Patient Oriented Therapy Non STE ACS <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> Patient Oriented Therapy Non STE ACS Prof dr Midhat nurkić FESC Director clinic for cardiovascular disease UKC Tuzla

Acute Coronary Syndrome (ACS) Definition: The spectrum of acute ischemia related syndromes ranging from UA to MI with or without ST elevation that are secondary to acute plaque rupture or plaque erosion. [----UA---------NSTEMI----------STEMI----]

Stable Unstable Q wave Non-Q Angina Angina MI wave MI CAD UA/NSTEMI Days- weeks Mins- hours Our current understanding of the unstable coronary syndromes is that they all fall on a spectrum of disease and begin with a coronary plaque rupture. The degree of thrombus determines the severity of the clinical syndrome, with total occlusion in ST elevation MI or severe (90%) stenosis in patients with non-ST elevation MI or unstable angina. In addition, it is worthwhile to note that 99% of all plaque ruptures are clinically silent. A small degree of rupture, leads to a small thrombus, which heals over, but leads to progression of the plaque - like rings on a tree. This is the understanding of how atherosclerosis progresses. This emphasized the key role that antithrombotic therapy plays in all both acutely and chronically in patients with unstable coronary syndromes. Antithrombotic Thrombolysis Primary PCI Therapy Cannon CP J Thromb Thrombolysis. 1995;2:205-218. 2

Spectrum of Chronic Coronary Syndrome Risk Factors + Hypertension Endothelial Dysfunction Atherosclerosis IHD/Angina Pectoris Chronic Coronary Syndrome Myocardial Ischemia Acute Coronary Syndrome Coronary Thrombosis Myocardial Infarction Arrhythmia & Loss of Muscle Remodeling Ventricular Dilation Congestive Heart Failure Endstage Heart Disease Baroldi G, The Etiopathogenesis of Coronary Heart Disease. 2nd ed. 2004. 10

Acute Evaluation of ACS Presentation Chest pain or Short of Breath Normal ST-segment Depression ST-segment Elevation ECG + Markers – + – + Diagnosis Unstable Angina Rule-Out Acute MI Anderson JL. J Am Coll Cardiol 2007;50:e1-157

ST Elevation MI Stable Angina Unstable Angina Non ST Elevation MI ECG – ST ↑ ECG - ST ↓ CK-MB Troponin CRP/BNP <- + Markers Identify MI patients, who are High-Risk Patients ->

CHD Mortality Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Recent Trends CHD Mortality Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Cardiovascular Procedure Trends Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

What is a UA/NSTEMI Patients Risk of inpatient Cardiac Mortality and ischemic events?

Risk Stratification Integral prerequisite to decision making Intensive initial assessment Continuous clinical assessment Targeted ECG and marker data Risk based on contingent probabilities Probability of obstructive CAD causing ischemia Risk given presence of obstructive CAD Risk scores should be a routine part of assessment throughout the hospital course and periodically after discharge Can you do this with bullets? Anderson JL. J Am Coll Cardiol 2007;50:e1-157

Variables Used in the TIMI Risk Score Age ≥ 65 years =1 point At least 3 risk factors for CAD =1 point Prior coronary stenosis of ≥ 50% =1 point ST-segment deviation on ECG presentation =1 point At least 2 anginal events in prior 24 hours =1 point Use of aspirin in prior 7 days =1 point Elevated serum cardiac biomarkers =1 point The TIMI risk score is determined by the sum of the presence of the above 7 variables at admission. 1 point is given for each variable. Primary coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events. Antman EM, et al. JAMA 2000;284:835–42. TIMI = Thrombolysis in Myocardial Infarction.

Downloadable Apps available TIMI Risk Score Downloadable Apps available TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 Days After Randomization % 0-1 4.7 2 8.3 3 13.2 4 19.9 5 26.2 6-7 40.9 Reprinted with permission from Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American Medical Association. All Rights reserved. The TIMI risk calculator is available at www.timi.org. Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8. TIMI = Thrombolysis in Myocardial Infarction.

