©2012 national heart foundation of australia management of acute coronary syndromes (acs) this...

©2012 National Heart Foundation of Australia

Management of acute coronary syndromes (ACS)

This presentation reflects the recommendations in the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand’s Guidelines for the Management of Acute Coronary Syndromes (ACS) (2006), updated in the 2007 and 2011 addenda. The presentation is designed for use in health professional development and training on acute ACS care.


Outline• Cardiovascular disease (CVD) – the facts and risk factors• Acute coronary syndromes (ACS)

• Presentation of ACS

ACS management: summary of updates in the 2011 addendum1

1. Systems of care

2. Investigations

3. Management of patients with ST-segment elevation myocardial infarction (STEMI)

4. Management of patients with non-ST-segment elevation ACS (NSTEACS)

5. Long-term management

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand

guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.


CVD – the facts• Heart disease is the single leading

cause of death.

• In 2009, 28 Australians died from a heart attack each day. That’s one life claimed every 51 minutes.1

• CVD is expected to affect 1 in 4 Australians by 2051.2

References1. National Heart Foundation of Australia. Heart Attack Facts. Available from: http://www.heartattackfacts.org.au. Accessed 19 June 2012.2. National Heart Foundation of Australia. The shifting burden of cardiovascular disease, report prepared by Access Economics. Melbourne: National Heart Foundation of Australia, 2005.


Modifiable risk factors:• smoking

• poor diet

• high cholesterol

• physical inactivity

• high blood pressure

• being overweight

• depression, social isolation andlack of social support.

Non-modifiable risk factors:• gender

• age

• family history of CVD

• diabetes

• human immunodeficiency virus (HIV).

Risk factors for CVD


Acute coronary syndromes (ACS)• ACS is a broad spectrum of clinical presentations, spanning STEMI (heart attack)

through an accelerated pattern of angina without evidence of myonecrosis1/infarction (muscle death).

• Myocardial infarction (MI) occurs when the blood supply to the heart muscle is interrupted due to partial or complete occlusion (thrombus) of the coronary artery. As a result, some of the heart muscle becomes infarcted (dies).

• A heart attack can be confirmed by an electrocardiogram (ECG) test.

Reference1. Chew DP, Allan RM, Aroney CN, et al. National data elements for the clinical management of acute coronary syndromes. Med J Aust 2005; 182 (9 Suppl):S1–S14.


Thrombus formation in the arterial lumen


Acute presentation of ACS• Critical factors to timely

treatment:

recognition

time

• People experiencing ACS symptoms should seek help promptly and activate emergency services.

Heart attack


Signs and symptoms of ACS presentationSymptoms may include:

• chest discomfort (tightness, pressure, heaviness) at rest or for a prolonged period (> 10 minutes, not relieved by sublingual nitrates)

• recurrent chest discomfort

• discomfort associated with syncope/acute heart failure.

The pain may spread to other parts of the upper body, including:

• back, neck, jaw, arm(s), shoulder(s) or epigastric pain.

The person may also experience:

• dyspnoea (shortness of breath), diaphoresis (profuse perspiration), dizziness, nausea or vomiting

• recent research shows that women, the elderly and people with diabetes are less likely to experience chest pain as a symptom.


2011 addendum to 2006 GuidelinesThe 2011 addendum to the 2006 Guidelines provides updates to:1. Systems of care to support delivery of ACS services

2. Early response3. Management of patients with STEMI4. Management of patients with NSTEACS5. Long-term management (after control of myocardial ischaemia).1

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the

management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.


Formal systems of care:

• defined continuum of care – from presentation to long-term management

• system-based approaches to deliver timely reperfusion at a local level (Grade B)

• routine audit integrated into all clinical ACS services (Grade B)

• training GPs/health workers to initiate fibrinolysis (if primary percutaneous coronary intervention [PCI] services are not readily accessible)

• practitioners are supported by ready access to expert cardiology consultation (Consensus)

• cardiac clinical networks established with appropriate protocols (Grade B).

1. Systems of care to support delivery of ACS services

For example: iCCnet CHSA network links > 70 hospitals, health centres and general practitioner [GP] surgeries across SA, aligned to the Health Reform Agenda principles.


