Acute Coronary Syndromes - OSU Center for Continuing ... - PDF of Slides.pdf · Acute Coronary...
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1
Non-ST-Segment ElevationAcute Coronary Syndrome
(NSTE-ACS)Vincent J. Pompili, M.D., FACCProfessor of Internal Medicine
Director of Interventional CardiologyThe Ohio State University
Richard M. Ross Heart Hospital
Non-ST-Segment Elevation Acute Coronary Syndrome
• Pathology, Pathophysiology, and Epidemiology• Risk and Risk Stratification• Initial Therapies and Management• Platelets and Anti-Platelet Therapies• Anti-Thrombin Studies and Recommendations• Early Invasive Strategy• Peri- and Post-Discharge Medications and
Management
Pathology, Pathophysiology, and
Epidemiology
The Vulnerable Plaque
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
Large Lipid Core
Thin, Vulnerable, Fibrous Cap
2
Ruptured Plaque with Occlusive Thrombus Formation
Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671.
ThrombusFormation
Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque
Adapted with permission from Falk E, et al. Circulation. 1998;92:657-671. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Characteristics of Unstable and Stable Plaque
Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Thin fibrous cap
Inflammatory cells
FewSMCs
Erodedendothelium
Activatedmacrophages
Thickfibrous cap
Lack ofinflammatory cells
Foam cells
Intactendothelium
MoreSMCs
Unstable Stable
Systemic and Focal Plaque Rupture by IVUS in ACS Patients Undergoing PCI
Adapted from Rioufol G, et al. Circulation. 2002;106:804-808.Slide courtesy of David Kandzari.
Plaque rupture at site of culprit
lesion
Plaque rupture elsewhere than site of culprit
lesion
Plaque rupture in different artery than
culprit lesion
%
%%
Analysis of 72 Arteries (n=24 TnI-positive ACS Patients)
% P
laqu
e ru
ptur
e
37.5
79.070.8
0
25
50
75
100
3
Frequency of multiple active plaque ruptures beyond the culprit lesion.
Patie
nts
(%)
80% of Patients With ≥2 Plaques
0
5
10
15
20
25
30
0 1 2 3 4 5
N=24
Frequency of Multiple “Active”Plaques in Patients With ACS
ACS indicates acute coronary syndrome.Adapted from Rioufol G, et al. Circulation. 2002;106:804-808. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Thrombus Formation and ACS
UA NQMI STE-MI
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Non-ST-Segment Elevation Acute Coronary Syndrome (ACS)
ST-Segment Elevation
Acute Coronary Syndrome
(ACS)
Old Terminology:
NewTerminology:
Atherothrombosis* is theLeading Cause of Death Worldwide1
*Atherothrombosis defined as ischemic heart disease and cerebrovascular disease.1The World Health Report 2001. Geneva: WHO; 2001. Reprod.with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
22.3
19.3
12.6
9.7
9
6.3
0 5 10 15 20 25 30
Atherothrombosis*
Infectious Disease
Cancer
Injuries
Pulmonary Disease
AIDS
Causes of Mortality (%)
* Based on data from the ARIC study of the National Heart, Lung, and Blood Institute, 1987-1994. Includes Americans hospitalized with definite or probable MI or fatal CHD, not including silent MIs. ACS indicates acute coronary syndrome; MI, myocardial infarction; ARIC, Atherosclerotic Risk in Communities; and CHD, coronary heart disease. From American Heart Association. Heart Disease and Stroke Statistics—2003 Update.
Epidemiology of ACS in the United States
• Single largest cause of death515,204 US deaths in 20001 in every 5 US deaths
• Incidence1,100,000 Americans will have a new or recurrent coronary attack each year and about 45% will die*550,000 new cases of angina per year
• Prevalence12,900,000 with a history of MI, angina, or both
Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
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Risk and Risk Stratification
GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG
Findings in Patients With ACS
Cum
ulat
ive
Mor
talit
y (%
)
0
2
4
6
8
10
0 30 60 90 120 150 180
Days From Randomization
T-wave inversion
ST ↓ ACS
STEMI with fibrinolytics
GUSTO indicates Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes; ECG, electrocardiogram; ACS, acute coronary syndrome; and STEMI, ST-segment elevation myocardial infarction.Figure adapted with permission from Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:707-713. Copyright © 1999, American Medical Association. All rights reserved.
Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Braunwald Classification of Risk for Patients with Unstable Angina
NormalSlightly elevated (TnT >0.01 but <0.1 ng/mL)
Elevated (TnT or TnI >0.1 mg/mL)
Cardiac Markers
Normal or unchanged ECG during an episode of chest discomfort
•T-wave inversions >0.2 mV•Pathological Q waves
•Angina at rest with transient ST-segment changes >0.05 mV•New or presumed new BBB•Sustained ventricular tachycardia
ECG
Age > 70 years•Pulmonary edema•New or worsening MR murmur•S3 or new/worsening rale•Hypotension, bradycardia, tachycardia•Age >75 years
Clinical Findings
New-onset or progressive CCS Class III or IV angina the past 2 weeks
Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD
Prolonged ongoing (>20 min) rest pain
Character of Pain
Prior MI, peripheral or cerebrovascular disease, CABG, or prior aspirin use
Accelerating tempo of ischemic symptoms in preceding 48 hrs
History
Low RiskNo high- or intermediate-risk feature but may have any of the following features:
Intermediate RiskNo high-risk feature but must have 1 of the following:
High RiskAt least 1 of the following features must be present:
Feature
Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
TIMI Risk Score• Age >65 years• >3 CAD Risk Factors• Prior Coronary Stenosis >50 % • ST deviation• >2 Anginal events <24 hours• ASA in last 7 days• Elevated Cardiac Markers (CK-MB or troponin)
Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835-842. Copyright © 2000, American Medical Association. All rights reserved.
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The TIMI Risk Score and Incidence of Adverse Ischemic
Events in Patients with NSTE-ACS
Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA.. 2000;284:835-842. Copyright © 2000, American Medical Association. All rights reserved.
4.78.3
13.219.9
26.2
40.9
0
10
20
30
40
50
0/1 2 3 4 5 6/7Number of Risk Factors
Dea
th, M
I, or
Urg
ent
Rev
ascu
lariz
atio
n (%
)
Troponin I Levels and Mortality in Patients with NSTE-ACS
Adapted with permission from Antman EA, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342-1349. Copyright © 1996, Massachusetts Medical Society. All rights reserved.
0
2
4
6
8
0-<0.4
0.4-<1.0
1.0-<2.0
2.0-<5.0
5.0-<9.0
>9.0
% M
orta
lity
at 4
2 D
ays
Troponin I Level
Prognostic Value of Troponin T or I in ACS: A Meta-Analysis
1.9
6.76.4
20.8
0
5
10
15
20
25
Death Death/MI
%
RR 3.9(2.9-5.3)
RR 3.8(2.6-5.5)
NegPos (Trop I + T)
Figure reproduced with permission from Heidenreich PA, Alloggiamento T, Melsop K, et al. The prognostic value of troponin in patients with non-ST elevation acute coronary syndrome: a meta-analysis. J Am Coll Cardiol. 2001;38:478-485. Slide modified with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Initial Therapies and Management
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• Bed rest• Continuous ECG Monitoring• Supplemental O2 to maintain SaO2 >90%• NTG (IV or PO as dictated clinically)• Beta-blockers (PO and/or IV)• IV Morphine prn pain, anxiety, and/or CHF• IABP for hemodynamic instability• ACEI for persistent hypertension in patients with
LV systolic dysfunction or CHF
ACC/AHA Class I Recommendations for Initial Management and
Anti-Ischemic Therapy
Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
Platelets and Anti-Platelet Therapies
Pathogenesis of Acute Coronary Syndromes:The integral role of platelets
PlaqueFissure or Rupture
PlateletAggregation
PlateletActivation
PlateletAdhesion
ThromboticOcclusion
Adhesion
The Role of Platelets in Atherothrombosis
Aggregation3
Reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
1
Activation2
7
ADP
•Ticlopidine•Clopidogrel
•Heparin•LMW Heparin
•Direct Thrombin Inhibitors
•Aspirin
Collagen ArachidonicAcid
Thrombin
IIb/IIIareceptors
fibrin
The Platelet
•GP IIb/IIIa inhibitors
Epinephrine
Platelet Inhibition With GP IIb/IIIa Inhibitors
Reproduced with permission from Yeghiazarians Y, Braunstein JB, Askari A, et al. Unstable angina pectoris. N Engl J Med. 2000;342:101-114. Copyright © 2000, Massachusetts Medical Society. All rights reserved.
placebo aspirin heparin ASA+hep0
2
4
6
8
10
12
% D
evel
opin
g M
I
Treatment
Treatment of Unstable AnginaResults of a study from the Montreal Heart Institute
Data from Theroux P, Quimet H, McCans J, et al. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med. 1988;319:1105-1111.
