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Management of patients with STEMI Raffaele Bugiardini

om: Thank you …….. Today I will talk about “Management of UA”,an issuue in which there is still much room for uncertainty. CAD is the killer n 1. Everybody knows that Pts with suspected ACS must be evaluated rapidly. Because. Management of patients with STEMI Raffaele Bugiardini.

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Management of patients with STEMI Raffaele Bugiardini

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  1. om: Thank you …….. Today I will talk about “Management of UA”,an issuue in which there is still much room for uncertainty. CAD is the killer n 1. Everybody knows that Pts with suspected ACS must be evaluated rapidly. Because.. Management of patients with STEMI Raffaele Bugiardini

  2. Myocardial Ischemia • Spectrum of presentation • silent ischemia • exertion-induced angina • unstable angina • acute myocardial infarction

  3. Acute Coronary Syndrome • The spectrum of clinical conditions ranging from: • unstable angina • NSTEMI (non-Q wave MI) • STEMI (Q-wave MI) • Characterized by the common pathophysiology of a disrupted atheroslerotic plaque

  4. Unstable Angina - Definition Clinical Circumstance C—Develops Within 2 wk of AMI (Postinfarction UA) A—Develops in Presence of Extracardiac Condition That Intensifies Myocardial Ischemia (Secondary UA) B—Develops in Absence of Extracardiac Condition (Primary UA) I—New onset of severe angina or accelerated angina; no rest pain IA IB IC II—Angina at rest within past month but not within preceding 48 h (angina at rest, subacute) IIA IIB IIC IIIA IIIB IIIC III—Angina at rest within 48 h (angina at rest, acute)

  5. INITIAL EVALUATION AND MANAGEMENT Patients with suspected IHD must be evaluated rapidly The physician then must place the evaluation in the context of 2 critical questions: • Are the symptoms a manifestation of ACS? • If so, what is the prognosis?

  6. om: Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency, some yes. There are two critical questions: Are the symptoms a manifestation of ACS ?If so, what is the prognosis ?

  7. om: Answering the question n 1 we have to remember that:… but ansering the Q n 2 we have to remember that…... 1)…..ischemic disconfor at rest rappresent an increased risk of death and non fatal AMI. 2)….the estimation of level of risk is useful for: 1 - selection of site of care ( CCU, monitored step-down unit, out-pt setting) 2-selection of therapy (gp2b/3a inhib.) The slite I showed you before “The presence or absence of the traditional risk factor ordinarily should not be used to determine whether an individual patient should be admitted or treated for ACS. However, the presence of these risk factors does apper to relate to poor outcomes in patients with established ACS.” ACC/AHA Practice Guidelines 2002

  8. What is in your differential diagnosis of chest pain?

  9. AMI Aortic dissection Pericarditis Atypical angina pain associate with hypertrophic cardiomyopathy Esophageal, other upper gastrointestinal, or biliary tract disease Pulmonary disease pneumothorax embolus with or without infarction pleurisy: infectious, malignant, or immune disease-related Hyperventilation syndrome Chest wall skeletal neuropathic Psychogenic Differential Diagnosis of Prolonged Chest Pain

  10. Likelihood that Signs and Symptoms Represent an Unstable Angina History Examination ECG Cardiac Markers High Likelihood Intermediate Likelihood Low Likelihood Probable ischemic symptoms Recent cocaine use Typical Angina CAD history Typical Angina, Age >70 yrs, Sex M, Diabetes Mellitus Transient MR Hypotension Diaphoresis, Pulmonary Edema Extracardiac vascular disease Chest disconfort by palpitation T wave flattering New ST-segment deviation or T-wave inversion Fixed Q waves Abnormal ST or T-waves not documented to be new T wave flattering or inversion in laeds with dominant R  cardiac TnI, TnT or CK-MB Normal Normal Normal Modified from Braunwald E et all 1994; AHCPR Pub. 94-0602

  11. LOW RISK PTS INTERMEDIATE RISK PTS Risk StratificationNon Invasive Stress Testing free of ischemia at rest and of CHF for a minimum 12 - 24 hours 2 - 3 days ACC/AHA Practice Guidelines 2002

  12. om: Most of you are GP and frequently recive telephone calls from pts who are concerned that their symptoms may reflect haert disease. Most of these calls regarding chest disconfort do not rapresent an emergency, some yes. There are to critical questions: Are the symptoms a manifestation of ACS ?If so, what is the prognosis ?

  13. The ESSENCE Study Heparin Enoxaparin 40 Combined Endopoint 35 30 25 20 15 10 5 4 6 8 10 12 14 0 2 Time since enrollment (months) Goodman SG, J AM Coll Cardiol 2000;36:693-8

  14. Antman et all developed a 7-point risk score. The risk of developing an adverse outcome ranged from 5% to 41% with the TIMI risk score defined as the sum of the individual prognostic variable. The end point cosidered were: death, (re)-AMI, or recurrent severe ischemia requiring revascularization The score was derived from the TIMI 11 trial. and has been validated in 3 additional trials: ESSENCE TACTICS-TIMI 18 PRISM-PLUS Among pts with UN/NSTEMI there is a progessively greater benefit from new therapy: LMWH, GP2b/3a, invasive strategy, with incrementing risk score. TIMI risk score 1- age > 65 yrs 2- > 3 coronary risk factors 3- more that 2 angina events within 24 hrs 4- prior angiographic obstruction 5- aspirin (in the 7 prior days) 6- ST-segment deviation 7- elevated cardiac markers Antman EM et al. JAMA 2000;284:835-42

