ACS
Rogers Kyle, MD
10/2/12
Learning Objectives
• Define Acute Coronary Syndrome (ACS)
• Review the diagnostic approach to suspected
ACS
• Review the rationale for risk stratification in
ACS
• Outline initial management of ACS
• Examine antithrombotic options in ACS
• Define ACS
– UA, NSTEMI, STEMI
• Evaluation
– Initial evaluation
• CP characteristics, EKG, biomarkers
Defining ACS
• Chest pain - rest, new, increasing
– 1/3 none (n/v, syncope, palps, dyspnea)
• Old, female, DM
• Less intervention, increased mort (JAMA 2000;284
(7):835)
• ECG
– STEMI
• Peaked T (localized inc K+)
• J point elev with concave ST
• ST elev, convex (no LVH, LBBB)
– 2mm in men, 1.5mm women precordial
– 1mm in other leads
• ST-T merge
• OR new LBBB
• RV infarct, post-MI
• NSTEMI
• Down-sloping ST ≥ 0.05 mV in 2 contig leads
• And/or T wave inversion ≥ 0.1 mV in 2 contig leads with
prominent R or R/S > 1
• Requires biomarker
• Non-Diagnostic
– 45% (normal in 20%)
– Repeat at 20-30 min interval with continued pain
Biomarkers
• Troponin
– Increased sens/spec over CK-MB
• Other causes:
– Demand ischemia – O2 demand/supply mismatch
» Demand – tachy, pre/after load, inc O2 consumption
peripherally
» Supply – tachy, hypotension, increased filling pressures,
hypoxia
» Ex - Critical illness, tachy, LVH, vasospasm, CVA/ICH
– Direct injury
» Defib shock, infiltrative disorders, chemoRx, inflam
– CHF
» Strain 2/2 vol/pressure overload
» Cell death 2/2 neurohumoral stim, cytokines
– Pulmonary disease
» PE, Pulm HTN
– CKD
– Burns
– Other
Management
• UA/NSTEMI vs. STEMI
• Complex, frequent updates
Management ACS
• Initial Evaluation
–
–
–
–
Pain relief
Assess hemodynamics – HTN/↓ BP, tachy/brady
Estimate risk (TIMI score)
Management strategy
• STEMI – lytics vs. PCI
• UA/NSTEMI – conservative vs. invasive strategy; if invasive, early vs. delayed
– Antithrombotics (antiplt and anticoag)
– Beta blocker (except when high risk for shock – age > 70, SBP < 120,
HR > 110/<60)
• IV vs. PO
– CCB
– Statin, ACE/ARB (AMI, EF < 40%, DM, HTN…?all), aldosterone antag (EF
< 40%, CHF)
STEMI
•
•
•
•
Focused update 2009
Pain relief
Hemodynamic assessment
PCI vs. lytics
– Early risk stratification (TIMI score) - ↑ age, ↓ BP, ↑ HR, CHF, AMI – the
higher the risk the more beneficial PCI vs. lytics
• Antithrombotic/antiplatelet therapy
• β-blocker
– 2007…2012 update on β-blocker – oral within first 24 hrs if no
contraindications; IV only if hypertensive and no
contraindications
• Statin/ACE/aldosterone antag
STEMI
Lancet 2003; 361: 13
STEMI
• Factors determining reperfusion strategy –
Thrombolysis vs. PCI
– If early in presentation (< 3 hrs) AND If door to balloon
time < 90 min → PCI
• > 90 min from PCI → lytics
• If PCI related delay < 60 min → PCI; if > 60 min → lytics
– “high risk” STEMI → PCI
– If between 3-12 hrs → PCI; lytics if PCI related delay
‘significantly greater than’ 120 min
– Beyond 12 hrs – no lytics (F XIII)
– If no response to lytics → transfer for PCI
– If responds to lytics → transfer for PCI ASAP (Transfer-AMI,
NEJM; 360:2705-18)
TIMI Risk Score STEMI
Circulation 2000; 102:2031
TIMI Risk Score STEMI
Circulation 2000; 102:2031
STEMI
• Factors determining reperfusion strategy –
Thrombolysis vs. PCI
– If early in presentation (< 3 hrs) AND If door to balloon
time < 90 min → PCI
• > 90 min from PCI → lytics
• If PCI related delay < 60 min → PCI; if > 60 min → lytics
– “high risk” STEMI → PCI
– If between 3-12 hrs → PCI; lytics if PCI related delay
‘significantly greater than’ 120 min
– Beyond 12 hrs – no lytics (F XIII)
– If no response to lytics → transfer for PCI
– If responds to lytics → transfer for PCI ASAP (Transfer-AMI,
NEJM; 360:2705-18)
STEMI
• Initial therapy
– O2, reperfusion strategy
– Antiplatelet therapy
• ASA 162-325mg (ISIS-2) + P2Y12 (clopidogrel, ticlopidine,
prasugrel or ticagrelor) + PPI if GIB risk
– Lytics – clopidogrel (others not studied)
– For PCI - prasugrel favored over clopidogrel (NEJM 07) – but more
bleeds…and ticagrelor too (NEJM 09)
• IIb/IIIa inhibitors – depends…on antitcoag (bival vs. hep +
IIb/IIIa) and use of P2Y12 (no) and IV vs. intracoronary and
agent used (abciximab, eptifibitide, tirofiban); PCI only
STEMI
– Anticoagulants
• PCI (typically d/c’d at end of procedure)
– UFH – continue if already begun and add IIb/IIIa or switch to
bivalrudin
– Lovenox – continue; + IIb/IIIa
– Fondaparinux – switch to bivalrudin
– Bivalrudin – superior to UFH + IIb/IIIa (HORIZONS-AMI, NEJM
2008; 358:2218-30)
• Lytics
– UFH, Lovenox, fondaparinux
UA/NTEMI
• Focused update 2007…and 2011, 2012
• Risk stratification
– Immediate high risk – shock, overt CHF, persistent
angina, unstable vent. Arrhythmias
– Early invasive strategy – 4-48 hrs – TIMI Risk Score
(moderate to high risk = score ≥ 3)*
Estimate Risk – TIMI Risk Score
• Anti-ischemic/analgesic therapy
– O2 (Cochrane Review)
– Nitrates – SL x 3, then IV if still with pain or htn, chf.
