Transcript Coronary Artery Disease

UHCW Cardiology Teaching
Dr Chris McAloon
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65 year old man
Playing golf
Sudden onset chest pain
Crushing, central, severe
Vomiting
No previous chest pain
HTN, Ex-Smoker
Otherwise well
GTN helped – not resolved
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Pain
◦ Character / Radiation / GTN spray effect
◦ Was this pain like your previous Angina/ MI pain?
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Autonomic features
Risk factors
◦ Smoker / Hypertension / Diabetes Hyperlipidaemia
/ Family history
◦ Previous MI / CABG / PCI / CVA
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Differentials
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Central Crushing Chest Pain
Exertional chest pain
Occurs at rest
Radiation
◦ Neck, arms (classically left)
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Levine’s Sign
◦ Clenched fist over chest
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Breathless
Autonomic features
ECS ACS NTE Guidelines 2011
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Nicotine Stains
GTN spray
Xanthelasma
Scar’s
◦ Chest
◦ Legs
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Evidence DM
BP/ Pulse/ Failure
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65 year old
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◦ Metallic Click
◦ Look left lateral
◦ Cyanosis etc
◦ Ankles/shins for SVG
scar
◦ Radial for graft scar
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CABG
35 year old
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Valve/ Congenital
surgery
ECS ACS Guidelines 2011
ECS ACS Guidelines 2011
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
Ischaemic Heart Disease
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
STEMI
Grech E D , Ramsdale D R BMJ 2003;326:1379-1381
©2003 by British Medical Journal Publishing Group
ECG Changes
Site of
Infarction
Vessel Occluded
V1-V3
Anteroseptal
LAD
V4, V5, AVL, I
Anterior Lateral
LAD, diagonal
Widespread
1, AVL, V1-V6
Large Anterior
Prox LAD (could be LMS
- Pump probs
II, III, AVF
Inferior
RCA (or Cx)
- Bradyarrhythmia
↓ ST V1-V2
Posterior
↑ ST in post leads
RCA (or Cx)
NB remember Cx occlusion can be silent on the ECG
ANTERIOR STEMI
ST elevation V1-V6, reciprocal changes in
II, III, AVF
STEMI
 31,412 in 2009-10
 Frequency falling
NSTEMI
 Estimated 100, 000 in 2009-10
 Recorded frequency rising
 50% not managed on ACU/ CCU
BCS Recommendations Acute Coronary Care Oct 2011
BCS Recommendations Acute Coronary Care Oct 2011
ECS ACS STE Guidelines 2011
THINK REPERFUSION STRATEGY:
■ Primary PCI if available (CALL THE CATH LAB)
■ Thrombolysis if not, then refer to PCI centre
(GTN)
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High Flow Oxygen (15L)
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300mg Aspirin/ 600mg Clopidogrel
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Analgesia: Morphine + Metoclopramide
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Reperfusion: PCI / Fibrinolysis
Successful
Thrombolysis
ST segment resolution
50% at 90 minutes
ECS Revasculration Guidelines 2011
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Direct paramedic transfer to PPCI centre or
timely inter-hospital transfer
PPCI with first medical contact-to-balloon
time <120 minutes
Monitoring on CCU (including for repatriated
patients)
Early initiation of secondary prevention and
cardiac rehabilitation
ECS Revasculration Guidelines 2011
BCS Recommendations Acute Coronary Care Oct 2011
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95% England covered by PPCI networks
Thrombolysis remains in place in remote
centres
◦ Geography impacts time to PPCI centre
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30% Thrombolysis fail to reperfuse and need
immediate rescue PCI
ECS ACS STE Guidelines 2011
Disruption of occlusion using a balloon
 Stent deployed to maintain anterograde blood
flow
Types
 Primary PCI – PCI within 2 hours
 Rescue PCI – PCI after failed thrombolysis
 Facilitated PCI – PCI bridged with lytic therapy
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◦ Time delayed PPCI
NSTEMI
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
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48 year old lady
Shopping
Central dull Pain on walking
Not relieved GTN spray
Gets on exertion normally
Recently distant decreasing to onset pain
Pain last night in bed
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
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Stable Angina
◦ pattern of frequency, intensity, ease of provocation,
or duration does not change over several weeks
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Accelerating Angina
◦ change in the pattern of stable angina
◦ greater ease of provocation, more prolonged
episodes, and episodes of greater severity or more
frequent use of sublingual GTN
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Unstable Angina
◦ pattern of chest pain changes abruptly
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Angina at rest—Also prolonged, usually > 20
minutes
Angina of new onset—At least CCS class III in
severity
Angina increasing—Previously diagnosed
angina that has become more frequent,
longer in duration, or lower in threshold
(change in severity by > 1 CCS class to at
least CCS class III)
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Class
Class
Class
Class
I – Pain strenuous exertion
II – Slight limitation ordinary exertion
III – Marked limitation physical exertion
IV – Pain on any exertion
CCS = Canadian Cardiology Society
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≥3 risk factors for coronary artery disease
≥50% coronary stenosis on angiography
ST segment change >0.5 mm
≥2 anginal episodes in 24 hours before
presentation
Elevated serum concentration of cardiac
markers
Use of aspirin in 7 days before presentation
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
ECS ACS Guidelines 2011
BCS Recommendations Acute Coronary Care Oct 2011
Simplified management pathway for patients with unstable angina or non-ST segment
elevation myocardial infarction.
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
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Aspirin 300mg
Clopidogrel 300mg (600mg if going to the
lab)
LMWH
Bisoprolol / Atorvastatin 80mg ON/
ACE/ARB (can be next day)
GTN Spray/ Infusion
HIGH RISK patients: GPIIbIIIa
Cath Lab within 48-96hrs
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High risk (GRACE >140) within 24 hours
◦ At Stafford discuss with Stoke
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Intermediate risk (GRACE < 140) and high
risk criterion within 72 hours
Low risk with recurrent symptoms
◦ Stress Test
ECS ACS Guidelines 2011
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Thienopyridine related to Clopidogrel
Active metabolite irreversible inhibitor of ADP
receptor
Effective when Clopidogrel Resistance
More rapid/ greater/ more consistent platelet
inhibition
No drug interactions
Licensed used STEMI going PPCI
Prasugrel vs Clopidogrel
Wiviott SD et al. N Engl J Med 2007;357:2001-2015
Prasugrel vs Clopidogrel
Wiviott SD et al. N Engl J Med 2007;357:2001-2015
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Cyclopentyl-triazolo-pyrimidine
Reversible inhibitor of ADP receptor
Rapid/ Predictable action
CYP450 interaction
NICE approval October 2011 ACS
Wallentin L et al. N Engl J Med 2009;361:1045-1057
Ticagrelor vs Clopidogrel
Wallentin L et al. N Engl J Med 2009;361:1045-1057
ECS ACS Guidelines 2011
Immediately
 Aspirin ± PPI (Bleeding risk)
 Clopidogrel (12 months)
 B Blocker
 ACEi- if intolerant give ARB
 Atorvastatin 80mg
 GTN Spray PRN
◦ 15 minute rule
Lifestyle
 Diet
 Physical Activity
 Stop Smoking
 Cardiac Rehab
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Definitions ACS
Incidence and Prevalence
Pathophysiology
Differential Diagnoses
STEMI Intervention – current evidence
NSTEMI intervention – current evidence
Antithrombotic therapy use
New anti-thrombotics