  15. Validation of TIMI Risk Score and Assessment of Treatment Effect According to Score in ESSENCE 45 Unfractionated Heparin (n=1564) 38.1 40 Enoxaparin (n=1607) 35 31 30 Rate of Composite End Point % 25 20 18.3 20 16.8 15.8 15 12.4 12 11.6 10 9.5 7.3 7.2 5 0/1 2 3 4 6/7 5 No. of Risk Factors Antman E, JAMA 2000;284:835-42

  16. Tools for risk stratificationinitial management • Age and History • Symptoms • Standard ECG • Biochemical Markers • Continous ECG

  17. Inverted T wave Q wave

  18. Types of lesions: Inferior • Often RCA • Potential involvement of RV dx

  19. Lateral Often LCX

  20. Septal Certainly LAD

  21. Anterior

  22. Posterior ! no ST ELEVATION

  23. Derivazioni destre Sospettato coinvolgimento del ventricolo destro in infarto POSTERIORE

  24. Up to you ….

  25. Right Side Chest leads

  26. Acute?

  27. Q waves in lateral wall myocardial infarction

  28. Example: ECG alone is not sufficient for diagnosis! The pazient had MI in 1989 , and subsequent evolution in aneurysm of the LV!

  29. CARDIAC MARKERS: ------------------------------------------------------------------------------ Cardiac enzymes creatine kinase (CK) aspartate aminotransferase (AST) lactate dehydrogenase (LD) Structural proteins cardiac troponin T (cTnT) cardiac troponin I (cTnI) Oxygen-binding proteins myoglobin -----------------------------------------------------------------------------

  30. Mortality Rates at 42 Days According to the Time From Onset of Pain to Study Enrollment and the Baseline Cardiac Troponin I Enrolled 0 to 6 hr after Pain Onset Enrolled > 6 to 24 hr after Pain Onset Enrolled 0 to 24 hr after Pain Onset 4 4 3.7 Troponin I 0.4 ng/ml Troponin I <0.4 ng/ml 3.1 3 2.6 2.5 2.4 2 1.7 1.4 1.0 1 0.8 P<0.01 P<0.05 0.5 0.4 0 No CK-MB Elevation No CK-MB Elevation No CK-MB Elevation All Pts All Pts All Pts Risk Ratio 3.8 1.7-8.5 1.8 0.6-5.5 1.8 0.4-7.6 9.5 2.2-4146 3.0 0.97-9.2 5.5 1.1-29.7 95% Confidence Interval Antman EM N Engl J Med 1996; 335:1342-49

  31. Relation between initial negative Troponin and ECG Negative TnT Negative TnI 5% 4% Mortality 3% 2% 1% 60% 0% 20% 40% 80% 100% Patients with Ischemia on ECG Heidenreich J Am Coll Cardiol 2001;38:478-85

  32. NORMAL REST ECG Abnormal LVEF 2% Normal LVEF 98 % Am Heart J 2000: 139:584

  33. Life table of cumulative risk and time of MI or death during 1 year of follow-up with regard to different types of ST-T segment change ST Elevation and Depression n=78 ST Depression Only n=216 Death or MI % ST Elevation Only n=93 Death or MI % T Wave Inversion Only n=287 No ST or T Wave Change n=237 0 60 120 180 240 300 360 Days Nyman N, J Intern Med 1993;234:293-301

  34. Prognostic Significance of different Clinical, ECG and Angiographic Variables for Identifying High Risk Pts with UA Positive predictive value Negative predictive value Sensitivity Specificity (%) (%) (%) (%) 883724838880 329292755989 467567685883 806965878888 Recurrent angina Duration of anginal episodes> 15 min Pain-free interval < 1 h Duration of TMI  60 min/24h High risk coronary lesion Duration of TMI  60 min/24h and high risk coronary lesion Bugiardini R, J Am Coll Cardiol 1995; 25:597-604

  35. Relations among prognosis, duration of ischemia at admission and symptoms Unfavorable clinical Outcome Favorable clinical Outcome Over 180 180 160 140 120 100 80 60 30 0 Fatal or Non fatal MI Other clinical outcome Duration of TMI at admission (min/24 hrs) No Yes No Yes Symptoms Predictive of coronary events Bugiardini R, J Am Coll Cardiol 1995; 25:597-604

  36. Simplified TIMI risk score CRITERIA a - age > 65 yrs b- ST deviation > 0.5 mm c- CK > 2 times normal or TnT high CLASSES Low Risk 0-1 Intermediate Risk 2 High Risk 3 Holper EM et al Am J Cardiol 2001;87:1008-10

  37. Simplified TIMI risk score Unfractionated heparin 30252015105 0 Enoxaparin 29.6 24.8 20.5 17.9 15 14.1 Event rate at day 43 802 870 848 797 307 286 Low (0/1) Inter (2) High (3) Holper EM, Am J Cardiol 2001;87:1008-13

  38. Prognostic value of low risk exercise test 1.0 Chronic Stable Angina .9 .8 Event-free survival Unstable Angina .7 .6 .5 0 500 600 700 100 200 300 400 Days Florenciano-Sandez R. J Am Coll Cardiol 2001;38:1974-9

  39. RESULTS OF THE EXERCISE TEST Patients With CSA (n=86) p Value Patients With UA (n=105) Duration (min) 92 0.0001 74 7711 NS % TMHR 8013 20,9025,835 NS 21,4817,079 Rate-pressure product Positive clinical response 17 (16%) 40 (46%) 0.0001 Positive ECG response 57 (66%) 0.0001 34 (32%) 64 (74%) 0.0001 Positive result 41 (39%) 0.0001 06 Duke index 55 Florenciano-Sandez R. J Am Coll Cardiol 2001;38:1974-9

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