Transcript Management of Acute Coronary Syndromes ( ACS )

Management of acute coronary
syndromes (ACS)
This presentation reflects the recommendations in the National Heart Foundation of Australia/Cardiac
Society of Australia and New Zealand’s Guidelines for the Management of Acute Coronary Syndromes
(ACS) (2006), updated in the 2007 and 2011 addenda. The presentation is designed for use in health
professional development and training on acute ACS care.
©2012 National Heart Foundation of Australia
Outline
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Cardiovascular disease (CVD) – the facts and risk factors
Acute coronary syndromes (ACS)
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Presentation of ACS
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ACS management: summary of updates in the 2011 addendum1
1. Systems of care
2. Investigations
3. Management of patients with ST-segment elevation myocardial
infarction (STEMI)
4. Management of patients with non-ST-segment elevation ACS (NSTEACS)
5. Long-term management
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand
guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
©2012 National Heart Foundation of Australia
CVD – the facts
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Heart disease is the single leading
cause of death.
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In 2009, 28 Australians died from a
heart attack each day. That’s one life
claimed every 51 minutes.1
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CVD is expected to affect 1 in 4
Australians by 2051.2
References
1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.
2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.
©2012 National Heart Foundation of Australia
Risk factors for CVD
Modifiable risk factors:
Non-modifiable risk factors:
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smoking
• gender
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poor diet
• age
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high cholesterol
• family history of CVD
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physical inactivity
• diabetes
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high blood pressure
• human immunodeficiency virus (HIV).
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being overweight
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depression, social isolation and
lack of social support.
©2012 National Heart Foundation of Australia
Acute coronary syndromes (ACS)
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ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack) through
an accelerated pattern of angina without evidence of myonecrosis1/infarction (muscle
death).
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Myocardial infarction (MI) occurs when the blood supply to the heart muscle is interrupted
due to partial or complete occlusion (thrombus) of the coronary artery. As a result, some of
the heart muscle becomes infarcted (dies).
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A heart attack can be confirmed by an electrocardiogram (ECG) test.
Reference
1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1–S14.
©2012 National Heart Foundation of Australia
Thrombus formation in the arterial lumen
©2012 National Heart Foundation of Australia
Acute presentation of ACS
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Critical factors to timely treatment:
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recognition
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time
People experiencing ACS symptoms
should seek help promptly and
activate emergency services.
©2012 National Heart Foundation of Australia
Heart attack
Signs and symptoms of
ACS presentation
Symptoms may include:
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chest discomfort (tightness, pressure, heaviness) at rest or for a prolonged
period (> 10 minutes, not relieved by sublingual nitrates)
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recurrent chest discomfort
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discomfort associated with syncope/acute heart failure.
The pain may spread to other parts of the upper body, including:
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back, neck, jaw, arm(s), shoulder(s) or epigastric pain.
The person may also experience:
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dyspnoea (shortness of breath), diaphoresis (profuse perspiration),
dizziness, nausea or vomiting
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recent research shows that women, the elderly and people with diabetes are
less likely to experience chest pain as a symptom.
©2012 National Heart Foundation of Australia
2011 addendum to 2006 Guidelines
The 2011 addendum to the 2006 Guidelines provides updates to:
1. Systems of care to support delivery of ACS services
2. Early response
3. Management of patients with STEMI
4. Management of patients with NSTEACS
5. Long-term management (after control of myocardial ischaemia).1
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the
management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
©2012 National Heart Foundation of Australia
1. Systems of care to support delivery of
ACS services
Formal systems of care:
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defined continuum of care – from presentation to long-term management
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system-based approaches to deliver timely reperfusion at a local level (Grade B)
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routine audit integrated into all clinical ACS services (Grade B)
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training GPs/health workers to initiate fibrinolysis (if primary percutaneous coronary
intervention [PCI] services are not readily accessible)
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practitioners are supported by ready access to expert cardiology consultation (Consensus)
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cardiac clinical networks established with appropriate protocols (Grade B).
For example: iCCnet CHSA network links > 70 hospitals, health centres and general
practitioner [GP] surgeries across SA, aligned to the Health Reform Agenda principles.
©2012 National Heart Foundation of Australia
2. Early response: treatment is time critical
Time from symptom onset and likely outcome
< 1 hour
Aborted heart attack or only little heart muscle damage
1–2 hours
Minor heart muscle damage only
2–4 hours
Some heart muscle damage with moderate heart muscle salvage
4–6 hours
Significant heart muscle damage with only minor heart muscle salvage
6–12 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable
In cases of major delay to hospitalisation (> 30 minutes) ambulance
crews should consider pre-hospital fibrinolysis.
©2012 National Heart Foundation of Australia
STEMI – what is it?
An ST-segment elevation myocardial infarction (STEMI) can be confirmed by an ECG.
STEMI is defined as presentation with clinical symptoms consistent with an ACS with
ECG features including any of:
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persistent ST-segment elevation ≥ 1 mm in two contiguous limb leads
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ST-segment elevation ≥ 2 mm in two contiguous chest leads
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new left bundle branch block (LBBB) pattern.
©2012 National Heart Foundation of Australia
3. Management of patients with STEMI
©2012 National Heart Foundation of Australia
Early response
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Implement reperfusion strategy for patients presenting within 12 hours of onset of
ischaemic symptoms consistent with ACS (determined by physical examination):
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immediate 12-lead ECG
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insert cannulae
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pain relief
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blood tests.
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Give aspirin 150–300 mg (unless already given, or contraindicated).
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Doctor sees patient within 10 minutes of arrival (Australasian Triage Scale
Category 2).
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Oxygen therapy indicated only for patients with hypoxia (oxygen saturation < 93%)
and those with evidence of shock (Consensus).
©2012 National Heart Foundation of Australia
Choice of reperfusion therapy
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In general, PCI is the treatment of choice, providing it can be performed promptly by a qualified
interventional cardiologist in an appropriate facility.1
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All PCI facilities should be able to perform primary angioplasty within 90 minutes of patient
presentation.
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Fibrinolysis should be considered early if PCI is not readily available.
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In cases of major delay to hospitalisation (> 30 minutes) consider pre-hospital fibrinolysis.
Reference
1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S9–29.
©2012 National Heart Foundation of Australia
PCI cardiac catheter
The catheter can be inserted via the radial or femoral artery (insertion via the femoral artery
illustrated below).
©2012 National Heart Foundation of Australia
PCI – how it works
©2012 National Heart Foundation of Australia
Primary PCI – technique and antithrombotic therapy
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Among patients with STEMI undergoing primary PCI the use of bivalirudin can be considered
as an alternative to heparin and GP IIb/IIIa inhibitors (Grade B).1
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Among patients undergoing primary PCI for reperfusion, consider antiplatelet therapy with
either:
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high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75 mg/day for at
least 12 months) (Grade B)
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prasugrel (60 mg oral bolus + 10 mg daily) (Grade B)
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ticagrelor (180 mg oral bolus + 90 mg twice daily) (Grade B).1
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Careful assessment of bleeding risk should be undertaken before using antithrombotic agents
(Grade B).1
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Consider use of mechanical thrombectomy techniques to reduce thrombus burden during
primary PCI (Grade A).1
Reference
1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for
the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.
©2012 National Heart Foundation of Australia
Bleeding risk
The following risk factors should be considered when assessing bleeding risk and choosing
antithrombotic therapies in patients with ACS (Grade B):
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age > 75 years
female
history of bleeding
history of stroke or transient ischaemic attack (TIA)
creatinine clearance rate < 60 mL/min
diabetes
heart failure
tachycardia
blood pressure < 120 mmHg or ≥ 180 mmHg
peripheral vascular disease (PVD)
anaemia
concomitant use of GP IIb/IIIa inhibitor
enoxaparin 48 hours prior
switching between unfractionated heparin and enoxaparin
procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart catheterisation).
©2012 National Heart Foundation of Australia
Fibrinolysis
Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the
coronary vessels to restore blood flow to the heart muscle.1
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Consider early routine revascularisation of patients receiving fibrinolysis, regardless of success of
pharmacologic reperfusion (Grade A).
Absolute contraindications
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Active bleeding or bleeding diathesis (excluding menses).
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Significant closed head or facial trauma within 3 months.
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Suspected aortic dissection.
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Any prior intracranial haemorrhage.
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Ischaemic stroke within 3 months.
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Known structural cerebral vascular lesion.
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Known malignant intracranial neoplasm.
Reference
1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis – primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm.
Accessed 7 August 2011.
©2012 National Heart Foundation of Australia
Fibrinolysis
Relative contraindications
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Current use of anticoagulants.
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Non-compressible vascular punctures.
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Recent major surgery (< 3 weeks).
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Traumatic or prolonged (> 10 mins) CPR.
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Recent internal bleeding (within 4 weeks).
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Active peptic ulcer.
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History of chronic, severe, poorly controlled hypertension.
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Severe uncontrolled hypertension on presentation (systolic ≥ 180 mmHg or
diastolic ≥ 110 mmHg).
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Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.
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Pregnancy.
©2012 National Heart Foundation of Australia
NSTEACS – what is it?
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Non-ST-elevation ACS (NSTEACS) applies to patients with suspected ACS in the
absence of other plausible causes of troponin elevation (e.g. sepsis, pulmonary
embolus).
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On physical examination, patients with NSTEACS may have a ‘normal’ ECG
reading, or show minor changes (occurs in up to 50% of patients).
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All patients with NSTEACS should have their risk stratified to direct management
decisions.
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The management of patients with NSTEACS requires evolving risk stratification:
clinical assessment, assessment of cardiac biomarkers and time.
©2012 National Heart Foundation of Australia
4. Management of patients with NSTEACS
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Clinical assessment: careful clinical
history, ECG, chest X-ray and
investigations to diagnose other
causes of chest pain and evaluate
the likelihood of evolving ACS.
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Troponin assessment: to assess the
likelihood of MI.
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Stratify risk.
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©2012 National Heart Foundation of Australia
Evolving risk stratification
Admit to coronary care unit or high
dependency unit:
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estimate ischaemic risk,
estimate bleeding risk, choose
augmented antithrombotic
therapy
→refer for angiography to
determine surgery/PCI, or
medical therapy.
©2012 National Heart Foundation of Australia
Evolving risk stratification
©2012 National Heart Foundation of Australia
Evolving risk stratification
Intermediate-risk NSTEACS
Recurrent ischaemia or elevated troponin?
YES
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admit to CCU or high dependency unit:
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estimate ischaemic risk, estimate
bleeding risk, choose augmented
antithrombotic therapy
→refer for angiography to determine
surgery/PCI, or medical therapy.
©2012 National Heart Foundation of Australia
NO
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undertake stress test (e.g. exercise ECG):
→positive – refer for angiography to
determine surgery/PCI, or medical
therapy
→negative – proceed to discharge patient
with urgent cardiac follow-up (on
upgraded medical therapy) according
to long-term management after control
of myocardial ischaemia.
Evolving risk stratification
Appropriate period of
observation. Consider if
stress test (e.g. exercise
ECG) needed?
YES
Stress test (e.g. exercise ECG)
using treadmill.
©2012 National Heart Foundation of Australia
NO
Proceed to discharge patient with urgent
cardiac follow-up (on upgraded medical
therapy) according to long-term
management after control of myocardial
ischaemia.
Antithrombotic therapy for NSTEACS
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For high-risk patients with NSTEACS, assess bleeding risk individually according to the
number and severity of bleeding risk factors (Grade A).
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Assign a management strategy according to bleeding risk.
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For patients at high risk of bleeding, use a ‘priority low-bleeding’strategy.
Antithrombotic agents with lower bleeding risk include:
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clopidogrel in preference to prasugrel (Grade B)
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fondaparinux in preference to enoxaparin (Grade B)
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bivalirudin in preference to enoxaparin (Grade B).
For patients at low risk of bleeding, use a ‘standard’ effective antiplatelet regimen
(prasugrel and ticagrelor) (Grade A). (cont.)
©2012 National Heart Foundation of Australia
Antithrombotic therapy for NSTEACS
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Minimise the number of agents used (Grade B).
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When additional agents are needed, substitute rather than add (Grade B).
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Consider shorter-acting or reversible agents (Grade B).
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Avoid using GP IIb/IIIa inhibitors, where possible (Grade B).
©2012 National Heart Foundation of Australia
5. Long-term management
Before discharging a patient:
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discharge medication regimen
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provide tailored lifestyle advice to reduce risk of further events,
including:
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smoking cessation
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good nutrition and moderate alcohol intake
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physically active lifestyle and weight management as relevant
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managing depression
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warning signs of a heart attack.
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Refer all patients to comprehensive cardiac rehabilitation programs.
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Provide all patients with a written action plan for chest pain, which
can be downloaded from www.heartfoundation.org.au
©2012 National Heart Foundation of Australia
Medication regimen
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Continued antiplatelet therapies for 12 months for all patients with stents (Grade A).
In addition:
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aspirin
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beta-blockers
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ACE inhibitors
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statins
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warfarin
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nitrates
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insulin/oral hypoglycaemics
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aldosterone antagonists.
©2012 National Heart Foundation of Australia
Concluding remarks
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This presentation is designed to ensure consistency of information regarding best practice
ACS management, based upon the 2011 addendum to the National Heart Foundation of
Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of
acute coronary syndromes 2006.
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Understandings of the pathophysiology of ACS have improved, together with increasingly
accurate diagnostic tools, better risk stratification and improved medical and invasive
treatments. However, these advances have led to an increase in the complexity of
possible treatment strategies. This is evolving.
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For more information please visit www.heartfoundation.org.au.
© 2012 National Heart Foundation of Australia ABN 98 008 419 761
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