1 / 60

Acute coronary syndromes

Acute coronary syndromes. Radka Adlová. ACS - introduction. includes any condition where the blood flow to the heart muscle is reduced the most feared complications of coronary artery disease (CAD) are associated with high mortality and morbidity

josephbarnes
Download Presentation

Acute coronary syndromes

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute coronary syndromes Radka Adlová

  2. ACS - introduction • includes any conditionwhere the blood flowto the heart muscle isreduced • themost fearedcomplications of coronaryarterydisease (CAD) • are associatedwithhigh mortality and morbidity • Cardiovasculardiseases (CVD) - presently theleading cause ofdeath in developedcountries • Coronary arterydisease is the cause of 13% of deaths worldwide, every sixthman and every seventh woman in Europe die becauseof acute myocardialinfarction (AMI)

  3. Cardiovascular Mortality

  4. Definiton The clinical presentations of CAD include: • silent ischaemia • stable angina pectoris • heart failure • unstable angina • myocardial infarction (MI) • sudden death

  5. Acute coronary syndromes ACS are usuallydividedinto: • UNSTABLE ANGINA PECTORIS - characterized by the presence ofischemia, lack of necrosisofheartmuscle • STEMI - ST - elevation MI • NSTEMI - non-ST elevation MI • Suddendeath - due to cardiacarrhythmias

  6. Acute coronary syndromes

  7. Definition • ST - elevation ACS (STE - ACS): • typical acute chest pain and persistent (for >20 min) • ST-segment elevation • Mostly reflect an acute total coronary occlusion

  8. ST elevation on the ECG

  9. Definition • Non – STE - ACS (NSTE - ACS): • acute chest pain • without persistent ST-segment elevation • persistent or transient ST segment depression or T-wave inversion

  10. ST depresion on the ECG

  11. Pathophysiology = Vulnerable plaque

  12. Epidemiology • The annual incidence of NSTE-ACS is higher than STEMI • The annual incidence of hospital admissions for NSTE-ACS is in the range of 3 per 1000 inhabitants • sex differences - men account for more than 90% of patients with AMI under the age of 40y. (a hormonalprofile of woman has a protective effect) • age differences - in patients aged under 40y. only one heart artery is affected

  13. Prognosis of STE vs. NSTE-ACS Hospital mortality - higher in patients with STEMI than among those with NSTE-ACS (7 vs. 5%) 6 months mortality - the mortality rates are very similar in both conditions (12 vs. 13%) Long-term follow-up - death rates higher among those with NSTE-ACS than with STE-ACS

  14. Prognosis of STE vs. NSTE-ACS The causes of the higher death rates of NSTE-ACS than of STE-ACS pts. during long-term follow-up are: • older pts. • more co-morbidities (diabetes and renal failure). • a greater extent of coronary artery and vascular diseases • persistent triggering factors such as inflammation

  15. Classification of MI • Type 1 - spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, ordissection • Type 2 – MI secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension • Type 3 – sudden unexpected cardiac death, including cardiac arrest but death occurring before blood samples could be obtained • Type 4 – associated with PCI: • Type 4a – MI associated with theprocedureof PCI • Type 4b – MI associated with stent thrombosis • Type 5 – MI associated with CABG

  16. Myocardial infarction 1. Atherosclerotic aetiology (type 1) 2. Non-atherosclerotic aetiology: (type 2-5) • arteritis • trauma • dissection • congenital anomalies • cocaine abuse • complications of cardiac catheterization, CABG

  17. Diagnosis of acute MI 2 from 3 criteriamustbefulfilled : • Clinicalsymtoms • Chestpain • ECG changes • ST elevationordepression • negative T wave • Elevatedcardiacbiomarkers • Troponin I or T • CK-MB • myoglobin

  18. Clinical presentation • STE/NSTE-ACS: - intense prolonged (20 min) painat rest - retrosternalpressureorheaviness (‘angina’) radiating up to theneck, shoulder and jaw and down to theulnar aspekt oftheleftarm - May beaccompanied by othersymptoms such as nausea, sweating, abdominalpain, dyspnoea,… Unstableangina: - New onset severe angina (class III of CCS) - Recentdestabilizationofpreviouslystable angina withat least CCS III angina characteristics

  19. Location of MI

  20. Location of the various types of MI ST elevation in: • Anteroseptal - V1-V3 • Anterolateral - V1-V6 • Inferior wall - II, III, aVF • Lateral wall - I, aVL, V4-V6 • Right ventricular - RV4, RV5 • Posterior- R/S ratio >1 in V1 and T wave inversion