Initial Evaluation - Risk Stratification IIa IIb III 12-lead ECG within 10 min for all patients with chest pain or symptoms suggestive of ACS Early risk stratification by symptoms, physical findings, ECG, cardiac markers Cardiac markers, Troponins and CK-MB, for initial assessment Use of risk stratification models (TIMI, PURSUIT, GRACE) can be useful to assist in decision making for treatment options Anderson JL. J Am Coll Cardiol 2007;50:e1-157

UA/NSTEMI Hospital Care Let’s Start with the Basics! Assuming the NSTEMI has been ruled in or out

ACC/AHA Guidelines ACS Treatment Overview: UA/NSTEMI Diagnosis of UA or NSTEMI is likely or definite Aspirin or clopidogrel (if patient is aspirin intolerant) Initial conservative management Initial invasive management Medical therapy Diagnostic angiography PCI or CABGa Evaluation of LV Function in pt with ischemia Long-term medical management: Clopidogrel, aspirin, β-blocker, ACEI, statin aIf possible, clopidogrel should be withheld for 5-7 days prior to the procedure. Anderson JL, et al. Circulation. 2007;116:803-877.

Selection of Initial Treatment Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment Class I Indications Bedrest/chair with continuous ECG Monitoring O2 therapy with saturation <90%, respiratory distress, or other high-risk features for hypoxemia SL NTG 0.4 mg q5min x3 then assessment of need for IV NTG IV NTG indicated first 48 hours for treatment of persistent ischemia, CHF or HTN; should not preclude tx with beta-blockers or ACE Oral Beta-Blocker in first 24 hours for pt who do not have Signs of CHF Low out-put state Increased risk of cardiogenic shock Contraindication to Beta blockers/heart block/COPD If Beta-Blockers are contraindicated a nondihydropyridine calcium channel blocker may be used if no LV dysfunction Wright RS et al. Circ 2011;123;2022-2060.

Early Treatment (Cont.) ACE inhibitor within 24 hours with pulmonary congestion or LVEF < 40% in the absence of hypotension or contraindication Because of the increased risk of mortality, reinfarction, HTN, CHF, and myocardial rupture NSAIDS except for ASA should be discontinued at presentation Class II indications: It is reasonable to admin O2 to all UA/NSTEMI pts in first 6 hours. IIa Morphine (1-5 mg IV) remains Class I for STEMI although may increase adverse events in UA/NSTEMI1,2 It is reasonable to administer morphine sulfate IV if the is uncontrolled ischemic CP despite NTG. IIa Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367. Meine T el al. Am Heart J 2005;149:1043- 9

Early Hospital Care 2011 Focused update Antiplatelet therapy ASA should be administered to USA/NSTEMI as soon as possible after hospital presentation and continued indefinitely (LOE A) Clopidogrel (loading dose followed by maintenance dose) should be administered to USA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance (LOE B) Ongoing clinical trials are evaluating if genotype assessment prior to starting clopidogrel will improve clinical outcomes Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Early Hospital Care 2011 Focused update Antiplatelet therapy Pt with definite USA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual-antiplatelet therapy on presentation (LOE A) ASA on presentation The second should be given before PCI as follows….. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Early Hospital Care 2011 Focused update Antiplatelet therapy Before PCI: Clopidogrel LOE B An IV GP IIb/IIIa inhibitor (LOE A) eptifibatide or tirofiban are the preferred agents At the time of PCI: Clopidogrel if not started before PCI LOE A Prasugrel LOE B An IV GP IIb/IIIa inhibitor LOE A Abciximab should not be used in patients who not planned for PCI Prasugrel contraindicated in patient who >75 years of age, prior stroke/TIA, body weight of <60 kg Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update Antiplatelet therapy For USA/NSTEMI patients in whom an initial conservative strategy is selected clopidogrel (loading dose followed by maintenance dose) should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month and ideally up to 1 year If recurrent sx continue then a third agent can be added if needed Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Loading Doses of Thienopyridine prior to PCI Clopidogrel 300-600mg as early as possible before the time of PCI (LOE A) Prasugrel 60mg should be given promptly and no later than 1 hour after PCI, Once coronary anatomy is defined and a decision is made to proceed with PCI (LOE B) Can add prasugrel early if risk of bleeding is low and need for CABG is low Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update Antiplatelet therapy For USA/NSTEMI patients in whom an initial conservative strategy is selected if recurrent symptoms/ischemia, CHF, or serious arrhythmias subsequently appear, then diagnostic angiography should be preformed Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update Antiplatelet therapy For patients with USA/NSTEMI treated conservatively without recurrent symptoms, CHF or arrhythmia a stress test should be performed If the pt is not classified as low risk after the stress test then angiography should be performed Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update If at low risk Post Stress Test: Continue ASA Continue clopidogrel for at least 1 month and ideally up to 1 year Discontinue GP Iib/IIIa inhibitor if started Continue UFH for 48 hours or administer enoxaparin or fondaparinux for the duration of hospitalization up to 8 days and then discontinue Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update For patients with USA/NSTEMI in whom CABG is selected post angiography Continue ASA Discontinue IV GP Iib/IIIa inhibitor 4 hours before CABG Continue UFH Discontinue enoxaparin 12-24 hours before CABG and dose with UFH per institution practice Discontinue fondaparinux 24 hours before CABG and dose with UFH per institution practice Discontinue bivalirudin 3 hours before CABG and dose with UFH per institution practice Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Hospital Care 2011 Focused update In patients taking thienopyridine in whom CABG is planned and can be delayed… Discontinue clopidogrel for at least 5 days Discontinue prasugrel for at least 7 days Unless the need for revascularization and or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding… LOE C Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

