ACUTE CORONARY SYNDROME

1
ACUTE CORONARY SYNDROME

• ACUTE CORONARY SYNDROME (ACS), including those
  associated with or without ST- segment elevation,
  share in common pathophysiology mediated by
  activated platelets and thrombin superimposed on
  a culprit plaque

2
ACS

• No ST elevation
• Unstable angina
• NSTEMI
• NQMI
• QMI

• ST elevation
• QMI
• NQMI

3
B. Primary
A. Secondary
C. Postinfarction (lt 2 weeks)
Classification
Braunwald classification of unstable angina Braunwald classification of unstable angina Braunwald classification of unstable angina Braunwald classification of unstable angina Braunwald classification of unstable angina


I New onset, severe or accelerated angina IA IB IC
II Subacute rest angina (gt 48 hours ago) IIA IIB IIC
III Acute rest angina (within 48 hours) IIIA IIIB IIIC
4
MI ST elevationNew bundle branch blockECG changes of posterior MIEvolution of Q waves 2  upper limit of CK-MB, CK Troponins T gt 0.2 ng/dlTroponin I gt 1.0-1.5 ng/dl

       Minimal injury Aborted ST elevation MITransient ST elevationST depressionT inversionMinor non-specific ECG changes lt 2  elevation CK-MB, CK Troponins T 0.01-0.2 ng/dl Troponin I 0.1 or 0.4 ng/dl to 1.0-1.5 ng/dl

       UA Transient ST elevationST depressionT inversionMinor non-specific ECG changesNormal ECG CK-MB, CK below upper limit Troponins T lt 0.01 ng/dl Troponin I lt 0.1 or 0.4 ng/dl
5
Prior risk
  -   older age (gt 65 years)
  -   prior myocardial infarction or heart failure
  -   co morbidity diabetes, hypertension
  -   impaired renal function
6
Acute ischemic risk
  -   refractory or recurrent ischemic pain
  -   ECG ST segment depression or transient ST elevation during pain
  -   ECG T wave inversion (lower risk than ST segment depression or transient ST elevation)
  -   impaired left ventricular function with ischemia
  -   release of cardiac enzymes CK, CK-MB, troponin T or troponin I
  -   raised C reactive protein (high sensitivity assay)
7
Management of AMI

• ASA or other anti platelets
• O2
• Analgesics
• Anticoagulants
• GP IIb/IIIa inhibitors
• Nitrate
• B blocker
• ACEi
• Thrombolytic
• Mechanical reperfusion

8
PCI in AMI

• Primary
• Rescue
• Early lt 4 days
• Deferred gt 4 days

9
Complication of AMI

• Mechanical
• Pump failuregtgtshock
• Free wall rupture
• Interventricular rupture
• Papillary muscle rupturegtgtMR
• pseudo aneurysm

• Arrhythmia
• Tachyarrhythmia's
• supraventricular
• ventricular
• Brady arrhythmias
• Bundle branch block

10
Other complications of AMI

• Recurrent chest pain
• Recurrent MI
• Pericarditis
• Deep vein thrombosisgtgtPulmonary emboli
• Lv aneurysm
• Lv thrombosisgtgtArterial embolism

11
ADMIRAL abciximab before direct angioplasty and
stenting in myocardial infarction regarding acute
and long-term follow300 pt, GP IIb/IIIa inhibitor

• Composite end point at 30 days 6 abciximab and
  14.6 in the placebo
• Mortality at 30-day 3.4 abciximab group and
  6.6 in the placebo
• Urgent revascularization 1.3 abciximab and
  6.6 in placebo
• Mortality at 6 months 3.4 abciximab group and
  7.3 in the placebo
• Composite end point at 6 months 7.4 abciximab
  and 15.9 in the placebo
• 
  
  NEJM 2001344

12
CADILLAC controlled abciximab and device
investigation to lower late angioplasty
complications2081 pt effect of IIb/IIIa
inhibitor

• Primary out come at 6 m MI, death, TVR, CVA
• Hospital mortality 1-1.6
• Strokes 0.4
• Re-infarction 0.6 PTCA
• 0 PCTA abciximab
• 0.8 stent
• 0.2 stent abciximab
• TVR 2.3 PTCA
• 0.2 PCTA abciximab
• 0.8 stent
• 0.2 stent abciximab
• 
  
  AHA 1999

13
CADILLAC controlled abciximab and device
investigation to lower late angioplasty
complications

• Recurrent ischemia
• 4.9 PTCA
• 1.4 PTCA
  abciximab
• 3.9 stent
• 1.2
  stent abciximab
• 
  
  AHA 1999

14
GUSTO V global use of strategies to open
occluded coronary arteries16588 pt
fibrinolytic/- GP IIb/IIIa inhibitor

• Mortality at 24-h 2.3 with reteplase and 2.2
  in reteplase abciximab
• Mortality at 7-d 4,5 with reteplase and 4.3 in
  reteplase abciximab
• Mortality at 30-d 5.9 in reteplase and 5.6 in
  the reteplase abciximab
• Stroke 0.3 in reteplase and 0.2 in the
  reteplase abciximab
• Re-infarction 3.5 in reteplase and 2.3 in the
  reteplase abciximab
• MACE at 7-d 20.6 in reteplase and 16.2 in
  reteplase abciximab
• More non-intracranial bleeding complications in
  the combination group
• The rates of intracranial hemorrhage and
  non-fatal disabling stroke were similar in
  patientslt 75 years
• 
  
