Acute Coronary Syndrome (ACS)

What is the leading cause of death in both men and women?

cardiovascular disease

What is the frequency of when someone in the United States would have an MI?

every 40 seconds

acute coronary syndrome (ACS)

clinical syndrome that is consistent with acute myocardial ischemia or infarction resulting from an imbalance in myocardial oxygen supply and demand

NSTE-ACS

partially-occluded vessel

STEMI

completely-occluded vessel

type 1 MI

MI caused by acute coronary atherothrombosis due to plaque rupture (i.e., primary coronary event)

type 2 MI

MI caused by an imbalance of myocardial oxygen supply and demand that is unrelated to acute coronary atherothrombosis

type 3 MI

MI resulting in sudden cardiac death that is suggestive of an ischemic process without definitive biomarker evidence

type 4 MI

MI related to percutaneous coronary intervention (PCI)

type 5 MI

MI related to coronary artery bypass graft (CABG) surgery

patient evaluation steps

1. history/chest pain characteristics

2. ECG/EKG

3. cardiac biomarkers

What constitutes CSA?

positive chest pain (stable)

ACS diagnoses

- UA

- NSTEMI

- STEMI

What constitutes unstable angina (UA)?

- positive chest pain (unstable)

- acute EKG changes (ST depression, T wave inversion)

What constitutes NSTEMI?

- c/o chest pain

- acute EKG changes (ST depression, T wave inversion)

- positive biomarker

What constitutes STEMI?

- c/o chest pain

- acute EKG changes (ST elevation)

- positive biomarker

Which patients are always considered high risk?

STEMI patients

What does assessment of patient/risk severity determine?

- short- and long-term risk of death and major adverse cardiovascular event (MACE)

- therapeutic decisions and interventions

- level of care (ICU, step-down, outpatient)

Which patients require further risk stratification through scoring tools?

NSTE-ACS patients

risk characteristics for UA/NSTEMI in relation to TIMI risk score

- age >65y

- >3 risk factors for CAD

- known CAD with prior coronary stenosis >50%

- aspirin use in the past 7 days

- >2 anginal episodes in the last 24 hours

- ST-segment deviation >0.5mm

- elevated cardiac biomarkers

risk factors for CAD

- family hx of CAD

- HTN

- DM

- current smoker

low TIMI risk

0-2

intermediate TIMI risk

3-4

high TIMI risk

5-7

short-term goals of therapy

- relieve angina and discomfort

- restore blood flow to the impacted artery

- prevent complete occlusion or infarct expansion

- prevent death and other ACS complications

long-term goals of therapy

- improve quality of life

- control risk factors

- prevent reoccurrence and risk of subsequent MACE

treatment of STEMI

invasive approach ("reperfusion therapy")

treatment of UA/NSTEMI (low-risk)

ischemic-guided approach ("medical management")

treatment of UA/NSTEMI (high- and intermediate-risk)

invasive approach ("reperfusion therapy")

reperfusion therapy

to quickly re-open the occluded vessel to restore blood flow

options for reperfusion therapy

- PCI

- CABG

- fibrinolytics

What is Time to Tissue?

the less time is takes between diagnosis and drug administration leads to less mortality rates

coronary angiography

diagnostic test to visualize coronary arteries

types of coronary catheterization

- coronary angiography

- PCI

examples of PCI

- balloon angioplasty (POBA)

- bare metal stent (BMS) placement

- drug eluting stent (DES) placement

balloon angioplasty

minimally invasive procedure to widen narrowed or obstructed coronary arteries

stent placement options

- bare metal

- drug eluting

bare metal stent (BMS)

metallic wire cage

When is BMS placement preferred?

in patients with high bleeding risk, compliance issues, and large arteries

drug eluting stent (DES)

coated with an anti-restenotic drug

Which stent has a higher risk of restenosis?

BMS

Which stent has a higher risk of repeat revascularization?

BMS

Which stent has a higher incidence of stent thrombosis?

DES

Which stent has a longer duration of antiplatelet therapy?

DES

Which stent has a higher cost/expense?

DES

stent complications

- stent thrombosis

- in-stent restenosis

stent thrombosis

acute formation of thrombus

causes of stent thrombosis

- platelet activation due to slow blood flow

- exposure to prothrombotic constituents

- non-adherence to therapy

in-stent restenosis

gradual narrowing of lumen

cause of in-stent restenosis

neointimal hyperplasia

indication for fibrinolytics

patients with STEMI and symptom onset of

fibrinolytic options

- alteplase (Activase) or t-Pa

- tenecteplase (TNKase) or TNK-tPa

What patients are NOT eligible for fibrinolytics?

patients with NSTE-ACS

alteplase (Activase) dosing

15mg IV bolus, then 0.75 mg/kg (max 50mg) over 30mins, then 0.5 mg/kg (max 30mg) over 60mins