Reproduced with permission from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502. Copyright © 2001, Massachusetts Medical Society. All rights reserved.
2
4
6
8
10
12
14
% W
ith E
vent
Clopidogrel + Aspirin
3 6 9
Placebo + Aspirin
Follow-up (months)
P =.00009
0 12
20%RRR
The Primary Composite End Point in the CURE Trial
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0.7911.5%14.3%ST Changes
0.8110.7%13.1%Enzyme Elevation
0.798.1%10.1%No Post-RandomRevascularization
0.8111.4%13.9%Post-Randomization Revascularization
0.798.8%10.9%No Enzyme Elevation
0.807.0%8.7%No ST Changes
RRPlavixPlaceboSubgroup
CURE: Primary End Point in Subgroups
Data from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.
NA0.938.8%9.4%Refract Ischemia
0.00040.8816.68%19.02%CV Death/MICVA/Ref Ischemia
0.031.343.6%2.7%Major Bleeding
NA0.851.2%1.4%Stroke
<0.010.775.19%6.68%MI
NA0.925.06%5.4%CV Death
0.000050.809.28%11.7%CV Death/ MI/CVA
P ValueRRPlavixPlaceboEndpoint
CURE Secondary End Points
Data from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.
PURSUIT Primary End Point
Reproduced with permission from the PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med.1998;339:436-443. Copyright © 1998, Massachusetts Medical Society. All rights reserved.
PURSUIT Primary Composite End Point
Not powered for statistical analysis
Reproduced with permission from the PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med.1998;339:436-443. Copyright © 1998, Massachusetts Medical Society. All rights reserved.
% W
ith D
eath
or M
I
02468
10121416
Integrilin
9.1%7.6%
11.6%
10.1%
15.7%14.2%
96 Hrs 7 Days 30 Days
Placebo
P=0.01
P=0.02
P=0.04
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Meta-Analysis of IV GP IIb/IIIa Inhibitors inNSTE-ACS: Death or MI at 30 Days
PRISM 7.1% 5.8%* 0.80 0.60-1.06
PRISM-PLUS 12.0% 8.7% 0.70 0.50-0.9813.6%* 1.17 0.80-1.70
PARAGON-A 11.7% 10.3% 0.87 0.58-1.2912.3% 1.06 0.72-1.55
PURSUIT 15.7% 13.4% 0.83 0.70-0.9914.2% 0.89 0.79-1.00
PARAGON-B 11.4% 10.6% 0.92 0.77-1.09
GUSTO-IV 8.0% (24h) 8.2% 1.02 0.83-1.24(48h) 9.1% 1.15 0.94-1.39
Overall 11.8% 10.8%t 0.91 0.85-0.98
Odds RatioPlacebo IV Gp IIb/IIIa 95% CI
Placebo BetterGp IIb/IIIa Better0 1.0 2.0
Study
P=.015* Without heparin. † With/without heparin. (l), Low dose; (h), High-dose. Adapted with permission from Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndrome: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-198.
Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
GP IIb/IIIa Inhibitor NSTE-ACS Studies AnalysisRisk-Adjusted Mortality at 30 Days
Data from (1) Peterson ED, Pollack CV Jr, Roe MT, et al. Early use of glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute myocardial infarction: observations from the National Registry of Myocardial Infarction 4. J Am Coll Cardiol. 2003;42:45-53 and (2) Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndrome: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-198. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
0.5 2.01.0
NRMI1
Boersma2 0.83-1.010.91
0.79-0.970.8895% CIOdds Ratio
Odds Ratio for Mortality at 30 Days
GP IIb/IIIa Inhibitor Favored(aspirin + heparin)
Control ArmFavored
(aspirin + heparin)
GP IIb/IIIa Therapy and Mortality (30 day) in Diabetics with NSTE-ACS
0.5 1.0 1.5 2.00
PARAGON APARAGON BPooled
Relative Risk of Death(versus placebo Rx)
GUSTO IVPRISM-PLUSPRISMPURSUIT
Mortality:6.2% vs. 4.6%OR=0.74 CI=0.59-0.92 P=0.007
Adapted with permission from Roffi M, et al. Circulation. 2001;104:2767-2771.
