Transcript Acute Coronary Syndromes Or, heart attacks for the would-be dumb ass

Acute Coronary Syndromes
Or, heart attacks for the would-be dumb ass
Brendan Munn
Emergency Residents’ Academic Day
August 27 2009
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Objectives
1.
2.
3.
4.
5.
review terminology and pathophys
approach to risk stratification
discuss ACS management with cases
review the literature on management
prevent and manage complications
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Definitions and Pathophys
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Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs
and tests
12 lead ECG
labs
initial cardiac
enzymes
electrolytes, cbc,
bun/cr, glucose,
coags
CXR
5/20/2016
Emergent
care
History &
Physical
IV access
cardiac monitors
MONA BHCG SA
assess reperfusion
manage complications
4
case 1
HPI :
52F with 0.5h central chest pain
no associated sx or radiation
CRF:
+FHx, smoker, HTN, T2DM
BMI 35
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Are Risk Factors Helpful?
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Are Risk Factors Helpful?
>17,000 post hoc with suspected ACS
compared with outcome of ACS
“limited clinical value in diagnosing acute
coronary syndromes, especially in patients
over 40 years”
“useful < 40 if no risk factors (LR 0.17) or if 4
or more (LR 7.39)
Han J. Ann Emerg Med 2007
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case 2
HPI : 73yoM w hx exertional chest pain
and SOB. crescendo use of NTG
spray over last 3 weeks. CP in ED.
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is this a NORMAL ecg?
what ABNORMAL findings
would you expect in ACS?
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NSSTT changes :
STE/STD < 1mm +/T wave morphology changes without inv or peak
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Are ECG Changes Helpful?
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Are ECG Changes Helpful?
1% of patients with normal ECG had AMI
and 4% had a final diagnosis of UA
in another study, w classic angina and normal
ECG 3% had final diagnosis of AMI
3-4% of patients with AMI and over 20% of
patients with UA have NSSTT findings
Lee TH. JAMA 1999; Zimetbaum P. NEJM 2003.
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case 3
HPI : 64F with 2h chest pain radiating to
both arms.
O/E : Diaphoretic, HR 120, BP 142/75
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ECG ?STEMI
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Is this ST Elevation?
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Is this ST Elevation?
ACS Definition
> 1.0mm in 2 contiguous precordial
> 2.0mm in 2 contiguous limb
method of calculation
baseline, j point
other causes of ST segment elevation
Wang K. NEJM 2003
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ST Elevation
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Causes of ST Elevation
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Causes of ST Elevation
(in 175 patients)
Brady J. Am J Emerg Med 2001
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ECG Pearls in ACS
50% of patients with AMI will have a clearly diagnostic
ECG at presentation (STE or STD)
ST segment elevation identifies those who benefit from
reperfusion therapy (lytics)
Mortality increases with the number of leads showing
STE, presence of LBBB and anterior location
Reciprocal changes are seen in 70% of inferior and 30%
of anterior MIs, which demonstrates over 90%
specificity and PPV for AMI
RV infarcts complicate 40% of inferior AMIs
Lee TH. JAMA 1999
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ECG is an important tool!
guidelines say:
get one within 10 minutes
repeat every 15 mins prn
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Are Cardiac Markers Helpful?
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Are Cardiac Markers Helpful?
Troponin (TnT, TnI)
very specific, >CK
good sensitivity, >CK
guidelines draw 8-12h
prognostic value
risk stratification
false positives
CK-MB
less specific, earlier
CK or CK-MB peak
predicts mortality
and LVEF for both
STEMI and
UA/NSTEMI post
infarct and post PCI
Hamm C. Circulation 2002, Aviles RJ. NEJM 2002,
Alexander JH. JAMA 2000, Savonitto S. J Am Coll Cardiol 2002
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Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs
and tests
12 lead ECG
labs
initial cardiac
enzymes
electrolytes, cbc,
bun/cr, glucose,
coags
CXR
5/20/2016
Emergent
care
History &
Physical
IV access
cardiac monitors
MONA BHCG SA
assess reperfusion
manage complications
25
case 4
HPI : 59F w 3h pleuritic CP, rad neck
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Are Clinical Features Helpful?
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Are Clinical Features Helpful?
Goodacre S.
Acad Emerg Med 2002
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How Good Are We in ACS?
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How Good Are We in ACS?