NTE 100mg

alteplase (Activase)

- FDA-approved for use in STEMI, acute ischemic stroke, and pulmonary embolism

- co-infusion with anticoagulation required

tenecteplase (TNKase)

- FDA-approved for use in STEMI and acute ischemic stroke, off-label for PE

- co-infusion with anticoagulation required

tenecteplase (TNKase) dosing

administered as a single weight-based IV bolus over 5 seconds

-

absolute CIs to fibrinolytics

- any prior intracranial hemorrhage

- known structural cerebral vascular lesion

- know malignant intracranial neoplasm

- ischemic stroke within 3 months, EXCEPT acute ischemic stroke within 4.5h

- suspected aortic dissection

- active bleeding or bleeding diathesis (excluding menses)

- significant closed-head or facial trauma within 3 months

- intracranial or intraspinal surgery within 2 months

- severe uncontrolled hypertension unresponsive to therapy (SBP >180mmHg or DBP >110mmHg)

relative CIs to fibrinolytics

- hx of chronic, severe, poorly controlled hypertension

- uncontrolled hypertension (SBP >180mmHg or DBP >110mmHg)

- hx or prior ischemic stroke >3 months

- dementia

- known intracranial pathology not covered in absolute CIs

- traumatic or prolonged CPR (>10min)

- major surgery (

monitoring for fibrinolytics

- bleeding

- CBC

- INR

- aPTT

Which fibrinolytic is more fibrin specific?

TNKase

What is the preferred method of reperfusion?

primary PCI

Why is PCI the preferred method of reperfusion?

- higher rates of infarct artery patency

- lower rates of recurrent ischemia/reinfarction

- reduced emergency repeat revascularization procedures

- lower incidence of intracranial hemorrhage and death

considering CABG

- significant left main disease

- multivessel disease

- diabetes with involvement of the left anterior descending (LAD)

- disease not amenable to PCI

types of grafts

- left internal mammary artery (LIMA)

- radial artery

- saphenous vein

goal door-to-balloon

goal door-to-needle

goal of first medical contact

patient stabilization

- analgesics (if having chest pain)

- oxygen (if SaO2

prevent clot expansion

- antiplatelets

- anticoagulants

secondary prevention

- statin + non-statin therapies

- beta blockers

- ACEi/ARB + aldosterone antagonists

analgesic options

- nitroglycerin

- morphine

- fentanyl

monitoring for nitroglycerin

- BP

- HR

- tachyphylaxis

- headache

What is the preferred analgesic for chest pain?

nitroglycerin

When to consider IV NTG?

- if anginal pain persists after oral therapy

- if ACS is accompanied by hypertension or PE

CIs to nitroglycerin

- concurrent use of PDE-5 inhibitors

- RV infarction or other preload dependent states

- SBP

monitoring for morphine and fentanyl

- BP

- HR

- RR

When is fentanyl used over morphine?

if morphine allergy or hemodynamic instability

oxygen options

- nasla canula

- non-rebreather mask

- ventilator

antiplatelets for clot expansion prevention

- aspirin

- P2Y12 inhibitor

- GP IIb/IIIa inhibitor

indication for aspirin

all patient with ACS

monitoring for aspirin

- bleeding

- CBC

CI to aspirin

aspirin allergy

loading dose of aspirin

162-325mg PO x1

maintenance dose of aspirin

75-100mg PO daily

How should the loading dose of aspirin be administered?

should be chewed and swallowing to achieve faster onset of antiplatelet action

Should loading doses still be administered in patient who are already on aspirin?

yes

How is the choice of P2Y12 inhibitors guided?

whether reperfusion therapy was received and the type of reperfusion therapy that was used

P2Y12 inhibitor options

- clopidogrel (Plavix)

- prasugrel (Effient)

- ticagrelor (Brilinta)

- cangrelor (Kengreal)

How many days to hold clopidogrel before surgery?

5 days

BBW for clopidogrel

diminished effectiveness in poor metabolizers of CYP2C19

How many days to hold prasugrel before surgery?

7 days

CI of prasugrel

hx of TIA or stroke

BBW for prasugrel

not recommended in patients >75y due to increased risk of fatal and intracranial bleeding and uncertain benefit

How many days to hold ticagrelor before surgery?

3-5 days

CI of ticagrelor

- severe hepatic impairment

- hx of intracranial hemorrhage

BBW for ticagrelor

maintenance dose of aspirin >100mg reduce effectiveness of ticagrelor

How long to hold cangrelor before surgery?

1 hour

When to switch patients to an oral P2Y12 inhibitor from cangrelor?

- prior to discharge

- immediately after discontinuation of cangrelor

P2Y12 inhibitor selection for PCI in ACS

aspirin + ticagrelor/prasugrel