Acute Coronary Syndrome

ЦЕЛИ

Определение понятия «acute coronary

syndrome» (ACS)

Общий обзор

Unstable Angina / NSTEMI

STEMI

Превентивные действия

Проблемы

CHD single leading cause of death in United States 452,327 deaths in the U.S. in 2004

1,200,000 new & recurrent coronary attacks per year

38% of those who with coronary attack die within a year of having it

Annual cost > $300 billion

Факторы риска

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Low HDL < 40

Elevated LDL / TG

Family History—event in

first degree relative >55

male/65 female

Age-- > 45 for male/55

for female

Chronic Kidney Disease

Lack of regular physical activity

Obesity

Lack of diet rich in fruit, veggies, fiber

Acute Coronary Syndromes

Сходная патофизиология

Сходные ранние проявления

STEMI требует экстренную реперфузию

Unstable Angina

Non-ST-Segment Elevation MI (NSTEMI)

ST-Segment Elevation MI (STEMI)

Diagnosis of Acute MI

STEMI / NSTEMI

At least 2 of the following

Ischemic symptoms

Diagnostic ECG

changes

Serum cardiac marker

elevations

Diagnosis of Angina

Typical angina—All three of the following Substernal chest discomfort

Onset with exertion or emotional stress

Relief with rest or nitroglycerin

Atypical angina 2 of the above criteria

Noncardiac chest pain 1 of the above

Diagnosis of Unstable Angina (UA)

Больные с типичной UA

Возрастает тяжесть и длительность приступа

Возникает в покое или при минимальной нагрузке

Не проходит при повышении дозы нитратов

Больные с нетипичной UA

Первый приступ во время обычной физической

нагрузки

Длительные боли в покое

Unstable

AnginaSTEMINSTEMI

Non occlusive

thrombus

Non specific

ECG

Normal cardiac

enzymes

Occluding thrombus

sufficient to cause

tissue damage & mild

myocardial necrosis

ST depression +/-

T wave inversion on

ECG

Elevated cardiac

enzymes

Complete thrombus

occlusion

ST elevations on

ECG or new LBBB

Elevated cardiac

enzymes

More severe

symptoms

Срочные мероприятия

Первичная оценка

ситуации и

стабилизация

Оценка

потенциального

риска

Сосредоточиться

только на

кардиологической

проблеме

Оценка ситуации

Анамнез

Первичные стабилизационные

мероприятия

Немедленная госпитализация (ICСU)

Время –

решающий фактор

в лечении!

Боли в груди

указывающие на ишемию

12 lead ECG

Obtain initial

cardiac enzymes

electrolytes, cbc

lipids, bun/cr,

glucose, coags

CXR

Действия в первые 10 минут

Establish

diagnosis

Read ECG

Identify

complications

Assess for

reperfusion

Initial labs

and tests

Emergent

care

History &

Physical

IV access

Cardiac

monitoring

Oxygen

Aspirin

Nitrates

Данные анамнеза

История болезни

Palliative/Provocative

factors

Quality of discomfort

Radiation

Symptoms associated

with discomfort

Cardiac risk factors

Past medical history -

especially cardiac

Оценка вида

реперфузии

Timing of presentation

ECG c/w STEMI

Contraindication to

fibrinolysis

Degree of STEMI risk

План обследования

Факторы, повышающие

риск

Hypotension

Tachycardia

Pulmonary rales, JVD,

pulmonary edema,

New murmurs/heart sounds

Diminished peripheral

pulses

Signs of stroke

Обследование

Vitals

Cardiovascular system

Respiratory system

Abdomen

Neurological status

ECG assessment

ST Elevation or new LBBB

STEMI

Non-specific ECG

Unstable Angina

ST Depression or dynamic

T wave inversions

NSTEMI

Normal or non-diagnostic EСG

ST Depression or Dynamic T wave

Inversions

ST-Segment Elevation MI

New LBBB

QRS > 0.12 sec

L Axis deviation

Prominent R wave V1-V3

Prominent S wave 1, aVL, V5-V6

with t-wave inversion

Cardiac markers

Troponin ( T, I)

Very specific and more sensitive than CK

Rises 4-8 hours after injury

May remain elevated for up to two weeks

Can provide prognostic information

Troponin T may be elevated with renal dz, poly/dermatomyositis

CK-MB isoenzyme

Rises 4-6 hours after injury and peaks at 24 hours

Remains elevated 36-48 hours

Positive if CK/MB > 5% of total CK and 2 times normal

Elevation can be predictive of mortality

False positives with exercise, trauma, muscle dz, DM, PE

Prognosis with Troponin

1.01.7

3.4 3.7

6.0

7.5

0

1

2

3

4

5

6

7

8

0 to <0.4 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 9.0

Cardiac troponin I (ng/ml)

Mo

rtality

at

42 D

ays

831 174 148 134 50 67

%%

%%

%

%

Цели лечения в ICCU

Decrease amount of myocardial necrosis

Preserve LV function

Prevent major adverse cardiac events

Treat life threatening complications

Лечение STEMI

STEP 1: Assessment

Time since onset of symptoms

90 min for PCI / 12 hours for fibrinolysis

Is this high risk STEMI?

