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A 55 y/o male HMS alumni

A 55 y/o male HMS alumni. Notices palpitations and mid-sternal “gnawing” chest pain after his 80 th fluid ounce of coffee for the day…. PMHx: LDL 165, (+) FHx CAD in father in early 50s. His EKG…. ?. Aspirin Abciximab Metoprolol PTCA tPA

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A 55 y/o male HMS alumni

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  1. A 55 y/o male HMS alumni • Notices palpitations and mid-sternal “gnawing” chest pain after his 80th fluid ounce of coffee for the day…. • PMHx: LDL 165, (+) FHx CAD in father in early 50s

  2. His EKG…

  3. ? Aspirin Abciximab Metoprolol PTCA tPA Lisinopril Insulin Morphine Clopidogrel Oxygen LMWH Nitrates Eptifibatide Statins Heparin Lidocaine

  4. Acute Coronary Syndromes STEMI NSTEMI Unstable Angina Stefanos Parpos, MD

  5. Outline • Why should I care ? • What is it ? • How do I diagnose it ? • How do I treat it ?

  6. Why Should I care ? I’ll just call the cardiologist…

  7. Why should I care ? • > 1.25 million acute MIs a year in America • About 500,000 a year in the US • Correct Rx decreases risk of death by 30-50%.

  8. So it’s common. So what? • People with MI are sick. • Missing the diagnosis randomizes them to the 1945 arm of acute cardiac care … Mortalityby “era”

  9. Why should I care ? • People w/ unstable angina and MI are sick • Easy interventions save lots of lives • 3D’s…Delay of Diagnosis = Death • Prompt coronary reperfusion, regardless of strategy used: • Limits Myocardial Necrosis • Preserves LV function • REDUCES MORTALITY

  10. What is it ?

  11. What is it ? Acute Coronary Syndrome Unstable Angina + ACS = NSTEMI + STEMI S

  12. For those of you keeping score… JACC 38(7), 2001, defines MI as: • MI by autopsy (ugh!), or • (+) enzymes and one of : Ischemic Symptoms ST elevation or depression New Q waves Cath with PCI Enzymes include Trop T, Trop I, or CK-MB

  13. How do I diagnose it ? How do I treat it ?

  14. How do I diagnose + treat it ? STEP 1:KNOW it might be there. • Chest pain, pressure, left arm, blah, blah, blah…. • Nausea/Vomiting, especially in diabetic • Vague “atypical” symptoms, especially in women

  15. How do I diagnose + treat it ? STEP 2: OK, they have chest pain. You only have 2 jobs. • Figure out who needs revascularization - cath - In the real world, lytics • Give drugs that decrease the rate of death.

  16. How do I diagnose + treat it ? STEP 3: EKG, EKG, EKG !!!! (did I mention……..EKG!!!!!) • There are 3 EKG categories that matter: 1) Needs to go to cath lab right now! 2) Not Normal - Scary - Not so scary 3) Normal

  17. Who needs cath now ? Or in the real world…who needs tPA? GOOD STORY AND ST elevation of 1mm or greater in two contiguous leads or LBBB not known to be old

  18. Who needs cath now ? This is one of those “take-home points”… • ST-elevation (or new LBBB) MIs are CAN’T-MISS. All else being equal, they need cath (or lytics) RIGHT NOW!!

  19. OK, they don’t need cath. Now what? ? Aspirin Abciximab Metoprolol PTCA tPA Lisinopril Insulin Morphine Clopidogrel Oxygen LMWH Nitrates Eptifibatide Statins Heparin Lidocaine

  20. An ACLS Slide Remember this for the exam … ACLS is very clear in saying everyone gets • O2-IV-cardiac-monitor (one word). and • ASA • NTG (“MONA greets all patients at the door.”) • Oxygen • Morphine (if pain unrelieved) + BB

  21. Think pathophysiology… Ustable Angina Pectoris (USA) Stable Angina Pectoris NSTEMI STEMI (+) enzymes Occluding thrombus Fixed lesion Ruptured Plaque

  22. Aspirin Beta Blockade Plavix Heparin LMWH G IIb/IIIa inhibitors ACE inhibitors Nitroglycerin Morphine Oxygen Statins Direct thrombin inhibitors Which goodies have mortality benefit in USA/NSTEMI ??? Invasive vs Conservative Approach

  23. Everybody gets… Apsirin (81-325mg) • 23% decrease in vascular death in STEMI and 49% decrease in nonfatal reinfarction (ISIS-2 Lancet. 1988;2:349-360) • (equivalent to streptokinase) • Only contraindications are true allergy, and maybe intracranial hemorrhage or absence of platelets. • If ASA allergic Plavix

  24. Everyone gets… Beta Blockade: • Decreases death about 20-40% when thrombolytics aren’t used; about 10% with. • Vastly underused in most hospitals • Contraindicated in bradycardia, hypotension, high degree AV block, and active CHF

  25. Some get…Clopidogrel (Plavix) CURE(NEJM 2001; 345: 494-502) USA/NSTEMI (n=12662) randomized to ASA+ clopidogrel vs ASA)  Plavix decreased CV death/MI/ or stroke by 20% CAPRIE (Lancet 1996; 348: 1329-1339) 19000 pt w/ AS vasc dz at risk for ischemic events CREDO (confirmed pretreat w/ plavix pre-CABG)

  26. Some get…Heparin (UFH) • Meta-Analysis (JAMA 1996; 276:811-815) Heparin in USA/NSTEMI. • Pt given Heparin and/or ASA alone • Primary end pt MI or death 2-12 wks • Heparin trended towards decrease death or MI (w/o true stat significance) • Heparin trended to increased bleed.