  Lancet 2001

15
STENT-PAMI primary angioplasty in myocardial
infarctionPCI/- stent in ACS 900 pt

• angina at 6 months occurred in 11.3 patients in
  the stent and 16.9 in angioplasty
• TVR 7.7 vs. 17.0 in stent and angioplasty
• The primary end point 12.6 and 20.1
• 6-month mortality 4.2 and 2.7
• 
  
  

NEJM 1999
16
STENT-PAMI primary angioplasty in myocardial
infarctionLong term effect of PCI as compared to
streptokinase for AMI395 pt

• Mortality over 5 ys was 13 in the angioplasty,
  24 in the streptokinase
• TVR lt30 ds in PCI 12.4 and in thrombolytic
  42.8
• TVR gt30 ds in PCI 34.1 and in thrombolytic
  28.3
• Re-MI in first 30 days 0.5 in angioplasty and
  9 in streptokinase.
• Re-MI After 30 days 6 in the angioplasty vs.
  12 in streptokinase
• 
  
• 
  
  NEJM 1999

17
STENTIM-2Comparison of PTCA and Stenting in
AMI-2 in 211 pt

• Re-infarction 4 in PTCA and 3.6 in stent
• Repeat revascularization 5.4 in PTCA and 5 in
  stent
• In-hospital event free survival 94.6 in PTCA
  and 95 in stent
• Six-month event free survival 72.7 in PTCA and
  82 in stent
• Six-month revascularization 26.4 in PTCA and
  16.8 in stent
• One year revascularization 28.2 in PTCA and
  17.8 in stent
• Restenosis 39.6 in PTCA and 25.3 in stent
• 
  
  JACC 2000

18
GUSTO IV ACSeffect of GP IIb/IIIa inhibitor
in7800 pt

• primary endpoint death or myocardial infarction
  at 30 days.
• FINDINGS 30- day death and MI 8.0 patients on
  placebo
• 
  8.2 abciximab on 24 h
• 
  9.1 on 48 h abciximab died
• This study indicates that abciximab is not
  beneficial as first-line medical treatment in
  patients admitted with acute coronary syndromes.
• 
  
  Lancet. 2001 Jun

19
GUSTO-IV PilotEarly PCI after reteplase/-
abciximab

• 30-day composite end point in early PCI
• (death, re-infarction, urgent revascularization)
  (5.6)
• Death 3.4,
• Re-vascularization 1.6
• Re-infarction 1.2
• 30-day composite end point in no early PCI
• (death, re-infarction, urgent revascularization)
  (16)
• Re-vascularization 9.3
• Re-infarction 4.9
• 
  
  JACC 200036

20
STATStenting vs. Thrombolysis in AMI Trial
in123 pt

• Primary end point at 6-month 24.2 in stent vs.
  55.7 in t-PA
• Re-infarction 6.5 in stent and 16.4 in t-PA
• Stroke 1.6 in stent and 4.9 in t-PA
• TVR 14.5 in stent and 49.5 in t-PA
• Recurrent UA 9.7 in stent and 26.2 in t-PA
• 
  
  JACC 2001

21
IMPACT-AMIt-PA /- IIb/IIIa integrin receptor
blockade

• The primary end point was TIMI grade 3 flow at
  90-minute angiography. Secondary end points were
  time to ST-segment recovery, an in-hospital
  composite (death, reinfarction, stroke,
  revascularization procedures, new heart failure,
  or pulmonary edema), and bleeding variables
• The highest Integrilin dose groups had more
  complete reperfusion (TIMI grade 3 flow, 66
  versus 39 for placebo-treated patients P.006)
• Shorter median time to ST-segment recovery (65
  versus 116 minutes for placebo P.05).
• Mortality 5.6 in integrin treated and 3.6 in
  placebo treated group
• Death and re-infarction 8 in integrin treated
  and 7.3 in placebo treated
• The groups had similar rates of the composite end
  point (43 versus 42 for placebo-treated
  patients)
• 
  
  Circulation 199795

22
RAPPORTReoPro and Primary PTCA Organization and
Randomization Trial

• The primary end point was death, reinfarction, or
  any (urgent or elective) target vessel
  revascularization (TVR) at 6 months
• abciximab significantly reduced the incidence of
  death, reinfarction, or urgent TVR at all time
  points assessed 9.9 versus 3.3, at 7 days
• 11.2 versus 5.8, at 30 days and 17.8
  versus 11.6, at 6
• months
• The effect of abciximab with respect to
  death or reinfarction 4.7 versus 1.4, at 7
  days 5.8 versus 3.2, at 30 days and 12.0
  versus 6.9, at 6 months
• 
  
  Circulation 199898

23
TIMI-14 (Substudy)Thrombolysis in Myocardial
Infarction-14 (alteplase, abciximab) alone or
abciximab reduced dose of lytics

• ST segment resolution 59 in combination of tPA
  abciximab vs. 37 in full dose tPA alone
• 30-day mortality 1.1 with complete ST
  resolution
• 4.7 with
  incomplete ST resolution
• 7.1 with no ST
  resolution
• 
  
  Circulation 2000101

24
ISAR-2Intracoronary Stenting and Antithrombotic
Regimen-2coronary stenting /- abciximab

• 30-day MACE 5 in abciximab and 10.5 in heparin
  groups
• 30-day death 2 in abciximab and 4.5 in heparin
  groups
• 30-day MI 0.5 in abciximab and 1.5 in heparin
  groups
• 30-day TVR 3 in abciximab and 5 in heparin
  groups
• At one year there was 5.7 absolute reduction in
  cardiac events
• At six-month restenosis 31.1 in abciximab and
  30.6 in heparin groups
• 
  
  JACC 200035