Acute coronaire syndromenProf dr M Claeys

UZ AntwerpenUniversiteit Antwerpen

Aanvullingen van Paul Calleop basis van ESC guidelines 2015

(ivm non-STEMI) en ERC guidelines 2015 (ivm ACS)

DIAGNOSE viaBIOCHEMISCHE MERKERS / BIOMARKERS

snel duur gevoelig specifiekCK MB +++ kort +++ +++

Myoglobine ++++ kort+ ++++ -

Troponine + lang+ ++++ ++++

SGOT + lang ++ ++

LDH - lang+ ++ ++

TRIADE VAN ACS

AnamneseCardiac enzymes

Surface ECG

Anamnese

• Klachtenpatroon Stabiel AP ACS

– aard: drukkend, beklemmend– lokalisatie retrosternaal, li schouder/hals– uitlokkende factoren inspanning los van inspanning – duur <20 minuten > 20 minuten– reproduceerbaarheid ja niet altijd– begeleidende symptomen neen vaak

(zweten, malaise, nausea)– reactie op nitraten ja niet altijd (MI)

Early diagnosis (preferentially prehospital)

• Rhythm monitoring

• 12 lead ECG

+ wireless data transfer!

Early -in-hospital management forall potentially ACS patients

1. Check vital signs2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 l/min) when O2sat<90%

4. Establish IV access5. Take 12-lead ECG6. Obtain serum cardiac markers

7. Cardiological assessment:ST elevation AMI ACS without ST elevationACS doubtful or non cardiac pathology

< 3‘

< 10‘

< 20‘

Inferior infarction

ST- Elevation: in lead III > II ST- Elevation: in II > III

From “ECG uit of in het hoofd” Andries E, Stroobandt R, De Cock N et al., Garant, 2006

Proximal occlusion RCA ST-elevation > 1 mmpositive T-wave

Distal occlusion RCA No ST-elevationpositive T-wave

Occlusion LCX Negative T-wave

Right Ventricular Myocardial Infarction V4R

Proximal LAD Occlusion

Distal LAD Occlusiondistal to both S1 and D1

ST- Elevation: in II > III and aVF

ST- Elevation: in lead V5-V6

Proximal LAD Occlusion Distal LAD Occlusion

KEY POINT: Anterior infarction

DIAGNOSIS of anterior wall infarction

ST-elevation in the precordial leads V1 to V4

SITE of OCCLUSION in the LAD and AREA at RISKcan be recognized in the frontal leads

--------> GO IMMEDIATELY FOR

EXPERT OPINION

Case: 81 y old female

• Medical history:– no severe diseases– No cardiac risk factors– No medications

• Actual medical problem– Prolonged chest pain(>36h)– Last hours more dyspnea on exercise

(NYHA class ¾)– General malaise- dizziness- diaphoresis

Case: 81 y old female

• Clinical examination:– RR: 90/65 , heart rate 90 bpm,– Systolic murmur, – Normal CVP, bilateral lung crackles

(Killip 2)

• Labo:– Trop 10 ng/ml, creat 1.5mg%– NT-proBNP: >8000 pg/ml

ECG

RX thorax

Case: 81 y old female

• Diagnostic evaluation:– Subacute posterior infarction– Signs of left cardiac failure – (evolution to cardiogenic shock)– Discrepancy between severity/extent of

ischemia and hemodynamic status

• Management– Echocardiography or cardiac

catheterisation– Medical treatment: ASA - UFH

TTE

ACS zonder ST elevatie: hoofdstamstenose of 3VD

ST- Depression: in > 8 leads (most pronounced in V4)

ST- Elevation: in lead aVR and V1

Kritische Proximal LAD Stenosis (Wellens Syndrome)

CAVE:

Bij pijnaanval

Pseudonormalisatie !!!

Early-in -hospital management

1. Check vital signs2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 l/min) when O2sat<90%

4. Establish IV access5. Take 12-lead ECG6. Obtain serum cardiac markers

7. Cardiological assessment:ST elevation AMIACS without ST elevationACS doubtful or non cardiac pathology

< 3‘

< 10‘

< 20‘

CRUCIAL NOTE : BIOMARKERS OF NO IMPORTANCE IN STEMI OF RECENT ONSET

ST- Elevation AMI : management

1. Check intake ASA / nitrates SL (but beware of right ventricular myocardial infarction)

2. Prasugrel/Ticagrelor/clopidogrel3. Pain relief with opiates

4. Initiate Reperfusion therapy

Thrombolyse PTCA

60 60 5763

85

0

20

40

60

80

100

tPA

rPA

NPATNK 40

PTCA

60 60 5763

85

0

20

40

60

80

100

tPA

rPA

NPATNK 40

PTCA

The 90 Minute Wall:The 90 Minute Wall: Rates of TIMI Grade 3 FlowRates of TIMI Grade 3 Flow

% T

IMI 3

Flo

w%

TIM

I 3 F

low

Primary PCI vs. thrombolytic therapy

Keeley Lancet 2003;361:13

75

2,5

6

1

6,88

97 6,8

21

2

14

0,05

5,3

1,1

0

5

10

15

20

25 PTCALysis

Death Death excl.

