coronary syndromes
DESCRIPTION
Coronary syndromes. Giuseppe Biondi-Zoccai , MD Sapienza University of Rome , Italy [email protected]. Learning goals. Preamble Definitions Impact Approach Management. Learning goals. Preamble Definitions Impact Approach Management. Time machine. - PowerPoint PPT PresentationTRANSCRIPT
![Page 2: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/2.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 3: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/3.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 4: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/4.jpg)
Time machine
Teixera et al, Int J Cardiol 2013
![Page 5: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/5.jpg)
Myocardial infarction in the 60’s
![Page 6: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/6.jpg)
Myocardial infarction today
![Page 7: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/7.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 8: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/8.jpg)
Differential diagnosis of coronary syndromes
• Asymptomatic CAD• Chronic stable angina• Unstable angina• Acute myocardial infarction
In addition:• Ischemic cardiomyopathy• Sudden ischemic cardiac death• Myocardial ischemia due to spasm or mismatch
Wijns et al, Eur Heart J 2010
![Page 9: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/9.jpg)
From diagnosis to risk stratification
http://en.wikipedia.org/wiki/Acute_coronary_syndrome
![Page 10: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/10.jpg)
Third universal definition of myocardial infarction
• Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following:– Symptoms of ischemia.– New or presumed new significant ST-segment–T wave (ST–T)
changes or new left bundle branch block (LBBB).– Development of pathological Q waves in the ECG.– Imaging evidence of new loss of viable myocardium or new
regional wall motion abnormality.– Identification of an intracoronary thrombus by angiography or
autopsy.
Thygesen et al, Eur Heart J 2012
![Page 11: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/11.jpg)
Third universal definition of myocardial infarction: subtypes
Thygesen et al, Eur Heart J 2012
![Page 12: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/12.jpg)
Third universal definition of myocardial infarction: subtypes
• 1 - Spontaneous MI: related to plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in one or more of the coronary arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis.
• 2 - Secondary MI: In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between myocardial oxygen supply and/or demand, e.g. spasm, anemia, etc.
• 3 - Fatal MI: Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB.
Thygesen et al, Eur Heart J 2012
![Page 13: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/13.jpg)
Third universal definition of myocardial infarction: subtypes
• 4a – Related to PCI: >5 x 99th percentile URL in patients with normal baseline values (>99th percentile URL) or a rise of cTn values >20% if the baseline values are elevated and are stable or falling. In addition, symptoms, new ischemic ECG changes, angiographic loss of patency, or imaging demonstration of MI.
• 4b – Related to stent thrombosis: angiography or autopsy evidence and cardiac biomarkers values with at least one value above the 99th percentile URL.
• 5 – Related to CABG: cardiac biomarker values >10 x 99th percentile URL. In addition, new pathological Q waves or new LBBB, or angiographic documented new graft or new native coronary artery occlusion, or imaging evidence of MI.
Thygesen et al, Eur Heart J 2012
![Page 14: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/14.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 15: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/15.jpg)
Stable CAD in diabetics
Farkouh et al, New Engl J Med 2012
![Page 16: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/16.jpg)
Stable CAD
Farkouh et al, New Engl J Med 2012
MAC
CE (%
)
![Page 17: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/17.jpg)
Stable CAD in diabetics
Farkouh et al, New Engl J Med 2012
![Page 18: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/18.jpg)
Medically managed ACS
Roe et al, New Engl J Med 2012
![Page 19: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/19.jpg)
Invasively managed ACS
Wallentin et al, New Engl J Med 2009
Card
iova
scua
lr de
ath,
M
I, or
stro
ke (
%)
![Page 20: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/20.jpg)
STEMI
Montalescot et al, Lancet 2012
Card
iova
scua
lr de
ath,
M
I, or
stro
ke (
%)
![Page 21: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/21.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 22: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/22.jpg)
High-sensitivity troponins
Thygesen et al, Eur Heart J 2012
![Page 23: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/23.jpg)
Ischemic scores
Discrimination (c statistic)
D’Ascenzo et al, Contemp Clin Trials 2012
![Page 24: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/24.jpg)
Bleeding scores
www.crusadebleedingscore.com
![Page 25: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/25.jpg)
SYNTAX score
www.syntaxscore.com
![Page 26: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/26.jpg)
SYNTAX score
www.syntaxscore.com
![Page 27: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/27.jpg)
SYNTAX score
Farooq et al, Lancet 2013
![Page 28: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/28.jpg)
Learning goals
• Preamble• Definitions• Impact• Approach• Management
![Page 29: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/29.jpg)
Radial access
Romagnoli et al, J Am Coll Cardiol 2012
![Page 30: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/30.jpg)
Prehospital thrombolysisDe
ath,
shoc
k, C
HF, o
r rei
nfar
ction
(%)
Armstrong et al, New Engl J Med 2013
![Page 31: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/31.jpg)
Bivalirudin
NAC
E (%
)M
ACE
(%)
Kastrati et al, New Engl J Med 2008
![Page 32: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/32.jpg)
Prasugrel
Wiviott et al, New Engl J Med 2008
Cardiovascular death, MI or stroke
Non-CABG-related TIMI major bleeding
![Page 33: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/33.jpg)
TicagrelorVascular death, MI or stroke Major bleeding
Months Months
Wallentin et al, New Engl J Med 2009
![Page 34: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/34.jpg)
Adjusted indirect comparison
Biondi-Zoccai et al, Int J Cardiol 2011
![Page 35: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/35.jpg)
CangrelorSt
ent t
hrom
bosis
(%)
Bhatt et al, New Engl J Med 2013 (57% CSA, 25% NSTEACS, 18% STEMI)
![Page 36: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/36.jpg)
Rivaroxaban
Mega et al, New Engl J Med 2012
![Page 37: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/37.jpg)
Beta-blockers
Bangalore et al, JAMA 2012
Card
iova
scul
ar d
eath
, M
I or s
trok
e (%
)
![Page 38: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/38.jpg)
Statins
Patti et al, Circulation 2011
![Page 39: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/39.jpg)
Fractional flow reserve
De Bruyne et al, New Engl J Med 2012
![Page 40: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/40.jpg)
CABG or PCI?
Mohr et al, Lancet 2013
![Page 41: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/41.jpg)
Off-pump vs on-pump CABG
Palmerini et al, J Am Coll Cardiol 2012; Palmerini et al, Am Heart J 2013
![Page 42: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/42.jpg)
Drug-eluting stents
Palmerini et al, Lancet 2012
![Page 43: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/43.jpg)
Drug-eluting stents
Palmerini et al, Lancet 2012
![Page 44: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/44.jpg)
Drug-eluting balloons
Byrne et al, Lancet 2013
![Page 45: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/45.jpg)
Bioresorbable stents
Palmerini et al, Lancet 2012
![Page 46: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/46.jpg)
Bioresorbable stents
Serruys et al, Lancet 2009
![Page 47: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/47.jpg)
Take home messages• Developments in the field of coronary syndromes
represent an outstanding example of the successful combination of pathophysiologic, diagnostic, prognostic, pharmacologic and device research.
• Despite the dramatic prognostic improvement, several issues remain unsettled.
• In addition, the worsening plethora of management options will make the treatment of individual patients more and more complex, unless risk-beneficial and cost-beneficial tailoring tools are developed.
![Page 48: Coronary syndromes](https://reader036.vdocuments.mx/reader036/viewer/2022081507/568166e1550346895ddb171c/html5/thumbnails/48.jpg)
Many thanks for your attention
For these slides and further ones on similar topics feel free to visit:
www.metcardio.org/slides.html
For additional details or queries feel free to contact me directly: