Ischemic Heart Disease/MI Review R. Keith Bailey, MD, MPAS VAPAA Conference Houston, Tx 2017

Nothing to report regarding conflicts of interest Sponsored by VAPAA

Acute Coronary Syndromes UA: Unstable Angina Rapidly worsening chest pain of cardiac etiology No ST segment elevation on the admitting ECG Negative serial troponin blood tests NSTEMI: Non-ST segment elevation MI Positive serial troponin blood tests STEMI: ST segment elevation MI Prolonged chest pain of cardiac etiology ST elevation or new LBBB on the admitting ECG Troponin not required for the diagnosis (but ++)

STEMI Definition Acute Clinical Syndrome, ongoing for at least 30 minutes A Diagnostic ECG (done within 10 minutes of arrival to ER): >1 mm ST elevation in two anatomically contiguous leads New Left Bundle Branch Block (LBBB) No Alternative Explanation Acute Pericarditis, Aortic Dissection, Pneumothorax, Pancreatitis, Pulmonary Embolus

TIMI IIIB Results % Mortality at 42 days Troponin I Predicts Mortality in UA/NSTEMI 7.5 8 6.0 6 % Mortality at 42 days 3.7 3.4 4 1.7 2 1.0 831 174 148 134 50 67 0 to <.04 0.4 to <1.0 1.0 to <2.0 2.0 to <5.0 5.0 to <9.0 > 9.0 Cardiac Troponin I ng/ml Risk Ratio 1.0 1.8 3.5 3.9 6.2 7.8 Antman EM, NEJM 1996;335:1342

60 yo male presents to the ER with severe epigastric pain which radiated to his throat and arm. Risk Factors for CAD included: Hypertension, hyperlipidemia, Diabetes Mellitus, positive family history and Smoking 2 ppd for 40 yrs. PH no previous admissions or hospitalizations Physical Examination: BP 90/50 P 65/min remainder of his physical examination except for a systolic murmur was normal ECG -

Myocardial Infarction Anastomoses / Collateral Circulation

Angina Pectoris

Arterial Plaque

Coronary Atherosclerosis

Blockage Treatment

ISIS–2 INTERNATIONAL INFARCT STUDY OF INFARCT SURVIVAL CARDIOVASCULAR MORTALITY AT 4 WEEKS TREATMENT MORTALITY % Streptokinase 10.4 Aspirin 10.7 Aspirin + Streptokinase 8.0 Placebo 13.2

Andreas Gruentzig, M.D. 1939-1985 In September 1977, in Zurich Switzerland, Gruentzig performed the first coronary angioplasty on an awake human. "I want to do the least necessary to help the patient heal themselves". Plane crash October 1985

Who Should Get Primary PCI? “Generally preferred” in patients presenting with < 3 hours symptoms if : Door to balloon time is < 90 minutes (Door to balloon) – (door to needle) is < 1 hour Otherwise lytics are the preferred alternative In High Risk STEMI (acute pulmonary edema or shock) In those with a contraindication to lytics In patients presenting > 3 hours from symptom onset (door to balloon time “as brief as possible”, with goal <90 minutes)

ACC/AHA Guidelines for Primary PCI “The procedure should be supported…in an appropriate laboratory (one that performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and that has cardiac surgery capability.”

ACC/AHA Guidelines for PCI in Acute STEMI “If immediately available, primary PCI should be performed in patients with STEMI who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform> 75 PCI procedures per year).”

Why is PCI Listed as Preferable to Thrombolysis? Very effective at opening the occluded artery With PCI: 90% - 95% patency rate, regardless of symptom duration With lytics: 50% to 70% within 2 hrs of symptom onset ~30% at 4-6 hrs ~20% >6 hrs Stenting removes residual stenosis Allows complete staging of CAD extent – CABG Focuses resuscitation/initial treatment efforts

Complication Thrombolytic therapy vs Primary PTCA 10 trial meta-analysis JAMA 1997;278:2093-8.)

ACC/AHA Guidelines for PCI in Acute STEMI “If immediately available, primary PCI should be performed in patients with STEMI who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform> 75 PCI procedures per year).”