  21. Location of MI

  22. Location of MI

  23. Location of MI

  24. Biochemical markers Markers of myocardial injury: • cardiac troponins (I and T) • creatinine kinase (CK) • CK isoenzyme MB (CK-MB) • Myoglobin • We have to perform repeated blood sampling and measurements are required 6-12 h after admission and after any further episodes of severe chest pain

  25. Biochemical markers over time

  26. Non-invasive myocardial imaging • Echocardiography - to evaluate LV systolicfunction, complications, aorticstenosis, aorticdissection, pulmonary embolism, orhypertrophiccardiomyopathy - shouldberoutinelyused in emergencyunits fortheriscstratification

  27. Imaging of the coronary anatomy • The imaging of the coronary anatomy is the most importat diagnostics method in evaluation of acute coronary syndrome • The gold standard of patients with ACS is conventional invasive coronary angiography

  28. Decesion-making algorithm in ACS

  29. Treatment of MI • while STEMIis an urgent situation with turbulentsymptomatology,NSTEMI may have symptomsmuch milder and above its immediateprognosis is better • Pts. should stay on coronary care unit - 2-3 days, than standard cardiology department • the total length of hospitalization is around1 week • even after leaving the CCU patients are able to move around the room and in the following daysrehabilitate and before discharge they are able to walk up the stairs • return to job possible approximately one month after the onset of the symptoms

  30. Treatment of STEMI • Open theoccludedartery as soon as possibleto restorebloodflowfortheheart = primary PCI ‘‘Timeismuscle“ • Checkforcomplicationofmyocardialinfarctionandtreatthem: • arrhythmia • heartfailure • bleeding

  31. Reperfusion Strategy Reperfusion therapy 37-93% PPCI rate varies between 5 and 92%; Thrombolysis 0-55% EUROPE IS VERY HETEROGENOUS!!!

  32. Process of the percutaneous coronary intervention

  33. Process of the implantation of stent

  34. Aspiration trombectomy • procedureforeliminationof trombus to preventembolisation • a specialhollowcatheterisintroducedintotheaffectedartery and thromboticmasses are aspiratedunderpressure

  35. Pre-hospital management • Antiplatelet therapy • Acetylosalicid acid 400-500 mg (i.v. or p.o.), • Clopidogrel 600mg or ticagrelor 180mg or prasugrel 60mg • Antithrombin therapy • Heparin 5 000 - 10 000 IU i.v. or enoxaparine • Resolve pain and fear • analgesic drugs • benzodiazepine

  36. Pre-hospital management • Nitrate - pain, hypertesion, heart failure • Isosorbide dinitrate 1-5 mg i.v. • Monitoring vital function and ECG ventricular fibrilation terminated by cardioversion

  37. Pre-hospital management • Betablockers - tachycardia, hypertension • Metoprolol - dose 25-50mg oral or 2 mg i.v. • ACE inhibitors - hypertension • Perindopril - dose 5 mg oral • Diuretic - heart failure • Furosemide 20 - 40mg i.v. • Anti-arrhythmic drugs -no prophylaxis • Mesocain 1% 10 mL i.v. • Amiodarone 150 mg i.v. bolus

  38. Hospital and discharge therapy • Antiplatelettherapy • Acetylosalicid acid - dose 100 mg p.o. (forlife) • Clopidogrel 75mg orticagrelor 90mg twice a dayorprasugrel 10mg (1 year) • Statins- benefit forallpatientswith IM • Atorvastatin 40-80mg, rosuvastatin 20-40mg (forlife) • ACE inhibitors- benefit forallpatientwith IM, more expressed in leftventriculardysfunction • perindopril - dose 5-10 mg oral • Betablockers- 1-3 yearsafter MI, longerforpts. Withleftventriculardysfunction, tachyarrhythmia

  39. Case report - 1 57-old female smoker, family history of CAD, pain 6 hours, nausea

  40. Coronary angiography

  41. Trombus aspiration

  42. Stent implantation

  43. Case report - 2 61-year old male with hypertension, pain 4 hours, vomiting, sweating

  44. Coronary angiography of LCA

  45. Trombus aspiration

  46. Stent implantation and final result

  47. Complications of MI • Early complicationsinclude: • Heartfailure, cardiogenicshock • Mechanicalcomplications : - ruptureof free wallofleftventricle - ventricularseptaldefect - acutemitralregurgitation • Arrhythmia - ventricular (up to 48 h) - bradycardia (9-25% ofpts) • Late complicationsinclude: • pericarditis • Aneurysmofleftorrightventricle

More Related