Shock

Nonfatal MI

Recurrent ischemia

Total CVA

Hemorr. CVA

Major bleeds

Death/ CVA/AMI

p=0.0002

p=0.0003 p<0.0001

p<0.0001

p=0.0004

p<0.0001

p=0.032

p<0.0001

Fre

quen

cy (

%)

De Luca, Circulation 2004

Primary PCI and timePrimary PCI and timePrimary PCI and timePrimary PCI and time

30 minutes delay increases 1-year mortality by 7.5%

Europese richtlijnen reperfusietijden : PCI

<90-120min

ST elevation MI (<12 h after onset of pain)

Admission in

PCI-center

Primary PCI

• Thrombus aspiration

• IIB-IIIa antagonists in case of high thrombotic burden

Admission in non-PCI-center OR

1st medical contact outside hospital

• Transfer time to PCI center < 90 min

(transfer time<60 if ischemic time<2h)

• Hemodynamic instability

(shock / cardiac failure/ malignant arrhythmias)

• Contra-indication thrombolysis

Thrombolysis

YES

NO

• PPCI: UFH and Prasugrel 60 mg/ Ticagrelor 180mg

•Trombolysis: Enoxaparin and clopidogrel 300mg (adjus ted dose if >75y)

ASA- Morphine - Heparin* - P2Y12 inhibitor *

Failed

Rescue PCI

Succes

Coronaro/

PCI 3-24h*

STEMI: prehospital pretreatment

• ATLANTIC TRIAL (30 min difference in Tica)

PrehospTica

InhospTica

Death 30d 3.3% 2.0%

Stent tromb 0.2% 1.2%*

NEJM 2014:371:1061

---------> MARGINAL, IF ANY, BENEFIT

Early -in-hospital management forall potentially ACS patients

1. Check vital signs2. Establish ECG monitoring + defibrillator 3. Give oxygen (3-5 l/min) when O2sat<90%

4. Establish IV access5. Take 12-lead ECG6. Obtain serum cardiac markers

7. Cardiological assessment:ST elevation AMI ACS without ST elevationACS doubtful or non cardiac pathology

< 3‘

< 10‘

< 20‘

DECISIONS TO BE TAKEN IN COLLABORATION WITH CARDIOLOGIST

https://www.outcomes-umassmed.org/grace/acs_risk/ac s_risk_content.html

Acute coronary syndrome without ST elevation

1. Check intake ASA 2. Check intake nitrates SL3. Start heparin

(Fondaparinux SC* or LMWH SC** or unfractionated IV)

4. Start nitrates IV (if systolic blood pressure > 100 mmHg)

5. Start Beta blockers6. Oral P2Y12 inhibitors

(clopidogrel/prasugrel/ticagrelor)

* Fondaparinux: 2.5mg 1/d SC

** LMWH: e.g. enoxaparine 1mg/kg 2x/d SC

Mehta et al. NEJM 2009 - TIMACS Study

Early ( ≤24 h, median=14h) or delayed intervention ( ≥36 h, median=50h) in 3031 patients

Death, MI, Refractory Angina

Death, MI, Stroke

GRACE>140

Acute coronary syndrome without ST elevation

Aspirin - Nitrate - Beta-blocker

P2Y12 inhibitor # -Anticoagulation *

*Anticoagulation : Fondaparinux (+UHF in case of PCI) / Enoxaparine / U FH

# P2Y12 inhibitor: Ticagrelor / Prasugrel (reimbursement only in diabetic patients with PCI )

clopidogrel (high bleeding risk or low risk ACS)

HIGH RISK

Recurrent severe ischemia Elevated troponin

Hemodynamic instability Early post infarct angina

Major arrhythmias (VF, VT) Diabetes mellitus

Coronarography:

Urgent (<2h) Elective (<72h)(< 24h if Grace score>140)

consider IIB -IIIA antagonist + hep or bivaluridin

LOW RISK

No recurrent ischemia

No rise in trop

No diabetes

Non-invasive testing

Management of acute complications

• VT : amiodarone / xylocaïne ---> DC shock• Bradycardie:

atropinevoorlopige PM bij hooggradig AV blok

bij een nieuw bifascilair of trifasciculair blok

• Longoedeem: diuretica / nitraten• Shock: inotropica, vasopressoren

IABP

57

Bradycardie

Definitie < 60/min• Sinusbradycardie

Acuut inferior infarct, medicamenteus, fysiologisch

• Sick sinussyndroomSinusbradycardieSinusarrest

• AV-blokTweede graadsDerde graads

ERC guidelines 2015

- Aminophylline (100 – 200 mg slow IV injection) shouldbe considered if bradycardia is caused by inferior MI, cardiac transplant or spinal cord injury

- Glucagon dose: 0,05 mg/kg IV loading dose, followed b y1 to 15 mg/hour

- Do not give atropine to patients with cardiac transplant as it can cause high-degree AV block and sinus arrest