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

2. Nothing to report regarding conflicts of interest
Sponsored by VAPAA

3. 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 ++)

4. 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

5. 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
Antman EM, NEJM 1996;335:1342

6. 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 -

14. Myocardial Infarction
Anastomoses / Collateral Circulation

15. Angina Pectoris

16. Arterial Plaque

17. Coronary Atherosclerosis

18. Blockage Treatment

19. ISIS–2 INTERNATIONAL INFARCT STUDY OF INFARCT SURVIVAL CARDIOVASCULAR MORTALITY AT 4 WEEKS
TREATMENT MORTALITY %
Streptokinase
Aspirin
Aspirin + Streptokinase
Placebo

20. Andreas Gruentzig, M.D.
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

21. 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)

22. 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.”

23. 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).”

24. 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

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

27. 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).”

28. 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

29. 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
Between hours 6 and
Between hours 12 and <

30. 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

31. 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

32. 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)

33. 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

34. 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

35. 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.

36. 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.

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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