Antithrombotic and Antiplatelet Therapy in ACS
ACC/AHA Guideline Update for UA and NSTEMI. 2002.
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SYNERGY
LMWH
ESSENCE
1994 1995 1996 1997 1998 1999 2000 2002 2003 2004 2005 20062001
CURE
Clopidogrel
Bleeding risk
Ischemic risk
GP IIb/IIIa blockers
PRISM-PLUS
PURSUIT
ACUITYTACTICS TIMI-18
Early invasive
PCI ~ 5% stents ~85% stents Drug-eluting stents
ISAR-REACT 2
Milestones in ACS Management
OASIS-5
[ Fondaparinux ]Anti-Thrombin Rx
Anti-Platelet Rx
Treatment Strategy
Heparin
Aspirin
Conservative
ICTUS
Bivalirudin
REPLACE 2
Adapted from and with the courtesy of Steven Manoukian, MD.
ACC/AHA Recommendations for Antiplatelet Therapy in Patients
with NSTE-ACS
• Class IASAClopidogrel if ASA-allergic or intolerantClopidogrel in addition to ASA if early invasive approach not plannedClopidogrel should be withheld for 5-7 days if CABG plannedGP IIb/IIIa inhibitor if cardiac cath and PCI planned
Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
ACC/AHA Recommendations for Antiplatelet Therapy in Patients
with NSTE-ACS• Class IIa
GP IIb/IIIa inhibitor in patients with high-risk features if invasive strategy not plannedGP IIb/IIIa inhibitor in patients receiving clopidogrel if cardiac cath and PCI planned
• Class IIbGP IIb/IIIa inhibitor in patients without high-risk features and PCI not planned
• Class IIIAbciximab in patients in whom PCI is not planned
Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
Contraindications to GP IIb/IIIa Rx
• Active or recent bleeding (4-6 weeks)• Severe hypertension (SBP >180-200 mm Hg; DBP
>110 mm Hg) • Any hemorrhagic CVA (+/- intracranial neoplasm,
AVM, or aneurysm)• Any CVA within 30 days–2 years• Major surgery or trauma within 4-6 weeks• Thrombocytopenia ( <100,000/mm3 )• Bleeding diathesis/warfarin with elevated INR• (Doses must be avoided with renal insufficiency or
failure)
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Antithrombin Therapy Studies and
Recommendations
Comparison of Heparin + ASA vs ASA Alone
ASA indicates acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic Therapy in Acute Company Syndromes; RR, relative risk; and MI, myocardial infarction.Data from Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: a meta-analysis. JAMA. 1996;276:811-815. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
1 10
0.67 (0.44-0.1.02)
RR: Death/MI
ASA Alone 68/655=10.4%
Heparin + ASA 55/698=7.9%
0.1
Summary Relative Risk
Theroux
RISC
Cohen 1990
ATACS
Holdright
Gurfinkel
ESSENCE Results30%
25%20%
15%
10%
0 9 13Days After Randomization
17 215
5%
25 29
Unfractionated HeparinEnoxaparin (Lovenox)
Dea
th, M
I or
Rec
urre
nt A
ngin
a
P = 0.02Risk Reduction 16.2%
Adapted with permission from Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionatedheparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337:447-452. Copyright © 1997, Massachusetts Medical Society. All rights reserved
TIMI 11B: Enoxaparin vs. Heparin in NSTE-ACS
Dea
th, M
I or
Ur g
ent R
evas
cul a
ri zat
ion
Unfractionated HeparinEnoxaparin (Lovenox)
Days
20
16
12
8
4
2 4 6 8 10 12 140
16.7 %
14.2 %
p = 0.03Relative Risk Reduction = 15%
Adapted from Antman EM, et al. Circulation. 1999;100:1593-1601.
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Guidelines for the Use of Enoxaparin in Patients with NSTE-ACS
• 1 mg/kg SQ q12 hours (actual body weight)An initial 30 mg IV dose can be considered
• Adjust dosing if CrCl <30 cc/min 1 mg/kg SQ q24 hours
• Do not follow PTT; do not adjust based on PTT• Stop if platelets ↓ by 50% or below 100,000/mm3
• If patient to undergo PCI:0-8 hours since last SQ dose: no additional antithrombin therapy8-12 hours since last SQ dose: 0.3 mg/kg IV immediately prior to PCI
ACC/AHA Recommendations for Antithrombin Therapy in Patients with NSTE-ACS
• Class IAnticoagulation with subcutaneous LMWH or intravenous UFH should be added to antiplatelet therapyDose of UFH 60-70 U/kg (max 5000) IV followed by infusion of 12-15 U/kg/hr (initial max 1000 U/hr) titrated to aPTT 1.5-2.5 times controlDose of enoxaparin 1 mg/kg subcutaneously q12 hr; the first dose may be preceded by a 30-mg IV bolus
• Class IIaEnoxaparin is preferable to UFH as an anticoagulant unless CABG is planned within 24 hours
Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.