(careful with ↑HR, ↓BP, RV infarct, AS/HOCM, viagra)
(GISSI-3, ISIS-4); no mortality benefit
– MSO4 – relieve pain, anxiety; don’t mask angina
– Β-blockers – 40% mortality benefit; no ISA
(metoprolol, atenolol); iv or po (avoid with active
bronchospasm, brady, pulm edema, ↓BP, ±cocaine)
– CCB – if ischemia despite max β –blockade or if
contrainicated
– Statin – atorvastatin 80mg prior to d/c; LDL < 70
UA/NSTEMI – anti-thrombotic therapy
UA/NSTEMI – anti-thrombotic therapy
– Antiplatelet therapy
• ASA 162 – 325 mg → 75 – 100 mg QD
– Clopidogrel if ASA intol
• P2Y12 receptor blockers
– Add to ASA (CURE. NEJM 2001;345:494)
» If conservative strategy – clopidogrel/ticagrelor ± IIb/IIIa
(high risk patients)
» Invasive strategy (TIMI ≥ 3)
• Before PCI – clopidogrel/ticagrelor OR IIb/IIIa (unless on
bivalrudin)
• At PCI – clopidogrel/prasugrel/ticagrelor OR IIb/IIIa
• If initial conservative becomes high risk and goes to
angio - clopidogrel/ticagrelor OR IIb/IIIa
• if no angio and on ASA/clopidogrel/ticagrelor – can add
IIb/IIIa
• Prasugrel –
– better than clopidogrel if going to PCI (TRITON
TIMI-38. NEJM 2007;357:2001).
– No worry with omeprazole (not CYP2C19)
– Not for pts with prior TIA/CVA, ≥ 75 yrs, < 60 kg
– Especially good in DM
• Ticagrelor
– Better than clopidogrel - PLATO trial (NEJM 2009;
361:1045); + mortality benefit
– All ACS, PCI or conservative
– Very small excess bleeding
– Reversible P2Y12 (vs. clopidogrel, prasugrel) –
effects gone in couple of days.
– ASA interferes so use < 100 mg/d
UA/NSTEMI – anti-thrombotic therapy
– Anticoagulation
• UFH 60-70 U/kg (5000 max) → 12 U/kg/hr, PTT 50-75
• Enoxaparin – 1 mg/kg Q12 (vs. UFH - may be a little
better in conservative strategy)(JAMA 2004; 292:45)
• Fondaparinux – 2.5 mg (non-invasive strategy only)
• Bivalrudin – 0.1mg/kg → 0.25mg/kg/hr (really only
used during cath ≈ UFH + IIb/III)
– No lytics in UA/NSTEMI
References
• Jneid H. et al. (2012) 2012 ACCF/AHA Focused Update of the Guideline for
the Management of Patients With Unstable Angina/Non–ST-Elevation
Myocardial Infarction. J Am Coll Cardiol 60: 646-681.
• Kushner, FG, et al. (2009) 2009 Focused Updates: ACC/AHA Guidelines for
the Management of Patients With ST-Elevation Myocardial Infarction.
Circulation 120: 2271-2306.
• Antman, EM, et al. (2000) The TIMI Risk Score for Unstable Angina/Non-ST
Elevation MI JAMA 284 (7): 835-842.
• Morrow, DA, et al. (2000) TIMI Risk Score for ST-Elevation Myocardial
Infarction. Circulation 102: 2031-2037.
• Wiviott, SD, et al. (2007) Prasugrel versus Clopidogrel in Patients with
Acute Coronary Syndromes (TRITON–TIMI 38 Investigators) N Engl J Med
357(20): 2001-2015.
• Wallentin, L. (2009) Ticagrelor versus Clopidogrel in Patients with Acute
Coronary Syndromes. N Engl J Med 361(11): 1045-1057.