Updates in Acute Coronary Syndromes Management Mohammad Zubaid, MB, ChB, FRCPC, FACC
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Transcript of Updates in Acute Coronary Syndromes Management Mohammad Zubaid, MB, ChB, FRCPC, FACC
Updates in Acute Coronary Syndromes Management
Mohammad Zubaid, MB, ChB, FRCPC, FACCProfessor of Medicine, Kuwait University
Head, Division of CardiologyMubarak Alkabeer Hospital
Kuwait
The 1st Kuwait-North American update in Internal Medicine4th Medical Scientific Conference – Mubarak Alkabeer Hospital
February 7, 2014 – Jumeirah hotel, Kuwait
From plaque formation to progression to clinical manifestations
Plaque formation Clinical manifestations
STABLENo symptomsSilent ischemiaStable angina
UNSTABLEUnstable anginaNSTEMISTEMISudden cardiac death
Risk factor Slow
Atherosclerosisprogression
Atherothrombosis
Accelerated Progression
Distribution of ACS type in Kuwait
Discharge diagnosis 2534 patients
STEMI (288)n (%)
Age (Mean ±SD) 56.7±13.3Female 61 (21)Hypertension 145 (50)Diabetes 152 (53)Smoking 164 (57)Prior MI 41 (14)Prior PCI 25 (9)Prior CABG 7 (2)Prior TIA 7 (2)Prior stroke 19 (7)
Gulf COAST 2012
Kuwait population
Pooled analysis of the short-term results from 23 randomized trials comparing primary PCI and fibrinolytic therapy in 7739 patients
Stone G. Circulation 2008;118:538-551
Primary PCI
Recommendations Class Level
Indications for primary PCI
Primary PCI is the recommended reperfusion therapy over fibrinolysis if performed by an experienced team within 120 min of FMC
I A
Primary PCI is indicated for patients with severe acute heart failure or cardiogenic shock, unless the expected PCI related delay is excessive and the patient presents early after symptom onset.
I B
Steg et al, EHJ 2012;33:2569-2619
Periprocedural antithrombotic medicationsin primary PCI
Recommendations Class Level
Antiplatelet therapy
Aspirin oral or i.v. (if unable to swallow) is recommended I B
An ADP- receptor blocker is recommended in addition to aspirin.Option are:
I A
• Prasugrel in clopidogrel-naive patients, if no history of prior stroke/TIA, age <75 years.
I B
• Ticagrelor I B
• Clopidogrel, preferably when prasugrel or ticagrelor are either not available or contraindicated
I C
Steg et al, EHJ 2012;33:2569-2619
Fibrinolytic therapy
Recommendations Class Level
Fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications if primary PCI cannot be performed by an experienced team within 120 min of FMC
I A
In patient presenting early (<2 h after symptom onset ) with large infarct and low bleeding risk, fibrinolysis should be considered if time from FMC to balloon inflation is >90 min
IIa B
If possible, fibrinolysis should start in the Prehospital setting IIa A
A fibrin – specific agent (tenecteplase, alteplase, reteplase) is recommended ( over non – fibrin specific agents)
I B
Oral or i.v. aspirin must be administered I B
Clopidogrel is indicated in addition to aspirin I A
Steg et al, EHJ 2012;33:2569-2619
PCI post lysis
Recommendations Class Level
Transfer to a PCI capable center following fibrinolysis
Is indicated in all patients after fibrinolysis I A
Interventions following fibrinolysis
Rescue PCI is indicated immediately when fibrinolysis has failed (< 50% ST- segment resolution at 60 min).
I A
Emergency PCI is indicated in the case of recurrent ischemia or evidence of reocclusion after initial successful fibrinolysis.
I B
Steg et al, EHJ 2012;33:2569-2619
Prehospital and in-hospital management
Reperfusion stratergies within 24 h of FMC
STEMI diagnosis
Primary PCI capable center EMS or non primary-PCI capable center
Primary - PCI
Rescue PCI
Coronary angiography
Immediate fibrinolysis
PCI possible <120 min?