TIMI 1 Open Artery Theory Impact of 90 Minute Patency on Mortality Patent (N=161) 20 Occluded (N=128) 15 10 Mortality (%) 5 As seen in this figure, patients with a patent artery (yellow) at 90 minutes after the start of reperfusion therapy had lower 6 month and 1 year mortality regardless of treatment group. 8 16 24 32 40 48 Weeks from Randomization Dalen, et. al. Am J Cardiol 1988; 62:179-85

Time when thrombolytics started Lives saved/1000 compared to Standard Rx Time when thrombolytics started In the first hour 65 In the second hour 37 In the third hour 29 Between hours 3-6 26 Between hours 6 and 12 18 Between hours 12 and <24 9

Assessment of Reperfusion Options- STEMI Step I – Assess time and risk Time since onset of symptoms Risk of STEMI Risk of fibrinolysis Time required for transport to a skilled PCI Lab

Step II – Determine if fibrinolysis or an invasive strategy is preferred. Fibrinolysis is generally preferred if: Early presentation (less than or equal to three hours from symptom onset and delay to invasive strategy) Invasive strategy is not an option Cath lab occupied/ not available Vascular access difficulties Lack of access to a skilled PCI lab Delay to invasive strategy Prolonged transport Door to balloon > 90 minutes

Contraindications for Fibrinolytic therapy in ST Elevation MI Absolute Contraindications Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g. AVM) Known malignant intracranial neoplasm (primary or metastatic)

Contraindications for Fibrinolytic therapy in ST Elevation MI Absolute Contraindications Ischemic stroke within 3 months Suspected aortic dissection Active bleeding or bleeding diathesis (except menses) Significant closed head or facial trauma within 3 months

An invasive strategy is generally preferred if: Skilled PCI lab available with surgical backup Skilled PCI lab with surgical backup Door to balloon < 90 minutes High risk ST elevation MI Cardiogenic shock Killip class > or equal to III Contraindications to fibrinolysis including increased risk of bleeding and ICH Late presentation Symptom onset was > 3 hours ago Diagnosis of ST elevation MI is in doubt

0.5% of interventional patients go emergently/urgently to bypass because of Acute occlusion during attempts to cross a lesion with a guide wire or after inadvertent loss of guide wire access across the lesion. Dissections of the left main coronary artery or across major branches. Hemodynamic embarrassment. Recurrent occlusion after stenting. Perforation of a coronary vessel.

0.5% of interventional patients go emergently/urgently to bypass because of Dissection of the Aorta Extensive coronary dissection uncontrollable by stenting. Inability to pass a stent. Stent maldeployment.

Acute Coronary Syndrome Performance Measures Inpt ECG in hospital within 15 minutes prior to or 10 minutes after arrival Inpt Reperfusion as appropriate STEMI Inpt Reperfusion PCI in 120 min STEMI

Acute Coronary Syndrome Performance Measures Inpt Reperfusion Thrombolytic Rx in 30 min STEMI Inpt Risk High/Moderate seen by cardiologist within 60 days post discharge Inpt Risk High//Moderate with cardiology involvement in 24 hours

Acute Coronary Syndrome Performance Measures Inpt Risk High/Moderate with Dx cath prior to discharge Inpt Risk Moderate/Low with plan prior to discharge Inpt Troponin returned within 60 minutes of initial order

Conclusions In patients with STEMI with <12 hrs of symptoms reperfusion vs no reperfusion is best In patients with < 3hrs of symptoms, PCI is preferred reperfusion strategy if it can be delivered in a “timely”fashion Door to balloon time < 90 (120) minutes (Door to balloon) – (Door to needle) time < 60 minutes The longer from symptom onset ( > 3 hours), the more attractive PCI becomes Thrombolytic reperfusion success rate decreases with time PCI reperfusion success rate may not

Conclusions Remember the Time is Muscle and Time is Life If you transfer all STEMI patients to another hospital, MEASURE cumulative door to balloon times If times are sub-optimal > 90 minutes, consider giving Fibrinolytics in the absence of contraindications The efficacy of facilitated PCI with GPIIb/IIIa + half dose lytic is under investigation Clopidogel + lytics may also be an approach in certain patients

VHA Where we stand As of January 2017 : 79 operating cardiac catheterization labs 10% offer 24/7 coverage EMS transports Remainder offer elective Mon-Fri diagnostic procedures/ emergent PTCA or transport to backup facility Usually Affiliated University or community based

"Do, or do not. There is no 'try'." ('The Empire Strikes Back') Yoda ('The Empire Strikes Back')