Early Invasive Strategy Studies and
Recommendations in Patients with NSTE-ACS
Months
4%
20%
16%
12%
8%
TACTICS
1 2 3 4 5 6
15.9%
19.4%Initial Medical Rx
Early Cath + PTCA
Adapted with permission from Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879-1887. Copyright © 2001, Massachusetts Medical Society. All rights reserved.
13
TACTICS Trial Results Based on Troponin
Initial Medical RxEarly Cath + PTCA
Negative Troponin
Positive Troponin
5%10%15%20%25%
P=NS
P<0.001
Adapted with permission from Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879-1887. Copyright © 2001, Massachusetts Medical Society. All rights reserved.
TnT indicates troponin T; and ST, ST segment.Data from (1) Morrow DA, et al. JAMA. 2001;286:2405-2412 and (2) Cannon CP, et al. N Engl J Med. 2001;344:1879-1887. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Benefit of Invasive Strategy by Troponin and ST Changes
Death, MI, or Rehospitalization for ACS at 6 Months
12.4
25.0*
16.0 15.3*
0
5
10
15
20
25
30
TnT – TnT +
CV
Even
ts (%
)
P=NS
15.1
24.5*
16.6 16.4*
0
5
10
15
20
25
30
No ST change ST change
P=NS
P<.001 P<.001Conservative Invasive
The Primary Composite Ischemic End Point in RITA-3
Reproduced with permission from Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised Intervention Trial of Unstable Angina. Lancet. 2002;360:743-751.
Meta-Analysis of Trials of Early Cardiac Cath and
Revascularization Versus Initial Medical Therapy Alone in Patients with NSTE-ACS
Reproduced with permission from Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised Intervention Trial of unstable Angina. Lancet. 2002;360:743-751.
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Invasive vs Conservative Strategy for UA/NSTEMI
UA indicates unstable angina, NSTEMI, non–ST-segment myocardial infarction; ISAR, Intracoronary Stenting and Antithrombic Regimen Trial; RITA, Randomized Intervention Treatment of Angina; VANQWISH, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital study; MATE, Medicine vs Angioplasty for Thrombolytic Exclusions trial; TACTICS-TIMI18, Treat Angina with Aggrastat® and Determine Cost of Therapy with Invasive or Conservative Strategy; and FRISC, Fragmin during InStability in Coronary artery disease.
TIMI IIIB
Conservative Invasive
VANQWISH
MATE
FRISC II
TACTICS-TIMI 18
VINO
RITA-3
TRUCS
ISAR-COOL
Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.
Conclusions-Recent ACS Trials
• ICTUS—In troponin (+) patients, a selective invasive management strategy may be an option, but there was a high use of angiography and revascularization in the selective arm.
• ISAR REACT 2—Clopidogrel loading alone is not sufficient in ACS patients; Troponin (+) patients derive significant benefit with GP IIb/IIIa antagonists
• SYNERGY—Enoxaparin is an alternative in invasively managed patients, but may have slightly higher bleeding, especially when UFH is indiscriminately added in the cathlab
• OASIS 5—Fondaparinux has less bleeding than enoxaparin, non-inferior clinical outcomes at 9 days, and less death and death/MI at 6 months; UFH is probably required in the cathlab—dose unknown.
