DISC TWO – CINEANGIOGRAM-BASED CASE STUDIES

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CATH Panel Report 2003Enoxaparin Dosing Guidelines for ACSClinical Trials – Data andSummariesClinical PresentationsAnimated Clinical PathwaysClinical CME-AccreditedSymposia VideocastClinical Cardiology CME-Accredited MonographsQuick Consult Clinical Trials GuideClinical Pathways – PDF Files

GOCineangiogram-BasedClinical Case Studies

Note: Click on the “GO” hearts to accessindividual listings for a category.You must be online with an Internet connection to utilize the “Free CME” links on the CATH Panel Report, the clinical monographs, and the Symposia Videocast (located on Disc One)

ACS Problem Based Learning ACS Problem Based Learning Case StudiesCase Studies

Edward T. A. Fry, MD, FACC, FSCAI Edward T. A. Fry, MD, FACC, FSCAI Director, Interventional CardiologyDirector, Interventional Cardiology

St.Vincent Hospital, Indianapolis, INSt.Vincent Hospital, Indianapolis, INThe Indiana Heart CenterThe Indiana Heart Center

The Care Group, LLCThe Care Group, LLCIndiana Heart InstituteIndiana Heart Institute

ACS PBL Case #1ACS PBL Case #1

ACS PBL: Case #1ACS PBL: Case #1J.B. 65 y/o female, retired pathologist J.B. 65 y/o female, retired pathologist

Presents to ER at 9 PM with 2 hrs Presents to ER at 9 PM with 2 hrs SSCP and dyspnea, at rest. Better afterSSCP and dyspnea, at rest. Better afterTNG SL x 3 at home. Some DOE x 2 wks.TNG SL x 3 at home. Some DOE x 2 wks.

PMHx: Stent in LAD 8/00, hyperlipidemia,PMHx: Stent in LAD 8/00, hyperlipidemia,smokes, HTN, bilateral mastectomiessmokes, HTN, bilateral mastectomiesfor breast cancer, TAH (no HRT), NKAfor breast cancer, TAH (no HRT), NKA

Meds: ASA, Lisinopril, Atorvastatin, Metoprolol,Meds: ASA, Lisinopril, Atorvastatin, Metoprolol, Fluoxetine, RaloxifeneFluoxetine, Raloxifene

Case 1: EKG #1

ACS PBL: Case #1ACS PBL: Case #1BP 160/90 HR 64 RR 16 135 lbs.BP 160/90 HR 64 RR 16 135 lbs.

Sat.=93% on 2 lit.Sat.=93% on 2 lit.

PE:PE: Chest – clear, bilat. mastectomiesChest – clear, bilat. mastectomiesCor – RRR, SCor – RRR, S44, I/IV systolic murmur, I/IV systolic murmur

at the apex, no Sat the apex, no S33 Abd – Soft, nontender, no HSMAbd – Soft, nontender, no HSMExt – No edema. Pulses normal.Ext – No edema. Pulses normal.

Left carotid bruitLeft carotid bruit

ACS PBL: Case #1ACS PBL: Case #1Labs (ER):Labs (ER):

WBC=7.1 Hgb=13.0 Plts=315KWBC=7.1 Hgb=13.0 Plts=315KKK++=3.4 Lytes otherwise WNL=3.4 Lytes otherwise WNLCr=1.1 BUN=22 Gluc=101Cr=1.1 BUN=22 Gluc=101

CK=77 MB=2.8 TnI<0.3CK=77 MB=2.8 TnI<0.3

CXR: NADCXR: NADMonitor: NSR, BBB. No ectopy.Monitor: NSR, BBB. No ectopy.

ACS PBL: Case #1

Initial diagnostic impression / differentialInitial diagnostic impression / differential Initial treatment(s)Initial treatment(s) Additional labs, work-upAdditional labs, work-up DispositionDisposition Risk assessmentRisk assessment

Issues upon presentation:

ACS PBL: Case #1

Admitted to Critical Care UnitAdmitted to Critical Care Unit

NPO except medsNPO except medsASA 325 mg q AMASA 325 mg q AMOO22 4 lit/min 4 lit/minIV-NTG at 20 ug/minIV-NTG at 20 ug/minEptifibatide 180 ug/kg bolus, 2 ug/kg/minEptifibatide 180 ug/kg bolus, 2 ug/kg/minEnoxaparin 30 mg IV x 1 in ER andEnoxaparin 30 mg IV x 1 in ER and