Successful fibrinolysis
Yes No
Yes
No
Immediate transfer to PCI center
Immediate transfer to PCI center
Preferably < 60 min
Preferably ≤ 90 min(≤ 60 min in early presenters)
Preferably 3-24 h
Immediately
Preferably ≤ 30 min
Steg et al, EHJ 2012;33:2569-2619
Important treatment goals in the management of STEMI
Stages Target
Preferred for FMC to ECG and diagnosis ≤ 10 min
Preferred for FMC to fibrinolysis (FMC to needle) ≤ 30 min
Preferred for FMC to primary PCI (door to balloon) in primary PCI hospitals
≤ 60 min
Preferred for FMC to primary PCI in hospitals without cath facility
≤ 90 min(≤ 60 min if early presenter with large area at risk) if this target cannot be met, consider fibrinolysis
Acceptable for primary PCI rather than fibrinolysis ≤ 120 min(≤ 90 min if early presenter with large area at risk) if this target cannot be met, consider fibrinolysis
Preferred for successful fibrinolysis to angiography 3-24 hours
Steg et al, EHJ 2012;33:2569-2619
Components of delay in STEMI
Symptom onset FMC
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Reperfusion therapyDiagnosis
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≤ 10 min
Patient delay
System delay
Time to reperfusion therapy
Wire passage in culprit artery (primary PCI) Start of lysis
Steg et al, EHJ 2012;33:2569-2619
Reperfusion in eligible patients
Per country
Kuwait
(n=259)
Oman
(n= 315)
UAE
(n= 129)
Bahrain
(n= 119)
PPCI (%) 60.3 40 29
Lysis (%)86
9249 58
Shortfall (%)8
7.711 13
Reperfusion in eligible patients
Kuwait
Adan Hospital
(n=56)
Rest of Hospital
(n= 203)
PPCI (%) 270
Lysis (%)64
93
Shortfall (%)9
7
Was reperfusion administered in time?
Reperfusion Timeline
Thrombolysis in Kuwait
Thrombolysis Adan Hospital
(n=37)
Rest of Hospital
(n= 188)
Median D2NT (min) 34 41
D2NT ≤30 min (%) 43 36
Primary PCI experienceAdan Hospital
November 13 – December 30, 2013
Distribution of timeline
During working hours14 patients
After working hours45 patients
Door to ECG 5 7
ECG to cardiology notification 11 6
Cardiology response time 4 3
Door to balloon time 51 62
Door to balloon ≤60 minutes 71% 53%
Door to balloon ≤90 minutes 93% 89%
Distribution of timeline during and after normal working hours
Primary PCI experienceAdan Hospital
November 13 – December 30, 2013
Primary PCI experienceMubarak Alkabeer Hospital
November 13 – December 30, 2013Held off for two weeks in the middle
Distribution of timeline
Primary PCI experienceMKH vs. Adan Hospital
November 13 – December 30, 2013
Adan (33 patients) MKH (24 patients)
Symptom onset to ER arrival 205 124
Door to ECG 7 18
ECG to cardiology notification 9 20
Cardiology response time 4 3
Door to balloon time 64 111
Door to balloon ≤60 minutes 48% 0
Door to balloon ≤90 minutes 85% 15%
Door to balloon ≤120 minutes 97% 65%
Distribution of timeline (values in mean)
Components of delay in STEMI
Symptom onset FMC
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Reperfusion therapyDiagnosis
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≤ 10 min
Patient delay
System delay
Time to reperfusion therapy
Wire passage in culprit artery (primary PCI) Start of lysis
Steg et al, EHJ 2012;33:2569-2619
Cardiology response timeDoor to ECG
ECG to Cardiology
Door to balloon
Door to ECGECG to
CardiologyCardiology
response time Door to balloon
Ambulance notification
Ambulance response
Ambulance trip time
Adan Hospital
Mubarak AlKabeer Hospital
97 4 64
18 3 5 13 30 11120
Door to balloon in hospitals with and without cath labs in Kuwait
In-hospital cardiac catheterization
Prehospital and in-hospital management
Reperfusion stratergies within 24 h of FMC
STEMI diagnosis
Primary- PCI capable center EMS or non primary-PCI capable center
Primary - PCI
Rescue PCI
Coronary angiography
Immediate fibrinolysis
PCI possible <120 min?