ACC/AHA Guidelines update 2011 UA/NSTEMI: Long-Term Medical Management UA or NSTEMI at hospital discharge Inhospital management with medical therapy (without stenting) Inhospital therapy with bare-metal stent implantation Inhospital therapy with drug-eluting stent implantation Aspirina 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d for at least 1 mo, ideally up to 1 yr Aspirina 162-325 mg/d for at least 1 mo, then 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d or prasugrel 10 mg/d for at least12 months* Aspirina 162-325 mg/d for at least 3 mo with Sirolimus and 6 mo paclitaxel, then 75-162 mg/d indefinitely plus clopidogrelb 75 mg/d or prasugrel 10 mg/d for at least 12 mo Is an indication for anticoagulation present? If yes: add warfarinc,d If no: continue dual antiplatelet therapy Dipyridamole is not recommended in post USA/NSTEMI pt because it has not been shown to be effective. aIf patient is allergic to aspirin, use clopidogrel alone (indefinitely) or try aspirin desensitization. cContinue aspirin indefinitely and warfarin long term, if indicated for specific conditions. dIf warfarin is added to aspirin and clopidogrel, the recommended INR is 2.0-2.5. bIf patient is allergic to clopidogrel, use ticlodipine 250 mg PO bid. Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Evaluating Recurrent Risk Secondary Prevention Strategies Broad Goals during Hospital discharge phase Prepare the patient for normal activities Use the acute event as an opportunity to reevaluate the plan of care - lifestyle and risk factor modification The acute phase of UA?NSTEMI is usually over within 2 months Heart Disease and Stroke Statistics 2011Circulation. 2011;123:e18-e209

Reperfusion is the Issue but once stabilized….. ASA Anti-platelet Therapy Cholesterol goal Blood Pressure goal Beta-Blockers, RAAS Blockers (ACE, ARB, Aldosterone) Discharged with sublingual NTG and instructed in its use Diabetes management: HbA1c < 7% Warfarin for Afib/flutter or LV thrombus or other indication Daily physical activity 30 min 7 d/wk, minimum 5 d/wk Ask, advise, assess, and assist patients to stop smoking Cardiac Rehabilitation recommended esp. for those with mult. Risk factors or mod/high risk Annual influenza immunization Wright RS et al. J Am Coll Cardio 2011; 57;e215-e367

Secondary Prevention and Long Term Management Goals Class I Recommendations Physical activity: 2007 Goal: 30 min 7 d per wk; minimum 5 d per wk For all patients, it is recommended that risk be assessed with a physical activity history and/or an exercise test to guide prescription. For all patients, encouraging 30 to 60 min of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). Advising medical supervised programs (cardiac rehabilitation) for high-risk patients (e.g., recent acute coronary syndrome or revascularization, HF) is recommended. Encouraging resistance training 2 d per week may be reasonable (Class IIb; LOE: C) In stable patient sexual activity can cont within 7-10 days after ACS Driving 7 days post d/c in stable pt’s In complicated cases driving 2-3 weeks after sx resolved Air travel should be avoided for 2 weeks after an AMI and only if no angina, dyspnea, or hypoxia at rest. Flies with companion and has NTG