KILLIP classification

If higher risk may managed with more invasive X-Ray

Determine if fibrinolysis candidate

Meets criteria with no contraindications

Determine if PCI candidate

Based on availability and time to balloon rx

Fibrinolysis indications

ST segment elevation >1mm in two

contiguous leads

New LBBB

Symptoms consistent with ischemia

Symptom onset less than 12 hrs prior to

presentation

Absolute contraindications for fibrinolysis

therapy in patients with acute STEMI

Any prior ICH

Known structural cerebral vascular lesion (e.g., AVM)

Known malignant intracranial neoplasm

(primary or metastatic)

Ischemic stroke within 3 months EXCEPT acute

ischemic stroke within 3 hours

Suspected aortic dissection

Active bleeding or bleeding diathesis (excluding menses)

Significant closed-head or facial trauma within 3 months

Relative contraindications for fibrinolysis therapy

in patients with acute STEMI

History of chronic, severe, poorly controlled hypertension

Severe uncontrolled hypertension on presentation (SBP greater than 180 mm Hg or DBP greater than 110 mmHg)

History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in contraindications

Traumatic or prolonged (greater than 10 minutes) CPR or major surgery (less than 3 weeks)

Recent (within 2-4 weeks) internal bleeding

Noncompressible vascular punctures

For streptokinase/anistreplase: prior exposure (more than 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

STEMI cardiac care

STEP 2: Reperfusion strategy

Fibrinolysis preferred if:

<3 hours from onset

PCI not available/delayed

door to balloon > 90min

door to balloon minus door to needle > 1hr

Door to needle goal <30min

No contraindications

PCI preferred if:

PCI available

Door to balloon < 90min

Door to balloon minus door to needle < 1hr

Fibrinolysiscontraindications

Late Presentation > 3 hr

High risk STEMI Killup 3 or higher

STEMI diagnosis is not clear

Сравнительные итоги

Medical Therapy

Morphine

Аналгезия

Снижение боли—снижение активности sympatheticus,

уменьшение периферического сопротивления сосудов

и кислородной зависимости

Осторожно при гипотензии, гиповолемии и

дыхательной недостаточности

Oxygen (2-4 liters/minute)

Больным с гипоксемией ( 70%)

Ограничивает ишемию миокарда путем увеличения

доставки кислорода и снижает ST elevation

Nitroglycerin Снимает болевой синдром

Расширяет коронарные сосуды – увеличивает коронарный кровоток

Снижает общую сосудистую сопротивляемость и преработу

Осторожно при гипотензии, брадикордии, тахикардии и RV infarction

Aspirin (160-325mg)

Предотвращает агрегацию тромбоцитов

Стабилизирует атеросклеротическую бляшку и фиксирует тромб

Снижает смертность

Осторожно при язвенной болезни, гипертонии и кровотечениях

Beta-Blockers Снижает смертность до 14% в первые 7 дней и до

23% в дальнейшем

Снижает риск увеличения зоны инфаркта в 13% случаев

Осторожно при сердечной недостаточности, блокаде сердца и гипотензии

ACE-Inhibitors / ARB Назначаются больным с передним инфарктом,

застойными явлениями в легких, LVEF < 40% и при отсутствии гипотонии как противопоказания

Начинать в первые 24 часа

ARB назначают больным, которым противопоказаноназначение ACE-I

Heparin (max 4000u bolus, 1000u/hr)

Непрямое подавление тромбина

Не доказано преимущество перед реперфузией

Добавление при хирургической и тромболитической

реваскуляризации и PCI reperfusion

Не более 24-48 часов

Сочетается с аспирином

Additional medication therapy

Clopidodrel Необратимое подавление агрегации тромбоцитов

Поддержка при PCI и после нее не менее 9-12 месяцев

Glycoprotein IIb/IIIa inhibitors (Reo-Pro)

Подавляют агрегацию тромбоцитов

Поддержка при PCI - назначать как можно раньше до PCI

Интегрилин намного дешевле и не менее эффективен

Additional medication therapy

Aldosterone blockers

Post-STEMI patients

При незначительной почечной недостаточности

(креатинин < 2.0)

