Acute coronary syndromes Radka Adlová

ACS - introduction includes any condition where the blood flow to the heart muscle is reduced the most feared complications of coronary artery disease (CAD) are associated with high mortality and morbidity Cardiovascular diseases (CVD) - presently the leading cause of death in developed countries Coronary artery disease is the cause of 13% of deaths worldwide, every sixth man and every seventh woman in Europe die because of acute myocardial infarction (AMI)

Cardiovascular Mortality

Definiton The clinical presentations of CAD include: silent ischaemia stable angina pectoris heart failure unstable angina myocardial infarction (MI) sudden death

Acute coronary syndromes ACS are usually divided into: UNSTABLE ANGINA PECTORIS - characterized by the presence of ischemia, lack of necrosis of heart muscle STEMI - ST - elevation MI NSTEMI - non-ST elevation MI Sudden death - due to cardiac arrhythmias

Acute coronary syndromes

Definition ST - elevation ACS (STE - ACS): typical acute chest pain and persistent (for >20 min) ST-segment elevation Mostly reflect an acute total coronary occlusion

ST elevation on the ECG

Definition Non – STE - ACS (NSTE - ACS): acute chest pain without persistent ST-segment elevation persistent or transient ST segment depression or T- wave inversion

ST depresion on the ECG

Pathophysiology = Vulnerable plaque

Epidemiology The annual incidence of NSTE-ACS is higher than STEMI The annual incidence of hospital admissions for NSTE-ACS is in the range of 3 per 1000 inhabitants sex differences - men account for more than 90% of patients with AMI under the age of 40y. (a hormonal profile of woman has a protective effect) age differences - in patients aged under 40y. only one heart artery is affected

Prognosis of STE vs. NSTE-ACS Hospital mortality - higher in patients with STEMI than among those with NSTE-ACS (7 vs. 5%) 6 months mortality - the mortality rates are very similar in both conditions (12 vs. 13%) Long-term follow-up - death rates higher among those with NSTE-ACS than with STE- ACS

Prognosis of STE vs. NSTE-ACS The causes of the higher death rates of NSTE-ACS than of STE-ACS pts. during long-term follow-up are: older pts. more co-morbidities (diabetes and renal failure). a greater extent of coronary artery and vascular diseases persistent triggering factors such as inflammation

Classification of MI Type 1 - spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection Type 2 – MI secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension Type 3 – sudden unexpected cardiac death, including cardiac arrest but death occurring before blood samples could be obtained Type 4 – associated with PCI: Type 4a – MI associated with the procedure of PCI Type 4b – MI associated with stent thrombosis Type 5 – MI associated with CABG

Myocardial infarction 1. Atherosclerotic aetiology (type 1) 2. Non-atherosclerotic aetiology: (type 2-5) arteritis trauma dissection congenital anomalies cocaine abuse complications of cardiac catheterization, CABG

Diagnosis of acute MI 2 from 3 criteria must be fulfilled : Clinical symtoms Chest pain ECG changes ST elevation or depression negative T wave Elevated cardiac biomarkers Troponin I or T CK-MB myoglobin

Clinical presentation STE/NSTE-ACS: - intense prolonged (20 min) pain at rest - retrosternal pressure or heaviness (‘angina’) radiating up to the neck, shoulder and jaw and down to the ulnar aspekt of the left arm - May be accompanied by other symptoms such as nausea, sweating, abdominal pain, dyspnoea,… Unstable angina: - New onset severe angina (class III of CCS) - Recent destabilization of previously stable angina with at least CCS III angina characteristics

Location of MI

Location of the various types of MI ST elevation in: Anteroseptal - V1-V3 Anterolateral - V1-V6 Inferior wall - II, III, aVF Lateral wall - I, aVL, V4-V6 Right ventricular - RV4, RV5 Posterior- R/S ratio >1 in V1 and T wave inversion

Location of MI

Location of MI

Location of MI

Biochemical markers cardiac troponins (I and T) Markers of myocardial injury: cardiac troponins (I and T) creatinine kinase (CK) CK isoenzyme MB (CK-MB) Myoglobin We have to perform repeated blood sampling and measurements are required 6-12 h after admission and after any further episodes of severe chest pain