Successful fibrinolysis
Yes No
Yes
No
Immediate transfer to PCI center
Immediate transfer to PCI center
Preferably < 60 min
Preferably ≤ 90 min(≤ 60 min in early presenters)
Preferably 3-24 h
Immediately
Preferably ≤ 30 min
Steg et al, EHJ 2012;33:2569-2619
PCI post lysis
Recommendations Class Level
Transfer to a PCI capable center following fibrinolysis
Is indicated in all patient after fibrinolysis I A
Interventions following fibrinolysis
Rescue PCI is indicated immediately when fibrinolysis has failed (< 50% ST- segment resolution at 60 min).
I A
Emergency PCI is indicated in the case of recurrent ischemia or evidence of reocclusion after initial successful fibrinolysis.
I B
Steg et al, EHJ 2012;33:2569-2619
Kuwait Gulf COAST population
Rates of inhospital cath for STEMI patients
STEMI (288)n (%)
Cath during hospital stay 120 (42)
Adan Hospital 61 (87)
The rest of hospitals 59 (27)
Hospital arrival to PCI at Adan, Mean±SD, Median (days) 0.86±1.2, 0.00
Hospital arrival to PCI excluding Adan, Mean±SD, Median (days) 4.4±3.5, 3
Management of hyperglycemia in the acute phase of STEMI
Recommendations Class Level
Measurement of glycaemia is indicated at initial evaluation in all patients, and should be repeated in patients with know diabetes or hyperglycemia I C
Plans for optimal outpatient glucose control and secondary prevention must be determined in patients with diabetes before discharge I C
The goals of glucose control in the acute phase should be to maintain glucose concentrations ≤11.0 mmol/L (200mg/dL) while avoiding fall of glycaemia<5 mmol/L (<90mg/dL). In some patients, this may require a dose-adjusted insulin infusion with monitoring of glucose, as long as hypoglycemia is avoided
IIa B
A measurement of fasting glucose and HbA1c and , in some cases, a post- discharge oral glucose tolerance test should be considered in patients with hyperglycemia but without a history of diabetes
IIa B
Routine glucose-insulin-potassium infusion is not indicated III A
Steg et al, EHJ 2012;33:2569-2619
Routine therapies in the acute, subacute and long term phase of STEMI
Recommendations Class Level
Oral treatment with betablockers should be considered during hospital stay and continued thereafter in all STEMI patients without contraindications
IIa B
Oral treatment with betablockers is indicated in patients with heart failure or LV dysfunction I A
A fasting lipid profile must be obtained in all STEMI patients, as soon as possible after presentation I C
It is recommended to initiate or continue high dose statins early after admission in all STEMI patients without contraindication or history of intolerance, regardless of initial cholesterol values
I A
Reassessment of LDL should be considered after 4-6 weeks to ensure that a target value of ≤1.8 mmol/L (70 mg/dL) has been reached
IIa C
Steg et al, EHJ 2012;33:2569-2619
Routine therapies in the acute, subacute and long term phase of STEMI
Recommendations Class Level
ACE Inhibitors are indicated starting within the first 24 h of STEMI in patients with evidence of heart failure, LV systolic dysfunction, diabetes or an anterior infarct
I A
An ARB, preferably valsartan, is an alternative to ACE inhibitors in patient with heart failure or LV systolic dysfunction, particularly those who are intolerant to ACE inhibitors
I B
ACE inhibitor should be considered in all patients in the absence of contraindications IIa A