• ACUITY—Bivalirudin with provisional GPI has less bleeding than UFH/LMWH + GPI, comparable ischemic outcomes, and superior net clinical benefit. Bivalirudin + GPI is comparable to UFH/LMWH + GPI
Conclusions—Recent ACS Trials
• NSTE-ACS is common and associated with high morbidity and mortality
• Early invasive strategy is preferred in higher-risk individuals
• Early initiation of appropriate antiplatelet and antithrombin therapy is important for reduction of ischemic events
• Balancing the risk of ischemic and bleeding complications is essential to maximize clinical benefit in individual patients
• The evidence base and strategies for optimal management of NSTE-ACS continue to evolve
Conclusions—ACS Management
15
ACC/AHA Class I Recommendations for Invasive and Medical Strategies in Patients
with NSTE-ACS• Class I
An early invasive strategy in patients with any high-risk indicators:• Recurrent angina/ischemia at rest or with low-level activities• Elevated troponin• New or presumed new ST-segment depression• Recurrent angina/ischemia with CHF Sx and S3 gallop,
pulmonary edema, worsening rales, or new or worsening MR• High-risk findings on noninvasive stress testing• Depressed LVEF (<40%)• Hemodynamic instability• Sustained ventricular tachycardia• PCI with 6 months or prior CABG
In the absence of any of the above high-risk indicators, either an early conservative or an early invasive strategy
Available at www.acc.org/clinical/guidelines/unstable/unstable.pdf.
ST Elevation Acute Myocardial Infarction
(STEMI)Quinn Capers, IV, MD, FACC, FSCAI
Assistant ProfessorDirector, Peripheral Vascular Interventions,
OSU Ross Heart HospitalDirector, Cath Lab, University Hospital East
STEMI
STEMI
16
EKG: Acute anterior STEMI
Cardiac Cath Lab
Artery Opened Emergently
Before stent, artery closed,no blood flow to heart
After stent, artery open,blood flow to heart restored
17
Combination of blood clot and “plaque” removed from artery
S-T segment Elevation acute Myocardial Infarction (STEMI)• Definition: acute myocardial infarction that
occurs when coronary artery is completely occluded
• Differs from non-ST elevation MI in, which coronary artery is often not completely occluded
• Coronary artery is clogged with combination of “plaque” and thrombus
STEMI:Vascular Biology
• Normal coronary artery
• Lined with endothelial cells
• No resident inflammatory cells (monocytes/macrophages/lymphocytes
• Vasodilatory>Vasoconstriction
• Antithrombotic
• Atherosclerotic plaque
• Lined with endothelial cells
• Monocytes/macrophages infiltrate vascular wall and “destabilize” plaque
• Vasoconstriction>Vasodilatory
• Prothrombotic
• Features of the stable plaque:Thick fibrous cap separating sub-intimafrom flowing bloodHigh ratio of connective tissue: lipidsLow density of inflammatory cellsLow enzymatic activity within plaque: “cold”Less prone to rupture
STEMI:Vascular Biology
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• Features of the unstable or “vulnerable”plaque:
• Thin fibrous cap separating sub-intima from flowing blood
• High ratio of lipids to connective tissue• High density of inflammatory cells,
especially at “shoulders”• High enzymatic activity within plaque: warm• More prone to rupture
STEMI:Vascular Biology
STEMI: Vascular Biology
Unstable or “vulnerable” plaque:
• Unstable angina, acute MI (Non-STEMI or STEMI)
• High systemic inflammatory state (CRP, ESR, IL1)
• “Acute coronary syndromes”
• Changing the vulnerable plaque to a quiescent, stable plaque is major focus of treatment of CAD patients
• Statins (lipid lowering drugs)
• BP control
• Inhibition of renin angiotensin system
• Tobacco avoidance
STEMI:Vascular Biology
AT
STEMI: Pathophysiology
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STEMI:Pathophysiology
• Plaque rupture (70%) or endothelial erosion (30%)
• Results in flowing blood coming in contact with plaque contents
• Plaque contents are highly thrombogenic• Plaque + overlying thrombus impairs blood
flow to myocardium
Coronary Thrombosis:Clot begets Clot
Ruptured plaquepromotes thrombin formation and
recruits platelets to site
Activated plateletsaccelerate thrombin
formation
Thrombin stimulates platelet activation
STEMI:Clinical Presentation
• ST segment elevation MI (STEMI)Severe angina, shortness of breath, or bothPhysical exam can separate high from low risk pt
–Rales on lung auscultation, gallops on cardiac auscultation, tachycardia, low BP
EKG: ST segment elevation in at least two contiguous leads
STEMI:Clinical Presentation
• To Diagnose Acute MI, 2 of these 3 must be present:
Discomfort suspicious for cardiac ischemia (usually “deep seated” chest, arm, neck, or back discomfort)EKG abnormalities consistent with ischemia or infarction (ST segment depression or elevation or T wave inversion)Elevated markers of myocardial necrosis in the bloodstream (CPK, CPK-MB, troponin I, troponin T, myoglobin)
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Acute Coronary Syndromes:Treatment Principles
• Restore normal coronary blood flow as soon as possible (“Time is muscle”)
• Address coronary thrombosis, interrupt cycle
• Increase diameter of coronary artery to allow perfusion
• Main principle: do not delay immediate reperfusion
Acute Coronary Syndromes:Treatment Principles
• Decrease myocardial oxygen demand
• Decrease HR, BP
• Interrupt sympathetic nervous system/catecholamine stimulation of heart
STEMI:Specifics of Treatment
• Antiplatelet therapy• ASA, Clopidogrel
• Antithrombin therapy• Heparin, LMWH, other antithrombins
• Beta blocker
STEMI:Specifics of Treatment
• Nitroglycerin
• Supplemental Oxygen
• Anxiolytic
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STEMI:Specifics of Treatment
• Reperfuse without delay!