  27. Enoxaparin vs Heparin (UFH) • TIMI 11B(Circ 1999;100: 1593-1601) 3910 pt w/ USA/NSTEMI randomized to UFH vs LMWH in addition to ASA • Primary end pt: death, MI, or urgent revasc at 8 days and 43 days • Enoxaparin was superior to UFH for decreasing the composite MACE in pt w/ USA or NQWMI • ESSENCE(NEJM 1997; 337: 447-52 ) showed same benefit w/ lower risk patients w/o intitial IV bolus

  28. Some get…Glycoprotein IIb/IIIa inhibitors • Plenty of trial data… remember to check if trial is regarding use in ACS or as adjuctive Rx in ACS going for PCI • Bottom line for ACS benefit if high risk USA, planned PCI, or (+) enzymes • EPISTENT(Lancet 1998; 352: 87-92) GP IIb/IIIa blockade signif improved PCI 3 part radomization: stent + abciximab better than balloon angioplasty + abciximab better than stent + placebo Other trials: Epic, PRISM, PRISM PLUS, Capture, Restore, Pursuit, Paragon, Gusto-IV

  29. FYI…..Early Cath + revasc is better! • Invasive vs Conservative Approach (for historical reference) • Early Invasive Mgt: early cath + revasc • Conservative: stress, if (+)  cath TACTICS-TIMI 18(NEJM 2001; 344: 1879-87) USA/NSTEMI/ASA/Hep/Tirofiban early ivasive better, especially if + trop, ST changes, or TIMI risk score > 3

  30. Some get…ACE inhibitors

  31. Some get…Direct Thrombin Inhibitors OASIS II(Lancet 1999; 353: 429-438) lepirudin  no statistically significant benefit in NSTEMI/USA GUSTO II b(NEJM 1996; 335: 775-782) hirudin  no benefit in NSTEMI/USA (1/3 of pts in this trial had STEMI)

  32. Some get…STATINS • MIRACL(JAMA 2001; 285: 1711-1718) USA/NSTEMI randomized to atrovastatin or placebo Atorvastatin 80mg/d started w/in 96hrs of ACS admission, reduced recurrent ischemic events, especially recurrent symptomatic angina requiring rehospitalization, in the first 16 weeks of therapy. NO difference in death or MI Findings not coupled to degree of lipid lowering

  33. Don’t Give… • Digoxin • Prophylactic or PVC-suppressive lidocaine • Calcium Channel Blockers

  34. Put the data to use… Patient presenting w/ non STEMI ACS: Consider: • Story • EKG • Enzymes • Prior CAD

  35. AHA Class I Recommendations Definite ACS with continuing Possible ACS Likely/Definite ACS Ischemia or Other High-Risk Features or planned PCI Aspirin Aspirin Aspirin + + Subcutaneous LMWH IV heparin or IV heparin + IV platelet GP IIb/IIIa antagonist

  36. Summary • Aspirin for all • MONA for all • EKG for all • Super scary Cath/lytics • Scary/non-scary  monitor/adjunctive tx • High risk non STEMI ACS • Triple pharmacotherapy (anti-platelets) • BB, ACEi, +/- nitrates, +/- statins

  37. Now Let’s Consider STEMIs

  38. A reminder… • People with MI are sick. • Missing the diagnosis randomizes them to the 1945 arm of acute cardiac care … Mortalityby “era”

  39. Fortunately … We are in the reperfusion era where prompt coronary reperfusion, regardless of strategy used: • Limits myocardial necrosis • Preserves LV function • REDUCES MORTALITY

  40. But … • The majority of patients do not seek medical care for > 2 hours after onset of symptoms.

  41. So, the take home message … • Success of reperfusion depends on time to treatment • Maximum benefit from lytic therapy is seen within first four hours after onset of symptoms particularly the first 70 minutes

  42. Pre-hospital Management To reduce treatment delays, consider: • Pre-hospital lytics for transport time > 60 minutes (if MD present) • Cardiogenic shock, large AMI with CHF  direct triage to interventional-capable facilities

  43. General Algorithm EKG MONA Immediate assessment NSTEMI USA

  44. STEMI … Cath vs. Lytics

  45. STEMI Target Times • D-N < 30 minutes (lytics) • D-B < 90 minutes (primary PCI)

  46. STEMI … Lytic Checklist

  47. STEMI … Choosing Lytics

  48. Remember … t-PA • 15-mg bolus, then 0.75 mg/kg (maximum 50 mg) over 30 min, then 0.50 mg/kg (maximum 35 mg) over 60 min Note: Not the same dose as in massive PE 10 mg bolus, then 90 mg IV over 2 hrs

  49. If no reperfusion, then what? • Adjunctive treatment • On-going diagnostics & therapeutics • Risk stratification for ischemia

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