Biochemical markers over time

Non-invasive myocardial imaging Echocardiography - to evaluate LV systolic function, complications, aortic stenosis, aortic dissection, pulmonary embolism, or hypertrophic cardiomyopathy - should be routinely used in emergency units for the risc stratification

Imaging of the coronary anatomy The imaging of the coronary anatomy is the most importat diagnostics method in evaluation of acute coronary syndrome The gold standard of patients with ACS is conventional invasive coronary angiography

Decesion-making algorithm in ACS

Treatment of MI while STEMI is an urgent situation with turbulent symptomatology, NSTEMI may have symptoms much milder and above its immediate prognosis is better Pts. should stay on coronary care unit - 2-3 days, than standard cardiology department the total length of hospitalization is around 1 week even after leaving the CCU patients are able to move around the room and in the following days rehabilitate and before discharge they are able to walk up the stairs return to job possible approximately one month after the onset of the symptoms

Treatment of STEMI Open the occluded artery as soon as possible to restore blood flow for the heart = primary PCI ‘‘Time is muscle“ Check for complication of myocardial infarction and treat them: arrhythmia heart failure bleeding

Reperfusion Strategy Reperfusion therapy 37-93% PPCI rate varies between 5 and 92%; Thrombolysis 0-55% EUROPE IS VERY HETEROGENOUS!!!

Process of the percutaneous coronary intervention

Process of the implantation of stent

Aspiration trombectomy procedure for elimination of trombus to prevent embolisation a special hollow catheter is introduced into the affected artery and thrombotic masses are aspirated under pressure

Pre-hospital management Antiplatelet therapy Acetylosalicid acid 400-500 mg (i.v. or p.o.), Clopidogrel 600mg or ticagrelor 180mg or prasugrel 60mg Antithrombin therapy Heparin 5 000 - 10 000 IU i.v. or enoxaparine Resolve pain and fear analgesic drugs benzodiazepine

Pre-hospital management Nitrate - pain, hypertesion, heart failure Isosorbide dinitrate 1-5 mg i.v. Monitoring vital function and ECG ventricular fibrilation terminated by cardioversion

Pre-hospital management Betablockers - tachycardia, hypertension Metoprolol - dose 25-50mg oral or 2 mg i.v. ACE inhibitors - hypertension Perindopril - dose 5 mg oral Diuretic - heart failure Furosemide 20 - 40mg i.v. Anti-arrhythmic drugs -no prophylaxis Mesocain 1% 10 mL i.v. Amiodarone 150 mg i.v. bolus

Hospital and discharge therapy Antiplatelet therapy Acetylosalicid acid - dose 100 mg p.o. (for life) Clopidogrel 75mg or ticagrelor 90mg twice a day or prasugrel 10mg (1 year) Statins - benefit for all patients with IM Atorvastatin 40-80mg, rosuvastatin 20-40mg (for life) ACE inhibitors - benefit for all patient with IM, more expressed in left ventricular dysfunction perindopril - dose 5-10 mg oral Betablockers - 1-3 years after MI, longer for pts. With left ventricular dysfunction, tachyarrhythmia

Case report - 1 57-old female smoker, family history of CAD, pain 6 hours, nausea

Coronary angiography

Trombus aspiration

Stent implantation

Case report - 2 61-year old male with hypertension, pain 4 hours, vomiting, sweating

Coronary angiography of LCA

Trombus aspiration

Stent implantation and final result

Complications of MI Early complications include: Heart failure, cardiogenic shock Mechanical complications : - rupture of free wall of left ventricle - ventricular septal defect - acute mitral regurgitation Arrhythmia - ventricular (up to 48 h) - bradycardia (9-25% of pts) Late complications include: pericarditis Aneurysm of left or right ventricle

Tamponade

VSD

VSD

Aneurysm

Treatment of NSTE-ACS To immediate examination are indicated patients with: history of CAD or previous revascularization severe recurrent angina left ventricular dysfunction, heart failure or ventricular arrhythmias

Treatment of NSTE – ACS vs. STE thrombolysis is not at NSTEMI used There are 3 options of revascularization strategy: Conservative treatment - non-significant stenosis PCI - percutaneous coronary intervention - the base of treatment is again antithrombotic therapy and revascularization - DES, BMS Surgical revascularization - in patients with diffuse coronary artery involvement, for diabetics pts.

Case report - 3

Stenosis of LMCA

CABG - LIMA ad RIA,SVG ad RMS

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