При отсутствии гиперкалемии

При LVEF < 40%

При сердечной недостаточности с преобладанием

правой сердечной недостаточности

Важность ICCU

Monitor for complications:

recurrent ischemia, cardiogenic shock, ICH, arrhythmias

Review guidelines for specific management of

complications & other specific clinical scenarios

PCI after fibrinolysis, emergent CABG, etc…

Decision making for risk stratification at hospital

discharge and/or need for CABG

Unstable angina/NSTEMI

cardiac care

Выбор консервативной или инвазивной

терапия основывается на следующем:

Риск развития ACS

TIMI – степень риска

Категории риска АCS по критериям AHA

Low

Intermediate

High

Assessment Findings indicating

HIGH likelihood of ACS

Findings indicating

INTERMEDIATElikelihood of ACS in

absence of high-

likelihood findings

Findings indicating

LOW likelihood of ACS

in absence of high- or

intermediate-likelihood

findings

History Chest or left arm pain or

discomfort as chief

symptom

Reproduction of previous

documented angina

Known history of coronary

artery disease, including

myocardial infarction

Chest or left arm pain or

discomfort as chief

symptom

Age > 50 years

Probable ischemic

symptoms

Recent cocaine use

Physical

examination

New transient mitral

regurgitation,

hypotension, pulmonary

edema

Extracardiac vascular

disease

Chest discomfort

reproduced by palpation

ECG New or presumably new

transient ST-segment

deviation (> 0.05 mV) or T-

wave inversion (> 0.2 mV)

with symptoms

Fixed Q waves

Abnormal ST segments or

T waves not documented

to be new

T-wave flattening or

inversion of T waves in

leads with dominant R

waves

Normal ECG

Serum cardiac

markers

Elevated cardiac troponin

T or I, or elevated CK-MB

Normal Normal

Критерии риска, определяющие вероятность развития

Acute Coronary Syndrome

ACS risk criteria

Low Risk ACS

No intermediate or high

risk factors

<10 minutes rest pain

Non-diagnositic ECG

Non-elevated cardiac

markers

Age < 70 years

Intermediate Risk

ACS

Moderate to high likelihood

of CAD

>10 minutes rest pain,

now resolved

T-wave inversion > 2mm

Slightly elevated cardiac

markers

High Risk ACS

Elevated cardiac markers

New or presumed new ST depression

Recurrent ischemia despite therapy

Recurrent ischemia with heart failure

High risk findings on non-invasive stress test

Depressed systolic left ventricular function

Hemodynamic instability

Sustained Ventricular tachycardia

PCI with 6 months

Prior Bypass surgery

Low

riskHigh

risk

Conservative

therapy

Invasive

therapy

Chest Pain

center

Intermediate

risk

Invasive therapy option

UA/NSTEMI

Coronary angiography and revascularization

within 12 to 48 hours after presentation to ED

For high risk ACS

Clopidogrel

20% reduction death/MI/Stroke – CURE trial

Up to 9-12 months

Glycoprotein IIb/IIIa inhibitors

Conservative Therapy for UA/NSTEMI

Early revascularization or PCI not planned

Clopidogrel

Glycoprotein IIb/IIIa inhibitors

Only in certain circumstances (planning PCI, elevated TnI/T)

Surveillence in hospital

Serial ECGs

Serial Markers

Secondary Prevention

HTN, DM, HLP

Smoking, diet, physical activity, weight

Education, cardiac rehab program

Secondary Prevention

disease management

Blood Pressure

Goals < 140/90 or <130/80 in DM /CKD

Maximize use of beta-blockers & ACE-I

Lipids

LDL < 100 (70) ; TG < 200

Maximize use of statins; consider fibrates/niacin first line for TG>500; consider omega-3 fatty acids

Diabetes

A1c < 7%

Secondary prevention

behavioral intervention

Smoking cessation

Physical Activity

Goal 30 - 60 minutes daily

Rational diet

Thinking outside the box…

Medication Checklist

after ACS

Antiplatelet agent Aspirin* and/or Clopidorgrel

Lipid lowering agent Statin*

Fibrate / Niacin / Omega-3

Antihypertensive agent Beta blocker*

ACE-I*/ARB

Aldactone (as appropriate)

Summary ACS включает UA, NSTEMI, and STEMI

Успех лечения зависит от:

Немедленное начало лечения

Оценка степени риска (UA/NSTEMI vs. STEMI)

Немедленная реперфузия при STEMI (PCI vs. Thrombolytics)

Адекватная консервативная терапия vsИнвазивной терапии при UA/NSTEMI

Пристальное внимание при вторичному предотвращению развития ACS

Beta blocker, ASA, ACE-I, Statin