Coronary syndromes
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description
Coronary syndromes. Giuseppe Biondi-Zoccai , MD Sapienza University of Rome , Italy [email protected]. Learning goals. Preamble Definitions Impact Approach Management. Learning goals. Preamble Definitions Impact Approach Management. Time machine. - PowerPoint PPT Presentation
Transcript of Coronary syndromes
Learning goals
• Preamble• Definitions• Impact• Approach• Management
Learning goals
• Preamble• Definitions• Impact• Approach• Management
Time machine
Teixera et al, Int J Cardiol 2013
Myocardial infarction in the 60’s
Myocardial infarction today
Learning goals
• Preamble• Definitions• Impact• Approach• Management
Differential diagnosis of coronary syndromes
• Asymptomatic CAD• Chronic stable angina• Unstable angina• Acute myocardial infarction
In addition:• Ischemic cardiomyopathy• Sudden ischemic cardiac death• Myocardial ischemia due to spasm or mismatch
Wijns et al, Eur Heart J 2010
From diagnosis to risk stratification
http://en.wikipedia.org/wiki/Acute_coronary_syndrome
Third universal definition of myocardial infarction
• Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following:– Symptoms of ischemia.– New or presumed new significant ST-segment–T wave (ST–T)
changes or new left bundle branch block (LBBB).– Development of pathological Q waves in the ECG.– Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality.– Identification of an intracoronary thrombus by angiography or
autopsy.
Thygesen et al, Eur Heart J 2012
Third universal definition of myocardial infarction: subtypes
Thygesen et al, Eur Heart J 2012
Third universal definition of myocardial infarction: subtypes
• 1 - Spontaneous MI: related to plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in one or more of the coronary arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis.
• 2 - Secondary MI: In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. spasm, anemia, etc.
• 3 - Fatal MI: Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB.
Thygesen et al, Eur Heart J 2012
Third universal definition of myocardial infarction: subtypes
• 4a – Related to PCI: >5 x 99th percentile URL in patients with normal baseline values (>99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, symptoms, new ischemic ECG changes, angiographic loss of patency, or imaging demonstration of MI.
• 4b – Related to stent thrombosis: angiography or autopsy evidence and cardiac biomarkers values with at least one value above the 99th percentile URL.
• 5 – Related to CABG: cardiac biomarker values >10 x 99th percentile URL. In addition, new pathological Q waves or new LBBB, or angiographic documented new graft or new native coronary artery occlusion, or imaging evidence of MI.
Thygesen et al, Eur Heart J 2012
Learning goals
• Preamble• Definitions• Impact• Approach• Management
Stable CAD in diabetics
Farkouh et al, New Engl J Med 2012
Stable CAD
Farkouh et al, New Engl J Med 2012
MAC
CE (%
)
Stable CAD in diabetics
Farkouh et al, New Engl J Med 2012
Medically managed ACS
Roe et al, New Engl J Med 2012
Invasively managed ACS
Wallentin et al, New Engl J Med 2009
Card
iova
scua
lr de
ath,
M
I, or
stro
ke (
%)
STEMI
Montalescot et al, Lancet 2012
Card
iova
scua
lr de
ath,
M
I, or
stro
ke (
%)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
High-sensitivity troponins
Thygesen et al, Eur Heart J 2012
Ischemic scores
Discrimination (c statistic)
D’Ascenzo et al, Contemp Clin Trials 2012
Bleeding scores
www.crusadebleedingscore.com
SYNTAX score
www.syntaxscore.com
SYNTAX score
www.syntaxscore.com
SYNTAX score
Farooq et al, Lancet 2013
Learning goals
• Preamble• Definitions• Impact• Approach• Management
Radial access
Romagnoli et al, J Am Coll Cardiol 2012
Prehospital thrombolysisDe
ath,
shoc
k, C
HF, o
r rei
nfar
ction
(%)
Armstrong et al, New Engl J Med 2013
Bivalirudin
NAC
E (%
)M
ACE
(%)
Kastrati et al, New Engl J Med 2008
Prasugrel
Wiviott et al, New Engl J Med 2008
Cardiovascular death, MI or stroke
Non-CABG-related TIMI major bleeding
TicagrelorVascular death, MI or stroke Major bleeding
Months Months
Wallentin et al, New Engl J Med 2009
Adjusted indirect comparison
Biondi-Zoccai et al, Int J Cardiol 2011
CangrelorSt
ent t
hrom
bosis
(%)
Bhatt et al, New Engl J Med 2013 (57% CSA, 25% NSTEACS, 18% STEMI)
Rivaroxaban
Mega et al, New Engl J Med 2012
Beta-blockers
Bangalore et al, JAMA 2012
Card
iova
scul
ar d
eath
, M
I or s
trok
e (%
)
Statins
Patti et al, Circulation 2011
Fractional flow reserve
De Bruyne et al, New Engl J Med 2012
CABG or PCI?
Mohr et al, Lancet 2013
Off-pump vs on-pump CABG
Palmerini et al, J Am Coll Cardiol 2012; Palmerini et al, Am Heart J 2013
Drug-eluting stents
Palmerini et al, Lancet 2012
Drug-eluting stents
Palmerini et al, Lancet 2012
Drug-eluting balloons
Byrne et al, Lancet 2013
Bioresorbable stents
Palmerini et al, Lancet 2012
Bioresorbable stents
Serruys et al, Lancet 2009
Take home messages• Developments in the field of coronary syndromes
represent an outstanding example of the successful combination of pathophysiologic, diagnostic, prognostic, pharmacologic and device research.
• Despite the dramatic prognostic improvement, several issues remain unsettled.
• In addition, the worsening plethora of management options will make the treatment of individual patients more and more complex, unless risk-beneficial and cost-beneficial tailoring tools are developed.
Many thanks for your attention
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