if O2 saturation < 95%) • Aspirin (300-325 mg) to be chewed • Sublingual Nitroglycerine (tablets or spray) • Morphine sulfate (2-4 mg) I.V. (intravenous) • Furosemide (40 mg) if pulmonary congestion • Beta blocker (5 mg metoprolol I.V., repeat X3) • High-dose statin (atorvastatin 80 mg orally) • Treat ventricular arrhythmia promptly (!) • Obtain blood for cardiac biomarkers (Troponin-T, CPK, hemoglobin, electrolytes, coagulation, kidney and liver function)

35. Adding Clopidogrel to Aspirinin STEMI (COMMIT trial)

36. TRITON – TIMI 38:patients with ACS undergoing PCI 13,608 patients (10,074 UA/NSTEMI ; 3,534 STEMI) Wiviott SD. TRITON – TIMI 38. N Engl J Med 2007;357:2001

37. TRITON – TIMI 38:patients with STEMI undergoing PCI

38. K-M estimate of time to first primary efficacy event (composite of CV death, MI or stroke) 18,624 patients (10,174 UA/NSTEMI ; 8,430 STEMI) 13 12 11.7 Clopidogrel 11 10 9.8 9 Ticagrelor 8 7 Cumulative incidence (%) 6 5 4 NNT = 54 3 2 HR 0.84 (95% CI 0.77–0.92), p=0.0003 1 0 0 60 120 180 240 300 360 Days after randomisation No. at risk 9,333 8,628 8,460 8,219 6,743 5,161 4,147 Ticagrelor 9,291 8,521 8,362 8,124 6,743 5,096 4,047 Clopidogrel K-M = Kaplan-Meier; HR = hazard ratio; CI = confidence interval Wallentin et al. NEJM 2009;361:1045-57

39. 15% RRR

41. Medical therapy (advanced) • 2ndantiplatelet (ADP-receptor antagonist) • Prasugrel, Clopidogrel, Ticagrelor • Anticoagulant therapy • Unfractionated heparin (4000-5000 units) I.V. • Glycoprotein IIb/IIIa inhibitors, I.V. (provisional) • Tirofiban (Aggrastat) • Eptifibatide (Integrilin) • Bivalirudin (in patients undergoing PPCI) • Low-molecular weight heparin (LMWH) – for patients not managed by PPCI / thrombolysis • Enoxaparin, Fondaparinux

42. TIMI risk score for STEMI

43. MI complications: Heart Failure • Dilation of the ventricle – “remodeling” • Increased wall stress • Reduced ejection fraction • Reduced functional capacity • Fluid overload (pulmonary congestion, peripheral edema, pleural effusion) • Look for Mitral Regurgitation (MR) • Therapy: ACE inhibitors, Beta blockers, spironolactone, diuretics, digoxin

44. Impact of left ventricular functionon survival following MI Volpi A. GISSI-2 database. Circulation 1993;88:416

45. MI complications: Arrhythmias • Ventricular tachycardia / fibrillation • Prompt DC shock • Bradycardia: • Sinus bradycardia , AV block – inferior MI • Atropin, Dopamine, Pacemaker • Tachycardia: • Sinus tachycardia • Atrial fibrillation • Treat heart failure

46. MI complications: Pericarditis • Acute post MI pericarditis • Anti-inflammatory drugs, NSAID • Dressler syndrome • Anti-inflammatory drugs, steroids

47. Cardiac Rupture Syndrmes Complicating STEMI Ventricular Septal Rupture – VSD with Rt. To Lt. Shunt Free Wall Rupture – Tamponade with Shock Papillary Muscle Rupture – with Severe Mitral Regurgitation

48. MI complications: Rupture • Intra-aortic balloon pump (IABP) • If tamponade – prompt pericardiocentesis • Urgent surgery

49. Therapy on discharge • Healthy life-style • Aspirin • 2ndantiplatelet • ACE-inhibitor • Beta-blocker • Statin (high dose) • Cardiac rehabilitation • Risk factor control (smoking, diabetes, hypertension, obesity, hyperlipidemia, etc.)

50. Trends in in-hospital drug therapy over 10 years: following the guidlines Data from ACSIS: Acute Coronary Syndrome Israeli Survey