Analyzed clinical data from a multicentre prospective
trial of over 10,000 patients with chest pain
suggestive of ACS
17% ultimately met the criteria for ACS (8% had AMI
and 9% had UA)
2.1% of those with AMI and 2.3% of those with UA were
mistakenly discharged from the ED
Pope J. NEJM 2000
EMRAP Jan 2008
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Pope J. NEJM 2000
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Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs
and tests
Emergent
care
12 lead ECG
labs
initial cardiac
enzymes
electrolytes, cbc,
bun/cr, glucose,
coags
CXR
IV access
cardiac monitors
oxygen
aspirin
nitrates
5/20/2016
History &
Physical
read ECG
establish diagnosis
assess for reperfusion
identify complications
32
Approach
UA/NSTEMI
STEMI
risk assessment
ACC, TIMI
choose invasive
vs conservative
reperfusion
strategy
lysis vs PCI
medical therapy
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case 5
HPI :
68M 3h chest pressure
diaphoresis, N/V, SOB
hx anterior MI, stent 2001
O/E :
HR 110, BP 120/80, sat 94 RA
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ecg ST depression
use b williams, incl
V4R
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Risk Stratification
likelihood of
ACS
adverse outcome
missed diagnosis
ECG
Clinical Hx
Physical Exam
Markers
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Stratify Risk : ACC Guidelines
Low
Moderate
<10 minutes rest pain
moderate to high
likelihood CAD
non-diagnostic ECG
no elevation cardiac
markers
>10 minutes rest
pain now resolved
T inv > 2mm
age < 70
slight elevation
cardiac markers
High
elevated markers
ST depression
treatment failure
CHF
failed noninv stress
poor LV function
hemodynamic instability
sustained VT
PCI within 6 mos
prior CABG
clinic conservative invasive
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HIGH
history
INTERMEDIATE
Chest or left arm pain or
discomfort as chief
symptom
Chest or left arm pain
or discomfort as chief
symptom
Reproduction of previous
documented angina
Age
LOW
Probable ischemic
symptoms
Recent cocaine use
Known history of CAD/MI
physical exam
Diaphoresis, hypotension,
pulmonary edema, new
mitral regurgitation
Extracardiac vascular
disease
Chest discomfort
reproduced by
palpation
ECG
New transient ST-segment
deviation (> 0.05 mV) or Twave inversion (> 0.2 mV)
with symptoms
Fixed Q waves
T-wave flattening or
inversion in leads
with dominant R
waves
Abnormal ST
Old abnormal T waves
Normal ECG
cardiac
markers
5/20/2016
Elevated cardiac troponin
T or I, or elevated CK-MB
Normal
Normal
38
TIMI score
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routine invasive inc mortality
TIMI3b
early invasive <24h beneficial in TIMI >= 3 TACTICS
unstable, refractory, CHF for early invasive
5/20/2016
40
TIMI score
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GRACE score
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using scores
BAD NEWS
all scores for short term prognosis
(TIMI 14d, GRACE 30d)
GOOD NEWS
in the ED we live in the short term!
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Medical Treatment
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Medical Treatment
M orphine
O xygen
N itrates
A SA
B
H
C
G
eta Blocker
eparin
lopidogrel
P IIb/IIIa
Statin
ACEi / ARB
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Morphine
LOE
STEMI/NSTEMI class I/IIa, level C
dose
2-4mg IV then 2-8mg q5-15mins
mech
analgesia, dec adrenergic tone, dec
SVR, dec oxygen demand
care
hypotension, hypovolemia, respiratory
depression
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Oxygen
LOE
class I, level C
dose
2-4L/min
mech
may limit ischemia by inc O2 delivery
care
mouth breathers, smokers
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Nitrates
LOE
class I, level B
dose
0.4mg SLx3, infusion 0-640mcg/min
mech
analgesia, dilates coronary vessels, dec
SVR, dec preload
care
careful with PDE5 inhibitors,
hypotension, RV infarction
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ASA
LOE
class I, level A
dose
160-325mg chewed and swallowed
mech
irreversible inhibition of platelet
aggregation
care
hypersensitivity, bleeding d/o, PUD
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ASA
ISIS2
Lancet 1988
17,200 pt DBRCT streptoK vs ASA vs both in MI
aspirin benefit = strepto (NNT 20) without increased bleed
META-ANALYSIS
BMJ 2002
287 studies
low daily dose of 75-150mg effective secondary prevention
minimum 150mg loading dose in acute setting
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Beta Blockers
LOE
class I, level A
dose
metoprolol 5mg IV q5, 50 po q6h
mech
negative inotrope and chronotrope, dec
demand/inc perfusion, dec arrythmias,
improved diastolic relaxation
care
careful with CHF, brady/blocks,
hypotension, asthma
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Beta Blockers
ISIS1
Lancet 1986
16,000pt IV atenolol vs usual. benefit.
COMMIT/CCS 2
Lancet 2005
45,000pt DBRCT IV/po metoprolol vs none
in MI. no benefit, inc cardiogenic shock
Guidelines
5mg IV q5 and 50mg q6h po in first 24h
if no contraindications or risk cardio shock
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Heparin
LOE
class I-IIa, level C
dose
depends
mech
direct thrombin inhibitor
bleeding d/o, PUD, low risk patients
care
LMWH less HIT, easier but not better
renal dosing
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META-ANALYSIS
JAMA 1996
33% reduction MI/death heparin vs placebo w ASA in UA
ESSENCE
J Am Coll Card 1999
3,200 pt DBRCT ASA + enox vs UFH in UA/NSTEMI
SYNERGY
JAMA 2004
10,000 pt DBRCT enox vs UFH in NSTEMI w PCI, GPI
ExTRACT - TIMI25 J Am Coll Card 2007
20,000 pt DBRCT enox vs UFH in STEMI w lysis
META-ANALYSIS
Eur Heart J 2007
49,000 pt enox vs UFH in all ACS
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Murphy S.
