Transcript AKUTNI KORONARNI SINDROM, (AKS) DEFINICIJA, KLINIČKA …

Differential diagnosis and treatment
of acute coronary disease
Milev Ivan MD
Special Hospital for Surgical Diseases
“Filip II” - Skopje, Macedonia
June, 2009
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Acute coronary syndrome
defininiton
Chest pain is a major symptom of acute coronary
disease or syndrome (ACS). ACS includes non
stabile angina (NA), myocardial infarction (MI)
without ST elevation (NSTEMI) and MI with ST
elevation (STEMI).
Erosion or rupture of unstable atherosclerotic
plaque, and creation of thrombus formation
 The limitation of flow, oxygenation of
myocardium and collateral circulation are major
determinants of clinical signs.
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Development of Atherosclerotic
Plaques
Fatty streak
Normal
Lipid-rich plaque
Foam cells
Fibrous cap
Lipid core
Thrombus
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Vulnerable vs Stable Atherosclerotic
Plaques
Vulnerable Plaque
Lumen
Fibrous Cap
Lipid
Core
• Thin fibrous cap
• Inflammatory cell infiltrates:
proteolytic activity
• Lipid-rich plaque
Stable Plaque
Lumen
Lipid
Core
Fibrous Cap
• Thick fibrous cap
• Smooth muscle cells:
more extracellular matrix
• Lipid-poor plaque
Libby P. Circulation. 1995;91:2844-2850.
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Thrombosis Influences the Severity
of a Cardiovascular Event
Nonocclusive thrombus
Occlusive thrombus
• Unstable angina
• Non—Q-wave MI
• Q-wave MI
• Sudden death
Factors limiting thromb.: Factors favoring thromb.
• Minor plaque
disruption
• High flow
• Low thrombotic
tendency
• Major plaque
disruption
• Low flow or vasospasm
• Thrombotic tendency
Kullo IJ, et al. Ann Intern Med. 1998;129:1050-1060.
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Other reasons for NA and
NSTEMI
Non-oclusive thrombus
Dynamic obstruction (coronary spasms)
Infection
-inflammation with increase markers (CRP)
-infection with Chlamidia pneumonie, Helicobacter
pylori, cytomegalovirusi, herpes simplex virus
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ECG changes vs risqué of death or MIepidemiology
death or IM
30-days 6- months 1-year
ST elevation 9,4%
12,3%
16,1%
ST depression 10,5%
15,45% 18,1%
ST elevacija
and depression 12,4%
15,7% 25,6%
T wave
inversion
5,5%
8,1%
13,6%
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Chest pain - origin
acute aortic dissection (AAD)
pulmonary embolism
pericarditis
mitral valve prolaps
chest pain in obstructive cardiomiopathy
primary pulmonary hypertension
*consider non-cardiac disesases of pleura,
mediastinum and abdomen
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Chest pain-origin
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Acute coronary syndrome
- the importance
Urgent presentation
Needs high level of health organization
Great morbidity and mortality rate
Increasing of percentage of pts with unstable
angina and NSTEMI in recent years
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ACSy - triggers
hypertension, tachycardia, hard work –the
intracoronary changes in hemodynamic state.
Peak - early in the morning (sympaticus)
Factors inside the plaque
Emotional stress
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Diagnostic of coronary disease
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ECG
Standard 12-lead ECG is the best test
Additional leads V4R-V6R (inferior IM) for RV
assessment. V7-V9 posterior leads
Continious recording every 20 sec.
New LBBB, ST depression  1 mm V1 - V3, ST
elevation > od 2 mm suggest IM
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Laboratory markers
 Two folds increasing of CK after 6 h, peak 24 h.
 CK-MB sensitivity 90%, increase 6 h.
Troponin I /T is more specific.
Activity rise after 6 h, peak 12-24 h, and high level in
serum up to 7-10 days.
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Echocardiography
Assessment of wall motion
Sensitivity of acute IM is 93%, specificity
53%
Can not distinguish acute from previous
IM
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Coronarography
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Action- time is short, move swiftly &
decide...