60 mg sc q 12 hr (160 mg sc q 12 hr (1stst dose at 10 PM) dose at 10 PM)Home meds continuedHome meds continued

ACS PBL: Case #1

3:20 AM: More CP (5/10), treated withSL NTG x 2, MSO4 4 mg IV, Pain is“improving”.ECG: T-wave inversion, ST dep. V5-6

4 hr TnI <0.3 5:00 AM: Recurrent CP (8/10). ECG – No

change. Rx’d with TNG SL, MSO4

Case 1: EKG #2v

ACS PBL: Case #16:00 AM: Emergent Cath(8 hrs after last enoxaparin given)

Case #1

Press Space Bar or Enter to Advance Cines to next image

Stent successfully placed

Left Coronary angiogram – significant ruptured plaque visible

Right coronary angiogram – moderate disease visible

ACS PBL: Case #1Emergent PCI:

Eptifibatide continued at 2 ug/kg/minfor 12 hrs post PCI.

Heparin?Enoxaparin: 0.3 mg/kg IV at PCI

3.5 x 18 mm stent deployed, post-dilated to 4.0 mm.

Sheath removal?

PEPCI: Enoxaparin SC and IV PEPCI: Enoxaparin SC and IV PharmacokineticsPharmacokinetics

1.0 mg/kg sc + 0.3 mg/kg iv

0.0

0.20.40.6

0.81.0

1.2

1.41.6

1.82.0

0 2 4 6 8 10 12 14 16 18 20Time (h)

aXa

IU/m

l

Dosing of Enoxaparin in PCIDosing of Enoxaparin in PCI

PCIPCI-12 hr-12 hr 12 hr12 hr-8 hr-8 hr

Last dose ofLast dose ofEnoxaparin Pre-PCIEnoxaparin Pre-PCI

(none)(none)(none)(none)

Enox. doseEnox. doseAt PCI (iv)At PCI (iv)0.3 mg/kg0.3 mg/kg

(none)(none)0.3 mg/kg0.3 mg/kg

(none)(none)

1.0 mg/kg1.0 mg/kg0.75 mg/kg0.75 mg/kg

Abcix.Abcix.(none)(none)

(none)(none)

(none)(none)

PEPCIPEPCI NICE-3NICE-3

NICE-3NICE-3ColletCollet

NICE-1NICE-1NICE-4NICE-4

TrialTrial

ACS PBL: Case #1 CP resolved. ECG – NSR, LBBB, no changeCP resolved. ECG – NSR, LBBB, no change Sheath removed 4 hrs after start of PCI (10:00 Sheath removed 4 hrs after start of PCI (10:00

AM)AM) Subsequent enzymes were negative for MISubsequent enzymes were negative for MI Transferred to telemetry floorTransferred to telemetry floor Clopidogrel 300 mg x 1, then 75 mg daily.Clopidogrel 300 mg x 1, then 75 mg daily. Continued on ACE-I, Beta-Blocker, Statin, ASAContinued on ACE-I, Beta-Blocker, Statin, ASA Released home next AMReleased home next AM

ACS PBL Case #2ACS PBL Case #2

PBL Case #2: Acute MI S.S. 47 y/o male, Indianapolis Airport S.S. 47 y/o male, Indianapolis Airport

Security Guard, new onset severe CP at 4:00 Security Guard, new onset severe CP at 4:00 AM AM

Presents to ER at 5:00 AM. BP=150/85, Presents to ER at 5:00 AM. BP=150/85, HR=84 (NSR), 220 lbs, diaphoretic, Sat=94% HR=84 (NSR), 220 lbs, diaphoretic, Sat=94% RA, Chest-clear, SRA, Chest-clear, S44, RRR, No murmur, No , RRR, No murmur, No edemaedema

No hx of PUD, CVA, TIA, HTN, DM, MINo hx of PUD, CVA, TIA, HTN, DM, MI Strong family hx. Smokes 1 ½ packs/day Strong family hx. Smokes 1 ½ packs/day

Case 2: EKG #1

PBL Case #2: AMI – Rx Options

ThrombolysisThrombolysis Agent: TNK vs r-PA vs t-PAAgent: TNK vs r-PA vs t-PA Combination therapy?Combination therapy? Heparin: UFH vs enoxaparinHeparin: UFH vs enoxaparin