Eur Heart J 2007
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Fondaparinux 2.5mg
mech Anti-Xa
OASIS 5
NEJM 2006
20,000 PT DBRCT enox vs fonda for ACS
cheaper, equivalent, lower bleed rate
irrespective of switching antithrombotics, PCI
Guidelines
use in UA/NSTEMI if non invasive or if undecided
in invasive/STEMI needs UFH to reduce cath thrombus
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Clopidogrel
LOE
class I, level B
dose
300 - 600mg then 75mg daily
mech
irreversible inhibition of platelet
aggregation via ADP
care
CABG
evidence for use in support of cath, PCI
or if unable to take aspirin
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CAPRIE
Lancet 1996
19,500 pt DBRCT clopidogrel vs ASA in prevention
CURE
NEJM 2001
12,500 pt DBRCT clopidogrel vs placebo in UA/NSTEMI
CLARITY - TIMI 28
NEJM 2005
3500 pt DBRCT clopidogrel vs placebo in STEMI w lysis
COMMIT
Lancet 2005
45,500 pt DBRCT clopidogrel vs placebo in STEMI
w ASA +/- lytics, no PCI
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Clopidogrel - Guidelines
UA/NSTEMI/STEMI
loading dose + 75mg daily for min 14d
no loading dose in > 75y
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Glycoprotein IIb/IIIa Inhibitors
LOE
class IIa, level B
dose
depends
mech
competitive binding of GP receptor on
platelets, preventing fibrin crosslinkage
care
with the healthcare budget
few indications unless for cath
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Statin
LOE
class X, level X
dose
atorvastatin 80mg
mech
unknown acutely (pleiotropic?), long
term HMG-CoA reductase inhibition
and dec plaque
care
liver disease
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Statin
PROVEIT - TIMI 22
NEJM 2004
4000 pt RCT prava 40 vs atorva 80 in MI
MIRACL
JAMA 2001
3000pt RCT early atorvastatin 80 vs placebo in NSTEMI
ARMYDA-ACS
J Am Coll Card 2007
171 pt RCT atorvastatin 80 vs placebo in PCI
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ACE Inhibitor / ARB
LOE
class I, level A
dose
as low as 1.25
mech
decreases afterload, helps ventricular
remodeling
use in HF, DM, LV dysfunction, HTN
care
elevated Cr
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case 6
paramedics call enroute
?STEMI direct to cath
HPI : 30 mins CP
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Ecg 1
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repeat Ecg 2
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Reperfusion Strategy?
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Contraindications to
Thrombolysis
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Contraindications to
Thrombolysis
absolute
prior ICH
ischemic CVA < 3 mos
AVM/neoplasm
suspected dissection
bleeding diathesis
relative
bleeding disorder
anticoagulated
severe hypertension
ischemic CVA > 3 mos
prolonged CPR
recent surg, trauma, PUD
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23 trials.
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Lytics vs PCI
Fibrinolysis preferred if:
– <3 hours from onset
– PCI not available/delayed
• door to balloon > 90min
• door to balloon minus
door to needle > 1hr
– Door to needle goal <30min
– No contraindications
PCI preferred if:
– PCI available
– Door to balloon < 90min
– Door to balloon minus door
to needle < 1hr
– Fibrinolysis
contraindications
– Late Presentation > 3 hr
– High Risk STEMI
• Killip 3 or cardiogenic shock
– STEMI dx in doubt
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case 7
You are working in Lethbridge ED
HPI : 64yoM crushing chest pain for 6h
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lysis?
follow up of lysis?
transfer for PCI?
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other indications for cath
cardiogenic shock
killip >= 3
rescue PCI
new - any lysed patient within 6h
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Rescue PCI
repeat ECG at 90 mins
< 50% ST resolution
persist/worsen chest pain
cardiogenic shock
heart failure
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TRANSFER AMI
1000 patients
randomized to lysis plus PCI vs
conservative / rescue
PCI within 6h
46% RRR in death/MI at 30 days
Cantor W. NEJM 2009
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Review
1. is this a STEMI?
check ECG < 10mins, repeat q15 prn
2. rapid reperfusion for STEMI
thrombolytics vs direct PCI
rescue / transfer in lysis
3. risk stratification for UA/NSTEMI
conservative vs invasive strategy
TIMI score helpful
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Review
4. medical therapy MONA BHCG SA
heparin for high risk
fondaparinux 2.5mg if UA/NSTEMI
UFH if STEMI or early invasive
beta blocker and statin early if possible
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References
1.
2.
3.
4.
5.
Tintinalli
Up To Date
EMRAP
ACC Guidelines 2004/2007
Selected megatrials
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