uhcw cardiology teaching dr chris mcaloon. 65 year old man playing golf sudden onset chest pain ...
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Coronary Artery Disease
UHCW Cardiology TeachingDr Chris McAloon
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
Case One
History – what information do you need to elicit?
Pain ◦ Character / Radiation / GTN spray effect◦ Was this pain like your previous Angina/ MI
pain? Autonomic features Risk factors
◦ Smoker / Hypertension / Diabetes Hyperlipidaemia / Family history
◦ Previous MI / CABG / PCI / CVA Differentials
Central Crushing Chest Pain Exertional chest pain Occurs at rest Radiation
◦ Neck, arms (classically left) Levine’s Sign
◦ Clenched fist over chest Breathless Autonomic features
Cardiac Sounding Chest Pain
Isn’t Chest Pain always ACS?
ECS ACS NTE Guidelines 2011
Examination Nicotine Stains GTN spray Xanthelasma Scar’s
◦ Chest◦ Legs
Evidence DM BP/ Pulse/ Failure
Examination
65 year old ◦ Ankles/shins for SVG
scar◦ Radial for graft scar
CABG
35 year old◦ Metallic Click◦ Look left lateral ◦ Cyanosis etc
Valve/ Congenital surgery
Acute Coronary Syndrome
ECS ACS Guidelines 2011
ESC Definition ACS Pain
ECS ACS Guidelines 2011
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
Pathophysiology ACS
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
Plaque and Thrombin Formation
Ischaemic Heart Disease
Grech E D , Ramsdale D R BMJ 2003;326:1379-1381©2003 by British Medical Journal Publishing Group
Ruptured Atheromatous Plaque and Occlusive Thrombus
STEMI
ECG: ST elevation
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↑ ST in post leads
Posterior 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
Infero-posterior STEMI ST elevation in II, III and AF, R wave and ST depression in V1-2
Size of the Problem: England and Wales 2009-10
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
30 Day Mortality
BCS Recommendations Acute Coronary Care Oct 2011
STEMI Initial Diagnosis
ECS ACS STE Guidelines 2011
Management of STEMI
(GTN)↓
High Flow Oxygen (15L)↓
300mg Aspirin/ 600mg Clopidogrel↓
Analgesia: Morphine + Metoclopramide↓
Reperfusion: PCI / Fibrinolysis
THINK REPERFUSION STRATEGY:
■ Primary PCI if available (CALL THE CATH LAB) ■ Thrombolysis if not, then refer to PCI centre
STEMI Management
ECS Revasculration Guidelines 2011
Successful Thrombolysis ST segment
resolution 50% at 90 minutes
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
Standards STEMI Management
ECS Revasculration Guidelines 2011
The Changing Face STEMI Mx
BCS Recommendations Acute Coronary Care Oct 2011
95% England covered by PPCI networks Thrombolysis remains in place in remote
centres◦ Geography impacts time to PPCI centre
30% Thrombolysis fail to reperfuse and need immediate rescue PCI
The Changing Face STEMI Mx
ECS ACS STE Guidelines 2011
Disruption of occlusion using a balloon Stent deployed to maintain anterograde
blood flowTypes Primary PCI – PCI within 2 hours Rescue PCI – PCI after failed thrombolysis Facilitated PCI – PCI bridged with lytic
therapy◦ Time delayed PPCI
What is Percutaneous Coronary Intervention (PCI)?
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
Distal Embolisation of a Platelet-Rich Thrombus causing Occlusion
of Intramyocardial Arteriole
NSTEMI
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
Case Two
Grech E D , Ramsdale D R BMJ 2003;326:1259-1261
©2003 by British Medical Journal Publishing Group
Worrying ECG?
What do you do as the SHO clerking patient in
A+E?
Defining Angina Pectoris Stable Angina
◦ pattern of frequency, intensity, ease of provocation, or duration does not change over several weeks
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
Unstable Angina◦ pattern of chest pain changes abruptly
Three Presentations UA 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)
Class I – Pain strenuous exertion Class II – Slight limitation ordinary exertion Class III – Marked limitation physical
exertion Class IV – Pain on any exertion
CCS = Canadian Cardiology Society
Angina Pectoris CCS Classification
TIMI Risk Score ≥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
High TIMI score and Mortality
Bleeding Risk
ECS ACS Guidelines 2011
NSTEMI Outcome Based Location
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
Acute Management of NSTEMI-ACS 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
High risk (GRACE >140) within 24 hours◦ At Stafford discuss with Stoke
Intermediate risk (GRACE < 140) and high risk criterion within 72 hours
Low risk with recurrent symptoms◦ Stress Test
Timing Early Invasive Strategy
ECS ACS Guidelines 2011
Anti-thrombotic Therapy
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
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
Prasugrel vs Clopidogrel
Ticagrelor 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
Ticagrelor vs Clopidogrel
Prescribing in CKD
ECS ACS Guidelines 2011
Secondary Prevention for IHDImmediately 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
Definitions ACS Incidence and Prevalence Pathophysiology Differential Diagnoses STEMI Intervention – current evidence NSTEMI intervention – current evidence Antithrombotic therapy use New anti-thrombotics
Summary
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