• Reperfuse without delay!
• Reperfuse without delay!
STEMI:Specifics of Treatment
• Benefits of immediate reperfusion:Improves chances of survival
Minimizes myocardial damage
STEMI:Reperfusion Therapy
• Thrombolytic therapy
• Emergent cardiac cath/angioplasty/stent
• Emergent CABG
• Thrombolytic therapyMedications that enhance endogenous clot dissolving substancesExamples: tPA, rPA, streptokinaseGiven IV, dissolve coronary thrombusLeaves behind ruptured plaqueSuccess rate: 65-75%
STEMI:Reperfusion Therapy
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STEMI:Reperfusion Therapy
• Emergent cardiac cath/angioplasty/stent
Fastest way to open coronary artery
Most “complete” method of reperfusion
Allows risk stratification by visualizing other coronary arteries and assessing LV function and pressure
Success rate: 95%+
Fibrinolytic drug tx
• Improves survival in STEMI pts
• Works within 90 min of initiation of tx
• Initial success in 65-75% of pts
• 20-30% reocclude artery
• Intracranial bleed in approx 1%
• Artery left with severe stenosis
• Available in most, if not all hospitals
Thrombolytic Therapy vsEmergent Stent Placement
Percutaneous intervention
• Improves survival in STEMI pts
• Works within 30 min of initiating cath
• Initial success in >95% of pts
• <1% reocclude artery
• Intracranial bleed risk <0.1%
• Artery left with 0% residual stenosis
• Available in <1/3 of hospitals
• In multiple head-to-head studies, percutaneousintervention in STEMI pts proved superior to fibrinolytic drug therapy (better survival, better myocardial salvage, lower complication rates)
• Often used together (STEMI pt in small hospital placed on fibrinolytic drug, transported emergently to larger center for emergent cath)
• The point is : whether using fibrinolytic therapy or emergent coronary intervention, get the artery open as soon as possible!!! It can mean the difference between a relatively normal life, life with severe heart disease, and death.
Thrombolytic Therapy vsEmergent Stent Placement
Acute Coronary Syndromes:Treatment:STEMI
• Delays are a major problem, with delays at several steps:
• Patient delays seeking medical help (denial, poor access, social issues)
• Delay in ER staff performing EKG• Delay in EKG being presented to MD for
interpretation• Delay in drugs being mixed in pharmacy and
administered to pt• Delay in transporting pt from ER to cath lab or from
one hospital to another• Delay in cath lab staff coming in from home
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STEMI: The Aftermath• Therapies to start before hospital discharge:
• ACE inhibitors (prevent post-MI cardiac enlargement or “remodeling”, and sudden death)
• Statins (decrease lipids and change vulnerable, rupture-prone plaques to stable plaques)
• Aldosterone receptor antagonists (improve survival in pts with severe LV dysfunction post-MI)
• (These are all in addition to ASA, clopidogrel, beta-blocker)
STEMI: Summary• Unstable or “vulnerable” plaques are lipid-
filled, tense, metabolically active, and prone to rupture, causing acute coronary syndromes
• A main focus of treating CAD pts is transforming vulnerable plaques to stable plaques. Statins are the drugs with the most evidence supporting this.
STEMI: Summary• Coronary thrombosis is a hallmark of acute
coronary syndromes• Much of the therapy for STEMI is directed at
interrupting the vicious cycle of thrombosis (e.g., ASA, clopidogrel, heparin, IIb/IIIablockers)
• In STEMI, emergent reperfusion can be life-saving, the sooner the better
• We must continue efforts to decrease delays in opening the occluded artery in STEMI pts