Aldosterone antagonists are indicated in patients with an ejection fraction ≤40% and heart failure or diabetes, provided no renal failure or hyperkalaemia
I B
Steg et al, EHJ 2012;33:2569-2619
Adherence to medical therapy
Gulf COAST
STEMI/NSTEMI
Gulf COAST 2012
Gulf RACE2007¹
EHS-ACS-II2004²
NRMI-52004-2006³
Aspirin at arrival (%) 99 98 97 90
Aspirin prescribed at discharge (%) 97 97 90 91
Beta- blocker at discharge (%) 85 78 71 89
Statin at discharge (%)
97 84 80 82
Clopidogrel at discharge for medically treated AMI patients (%)
67 57 63 -
From plaque formation to progression to clinical manifestations
Plaque formation Clinical manifestations
STABLENo symptomsSilent ischemiaStable angina
UNSTABLEUnstable anginaNSTEMISTEMISudden cardiac death
Risk factor Slow
Atherosclerosisprogression
Atherothrombosis
Accelerated Progression
Work up of ischemic chest pain
Admission
Working diagnosis
Bio-chemistry
Acute Coronary Syndrome
ECGPersistent
ST-elevation
Diagnosis NSTEMI Unstable Angina
troponin rise/fall
ST/T– abnormalities
normal or undetermined
ECG
troponin normal
STEMI
Chest Pain
Hamm et al, EHJ 2011;32:2999-3054
Criteria for high risk with indicationfor invasive management
Primary
• Relevant rise or fall in troponin• Dynamic ST- or T- wave changes (symptomatic or silent)
Secondary
• Diabetes mellitus• Renal insufficiency (eGFR < 60 mL/min/1.73m2)• Reduced LV function (ejection fraction < 40 %)• Early post infarction angina• Recent PCI• Prior CABG• Intermediate to high GRACE risk score
Hamm et al, EHJ 2011;32:2999-3054
NSTEMI (574)n (%)
Age (Mean ±SD) 61.7±12.3Female 221 (39)Hypertension 403 (70)Diabetes 391 (68)Smoking 177 (31)Prior MI 208 (36)Prior PCI 120 (21)Prior CABG 45 (8)Prior TIA 28 (5)Prior stroke 57 (10)
Gulf COAST
Kuwait population
Decision – making algorithm in ACS
1.Clinical Evaluation 2. Diagnosis/Risk Assessment 3. Coronary angiography
Evaluation
• Quality of chest pain.• Symptom - orientated
physical examination.• Short history for the
likelihood of CAD.• Electrocardiogram (ST elevation?)
Validation• Response to antianginal
treatment.• Biochemistry/troponin.• ECG• Echocardiogram.• Calculated risk score
(GRACE)• Risk Criteria.• Optional: CT, MRI,
scintigraphy.
STEMI
No CAD
ACS possible
reperfusion
urgent < 120 min
no/elective
early <24h
<72h
Hamm et al, EHJ 2011;32:2999-3054
Antithrombotic treatment in NSTE ACS
Anticoagulation
Fondaparinux
Bivalirudin
LMWH Heparin
Aspirin
GPIIb/IIIainhibitors
Antiplatelet
Clopidogrel PrasugrelTicagrelor
Tissue Factor
Plasma clotting cascade
Prothrombin
Thrombin
Fibrinogen Fibrin
Collagen
ADP
Thromboxane A2
Conformational activation of GPIIb/IIIa
Platelet aggregation
Thrombus
Factor Xa
AT
AT
Targets for antithrombics
Hamm et al, EHJ 2011;32:2999-3054
Conclusions
Management of ACS has evolved rapidly over the past few years.
Early risk stratification and cardiac catheterization is a cornerstone in ACS management.
If we want to benefit our patients, it is important that we examine what we do.
Our ACS patients receive good medical therapy at discharge from hospital.
However, we rely heavily on lytic therapy for reperfusion in STEMI and it is not administered in efficient timing to get the most benefit from it.
In both STEMI and NSTE ACS, our use of cardiac catheterization falls short of guidelines recommendations.