 Door (events prior to arrival)
 Data – actual (obtain ECG, Lab)
 Decision (AMI & decide Th)
 Drug (Fibrinolytic or passing Angioplasty Cath)
 Triage ID AMI, Immediate Cardio consult
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EKG fibrinolytic Therapy eligibility
 ST elevation 1mm+ in 2 or more limb leads & 2mm+ in 2 or
more contiguous precordial leads, 2-6 hours before
 OR new or presumed new LBBB
 No benefit in ischemic pt who lack above EKG findings
 LBBB + AMI = poorer outcome due to likely proximal LAD
occlusion, putting signif. portion LV in ischemic jeopardy
 DO NOT USE in ST-depression... signif. poorer outcomes!!!
 Remember age is NO longer excluder, but age > 75  ICH
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When TO & When NOT TO
 Active Diabetic Retinopathy... strong relative C/I risk blindness
 DM pts + AMI 2X more likely to DIE
 CPR > 10 minutes long or extensive chest trauma from CPR
Hemithorax/cardiac tamponade
 IM > 12 hours before
 Prior Stroke/TIA, major risk for ICH, relative C/I, prior
Hemorrhagic stroke ABSOLUTE C/I
 Prior MI in setting AMI; 26%  mortality even if prior
fibrinolytics th
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When TO & When NOT TO
 Recent Surgery/Trauma/GI Bleed w/in 10 days is absolute C/I
 Women menses w/ AMI consider use; excessVag bleeding after
Fibrinolytics CTRL w/ Vag packing compressible site of
bleeding
 GI bleed in 10 days Absolute C/I
 HTA; SystBP > 180 or Diast.BP 110
 Significant liver dysfunction
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Our results (2005-2009,n=115)
Other;
50
CAD

Other
diseases
; 55
CAD; 65
Other
AAD
Differential diagnosis was confirmed with
clinical signs, repeated ECG, serum level of
cardiac markers (troponin I,T),
echocardiography and finaly with
coronarography.
Other diseases
STEMI;
15
NA; 40
STEMI
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AAD; 35
NSTEMI;
10
NSTEMI
NA
Results (2005-2009)
female;
20
previous
MI; 25
Major
risks; 60
male; 45
male
female
Major risks
previous MI
Fibrinolytic
therapy; 2
coronarography; 63
Fibrinolytic therapy
coronaro-graphy
IABP in PCI
CABG; 4
IABP; 6
reperfusion;
65
PCI; 59
PCI; 59
CABG
PCI
IABP
PCI
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reperfusion
Results (2005-2009)
Mortality in PCI
In hospital stay, days
mort; 2
PCI; 5
CABG;
11
All; 59
PCI
CABG
mort
Recoronarography in PCI
All
CABG in PCI group
Only rePCI; 3
PCI; 9
New
CABG; 7
All pts; 56
PCI
All pts
Only re-PCI
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New CABG
Case report (2005-2009)
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Case report(2005-2009)
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Case report (2005-2009)
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Catheterisation laboratory – Filip II
2000-2009
May 2005 - May 2009:
-802 intervention
800
700
690
600
-Coronary intervention: 690 pat.
500
-Intervent. of congenital
anomalies: 104 pat.
-Carotid stenting:
5 pat
400
300
200
104
100
-Peripheral stenting:
3 pat.
0
coronary
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congenital
anom.
5
3
carotid
peripheral
Coronary intervention
May 2005-May 2009
690 PCI -treatment:
39
-Out patients treatment:
651(94.3%)patients
-Hospital treatment (more than 24h):
39(5.9%) patients
651
Out patients Hospital
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Coronary intervention
May 2005-May 2009
690 PCI- approach:
TBA; 2
TUA; 11
TFA; 3
-TRA: 673 (97.5%) pat.
-TUA: 11 (1.5%) pat.
TRA; 673
-TFA: 3 (0.6%) pat.
TRA
-TBA: 2 (0.4 %) pat.
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TUA
TBA
TFA
Conclusion
Time from begining of chest pain to
reperfusion / D2B is a major factor in
treatment of pts with ACS.
Early diagnosis, urgent transport to PCI
centar, early begining of fybrinolitic
therapy and early differential diagnosis is
essential in treatment of ACS pts and
decreasing of mortality.
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