Transfer for Primary PCI (30 miles)?Transfer for Primary PCI (30 miles)? Facilitated PCIFacilitated PCI

PBL Case #2: AMI ASA 81 mg chewable x4, IV TNGASA 81 mg chewable x4, IV TNG Enoxaparin 30 mg IV bolus x 1 followed Enoxaparin 30 mg IV bolus x 1 followed

immediately by 100 mg SC and then q 12 hrs.*immediately by 100 mg SC and then q 12 hrs.* TNK 50 mg IV bolus x 1 at 5:30 AMTNK 50 mg IV bolus x 1 at 5:30 AM Metoprolol 25 mg PO BIDMetoprolol 25 mg PO BID 7:00 AM CP better, ST elevation nearly gone7:00 AM CP better, ST elevation nearly gone Arrangements for transfer to St. Vincent made at Arrangements for transfer to St. Vincent made at

7:30 AM7:30 AM

PBL Case #2: AMI

Patient arrives at St. Vincent at 9:00 AM Patient arrives at St. Vincent at 9:00 AM initially pain free.initially pain free.

At 9:30 AM, he has recurrent CP and At 9:30 AM, he has recurrent CP and inferior ST elevationinferior ST elevation

Emergency cath and possible PCI Emergency cath and possible PCI recommendedrecommended

Right coronary angiogram – significant occlusion

Case #2Case #2

Press Space Bar or Enter to Advance Cines to next image

Left coronary angiogram – No disease visible

Stent is placed. Balloon is inflatedat thrombis locationCatheterization successful

PBL Case#2: AMI

Rescue PCI:Rescue PCI: Heparin / Enoxaparin dosing?Heparin / Enoxaparin dosing? GP IIb/IIIa inhibitor therapy?GP IIb/IIIa inhibitor therapy? Sheath management?Sheath management? Reheparinization / LMWH?Reheparinization / LMWH?

PCI Following Enoxaparin

12 hr 8 hr 0

Time from last doseTime from last doseof Enoxaparinof Enoxaparin

0.3 mg/kg IV

None

Time afterTime afterPCIPCI

Sheath Pull*

* And >12 hr after TNK given,

4-8 hr

Case 2: EKG #2

PCI Following Enoxaparin

12 hr 8 hr 0

Time from last doseTime from last doseof Enoxaparinof Enoxaparin

0.3 mg/kg IV

None

Time afterTime afterPCIPCI

Sheath Pull*

* And >12 hr if TNK given,

4-8 hr

ENOX < 260 ENOX > 260 ENOX < 200-250

LMWH in the Invasive Treatment of ACS and MI: Take Home Message

Enoxaparin is superior to UFH in ACS’s Enoxaparin is superior to UFH in ACS’s and in thrombolysis with TNKand in thrombolysis with TNK

Enoxaparin has favorable interactions with Enoxaparin has favorable interactions with platelets that enhance use of GP IIb/IIIa platelets that enhance use of GP IIb/IIIa inhibitors.inhibitors.

Enoxaparin can be used safely and Enoxaparin can be used safely and effectively in PCI with or without a effectively in PCI with or without a GP IIb/IIIa inhibitor.GP IIb/IIIa inhibitor.

Patients can be easily transitioned from Patients can be easily transitioned from medical stabilization with enoxaparin to an medical stabilization with enoxaparin to an early invasive strategy of care including early invasive strategy of care including PCI in ACS’s and AMI.PCI in ACS’s and AMI.

Use of enoxaparin should Use of enoxaparin should notnot be an obstacle be an obstacle to cath or PCI. An early invasive strategy to cath or PCI. An early invasive strategy of care should of care should notnot be an obstacle to use of be an obstacle to use of enoxaparin.enoxaparin.

LMWH in the Invasive Treatment of ACS and MI: Take Home Message

Use of UFH in PCI is historical and Use of UFH in PCI is historical and emperic, founded on broad experience, but emperic, founded on broad experience, but little data.little data.

Growing body of data supports the use of Growing body of data supports the use of LMWH in PCI in multiple clinical settings.LMWH in PCI in multiple clinical settings.

LMWH may be superior to UFH in PCI.LMWH may be superior to UFH in PCI.

LMWH in the Invasive Treatment of ACS and MI: Take Home Message