acute coronary syndrome (acs): survival of the species by dione nordby msn, rn
TRANSCRIPT
Dione Nordby MSN, RNInterim Nurse Educator, St. Paul’s Hospital, Cardiac Intensive Care [email protected]
Acute Coronary Syndrome (ACS): Survival of the Species
ACS: Objectives
* The basics: coronary anatomy, ischemia, MI
* Pathophysiology of ACS
* Unpack ACS – What does it all mean?
U/A, NSTEMI, STEMI
* Discuss risk stratification methods for ACS
* Identify drugs used to treat and manage ACS
ACS: Coronary anatomy
RCA“inferior” RA/RVSA node (55%)AV node (90%)Tricuspid valveLV (posterior)
LCx“lateral”LASA node (45%)LV (posterior)MV
LAD“anterior”
Left/Right bundle LV (anterior)
APEX Septum
ACS basics: Ischemia
Critical ischemia
This deprives the heart muscle (myocardium) of blood and oxygen.
Irreversible cell death
Myocardial tissue dies and necroses
ACS basics: Myocardial infarction
Acute MI: Pathogenesis
ACS : atherosclerosis and CAD
The vulnerable plaque concept!
Plaque erosion OR Plaque rupture
ACS : atherosclerosis
ACS: What does it all mean?
A spectrum…
Non-ST Elevation MI (NSTEMI)
Unstable angina
ST Elevation MI (STEMI)
ACS : Unstable angina
* Symptoms of myocardial ischemia
* Typical versus Atypical
* Angina at rest or with minimal exertion, or increasing frequency
* Usually no ECG changes/ or transient
* Negative troponin
* Lower risk for complications/mortality
ACS: NSTEMI* Symptoms of myocardial ischemia- may be worse than UA
* Non-specific ECG changes or ST depression
* Positive troponin
* Intermediate/high/higher risk of complications/death
ACS : STEMI* Symptoms of myocardial ischemia – usually significant
* ST elevation on ECG
* Positive troponin
* Highest risk of complications/death
ACS : A spectrum
UA NSTEMI STEMI
ACS : Survival of the Species
78 yr old women c/o sudden central chest pain and nausea…What do we do?
Morphine?Oxygen?Nitrates?Aspirin
ACS : STEMI Treatment* RAPID REPERFUSION!!!* Monitor in critical care* Medical therapy: anticoagulation! + others…* Risk factor counseling
Rathore SS, Curtis JP, Chen J, et al. BMJ. 2009;338:b1807.Antman E. ST-segment elevation myocardial infarction: Management. In: Bonow RO, Mann DL, Zipes P, et al, eds. Braunwald's Heart Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2011a:1087-1110.
ACS : STEMI 2013 ACCF/AHA STEMI guidelines
ACS : PCI vs Lytic
Which would you rather receive?
ACS : PCI vc Lytic
It depends…
* PCI has better short and long term outcomes (most of the time)
< 120 mins from first medical contact
2013 ACCF/AHA STEMI guidelines
ACS : UA & NSTEMI - Treatment
* Risk stratification- Who needs what?
-TIMI risk score
-Grace risk model
* Continuous ECG monitoring
* Observe for complications
* Appropriate medical therapy
* Referral for risk factor counseling
ACS : Risk stratification scores
* Age ≥65 years* Presence of at least three risk factors for coronary heart disease (CHD)* Prior coronary stenosis of ≥50 percent* Presence of ST segment deviation on admission ECG* At least two anginal episodes in prior 24 hours* Elevated serum cardiac biomarkers* Use of aspirin in prior seven days
* Age
* Killip class
* Systolic blood pressure
* Presence of ST segment deviation
* Cardiac arrest at presentation
* Serum creatinine concentration
* Presence of elevated cardiac biomarkers
* Heart rate
TIMI SCORE GRACE RISK SCORE
ACS : TIMI what?
Antman EM, Cohen M, Bernink PJ, et. al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835-42.
ACS : UA & NSTEMI – Treatment strategies
* Urgent Invasive (< 2 h)VERY HIGH RISK!!!
* Early Invasive (within 24 h)HIGH RISK!!
* Delayed Invasive (24-72h)INTERMEDIATE RISK!
* Conservative/Ischemia-guidedLOW RISK
…then continuous risk stratification!!!
ACS: Medical Therapy
General principles:
* Similar NSTEMI/STEMITHE BIG FIVE !
* The higher risk the patient, the the greater the overall benefit derived
ACS : Medical therapy
Antiplatelet therapy:
*ASA 162- 325mg… then 81-325 mg daily
*P2Y12 inhibitor
LOAD: Plavix 300 - 600mg as early as possible (less or none if lytic and older)
OR Ticagrelor 180mg…
MAINTENANCE: for at least a year!Plavix 75 mg dailyTicagrelor 90 mg BID
PLATO TRIAL: N Engl J Med 2009; 361:1045-1057 September 10, 2009 DOI: 10.1056/NEJMoa0904327
ACS : Medical therapy
Anticoagulation:
NSTEMI
*enoxaparin s/c until d/c or PCI*UFH for 48h or PCI*Bivalirudin until PCI (early invasive)
STEMI & Fibrinolysis
*enoxaprin s/c min. 48h or d/c*UFH
STEMI & PCI
*UFH until PCI
* Bivalirudin (esp. if high bleeding risk)
GP IIa/IIIb may be considered in some patients
ACS : Medical therapy
Beta blockers (eg. metoprolol, bisoprolol)
heart ratespeed of AV conductionforce of contraction
Decreased MVO2 demand and increased supply!
* Within 24 hour of admission* PO daily, BID, TID (Unless contraindicated)
ACEI (eg. ramipril, perindopril)
Angiotensin I Angiotensin II Decreased afterload + decreased preload
mortalitymajor eventventricular remodeling
* Within 24 hours of admission * PO BID, TID
*ARB if contraindicated or intolerant
ACS : Medical therapy RAAS Inhibitors
ACS : Medical therapy
Statins: FOR EVERYONE! (eg. atorvastatin) Block production of cholesterol in liver
recurrent MICAD mortalityneed for revascularizationstroke
* On admission to hospital* PO daily
ACS : Secondary Prevention – YOU!!!
* Cardiac Rehab!
* Risk factor counseling(ie: defining patient specific risk factors )
* Ensuring patients are aware revascularization does not mean CURE!
ACS : Recovery
ACS : Survival of the Species
QUESTIONS?
ACS : Survival of the Species
Do all patients presenting with ischemia have chest pain?
You said aspirin significantly reduces mortality, why is it a risk factor for the TIMI risk score?
Is there a preferred choice of medication for fibrinolytic administration?
Additional recommended resources
Amsterdam, E. A. et al. (2014). 2014 AHA/ACC guideline forthe management of patients with Non-ST-Elevation acute coronary syndromes. Circulation, 1(30), e344-e426. doi:10.1161/CIR.00000000000001 34
O’Gara, P. T. et al. (2013). 2013 ACCF/AHA guideline for the management of ST-Elevation myocardial infarction. Circulation, 1(27). e362-e425.doi:1016/CIR.0601 3e3182742cf6