2. Early response: treatment is time critical Time from symptom onset and likely outcome

< 1 hourAborted heart attack or only little heart muscle damage

1–2 hoursMinor heart muscle damage only

2–4 hoursSome heart muscle damage with moderate heart muscle salvage

4–6 hoursSignificant heart muscle damage with only minor heart muscle salvage

6–12 hoursNo heart muscle salvage (permanent loss) with potential infarct

healing benefit

> 12 hoursReperfusion is not routinely recommended if the patient is

asymptomatic and haemodynamically stable

In cases of major delay to hospitalisation (> 30 minutes) ambulancecrews should consider pre-hospital fibrinolysis.


STEMI – what is it?

An ST-segment elevation myocardial infarction (STEMI) can be confirmed by an ECG.

STEMI is defined as presentation with clinical symptoms consistent with an ACS with ECG features including any of:

• persistent ST-segment elevation ≥ 1 mm in two contiguous limb leads

• ST-segment elevation ≥ 2 mm in two contiguous chest leads

• new left bundle branch block (LBBB) pattern.


3. Management of patients with STEMI


Early response• Implement reperfusion strategy for patients presenting within 12 hours of

onset of ischaemic symptoms consistent with ACS (determined by physical examination):

immediate 12-lead ECG

insert cannulae

pain relief

blood tests.

• Give aspirin 150–300 mg (unless already given, or contraindicated).

• Doctor sees patient within 10 minutes of arrival (Australasian Triage ScaleCategory 2).

• Oxygen therapy indicated only for patients with hypoxia (oxygen saturation < 93%) and those with evidence of shock (Consensus).


Choice of reperfusion therapy• In general, PCI is the treatment of choice, providing it can be performed promptly by

a qualified interventional cardiologist in an appropriate facility.1

• All PCI facilities should be able to perform primary angioplasty within 90 minutes of patient presentation.

• Fibrinolysis should be considered early if PCI is not readily available.

• In cases of major delay to hospitalisation (> 30 minutes) consider pre-hospital fibrinolysis.

Reference1. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184(8 Suppl):S9–29.


PCI cardiac catheterThe catheter can be inserted via the radial or femoral artery (insertion via the femoral artery

illustrated below).


PCI – how it works


Primary PCI – technique and antithrombotic therapy• Among patients with STEMI undergoing primary PCI the use of bivalirudin can be

considered as an alternative to heparin and GP IIb/IIIa inhibitors (Grade B).1

• Among patients undergoing primary PCI for reperfusion, consider antiplatelet therapy with either:

high-dose clopidogrel (600 mg oral bolus + 150 mg daily for 7 days, then 75 mg/day for at least 12 months) (Grade B)

prasugrel (60 mg oral bolus + 10 mg daily) (Grade B)

ticagrelor (180 mg oral bolus + 90 mg twice daily) (Grade B).1

• Careful assessment of bleeding risk should be undertaken before using antithrombotic agents (Grade B).1

• Consider use of mechanical thrombectomy techniques to reduce thrombus burden during primary PCI (Grade A).1

Reference1. Chew DP, Aroney CN, Aylward PE, et al. 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for

the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20(8):487–502.


Bleeding risk

• age > 75 years • female• history of bleeding• history of stroke or transient ischaemic attack (TIA) • creatinine clearance rate < 60 mL/min • diabetes• heart failure • tachycardia• blood pressure < 120 mmHg or ≥ 180 mmHg • peripheral vascular disease (PVD) • anaemia • concomitant use of GP IIb/IIIa inhibitor • enoxaparin 48 hours prior • switching between unfractionated heparin and enoxaparin • procedural factors (femoral access, prolonged, intra-aortic balloon pump, right heart

catheterisation).

The following risk factors should be considered when assessing bleeding risk and choosing antithrombotic therapies in patients with ACS (Grade B):


Fibrinolysis

Fibrinolysis is the administration of a pharmacologic agent to break down blood clots in the coronary vessels to restore blood flow to the heart muscle.1

• Consider early routine revascularisation of patients receiving fibrinolysis, regardless of success of pharmacologic reperfusion (Grade A).

Absolute contraindications

• Active bleeding or bleeding diathesis (excluding menses).

• Significant closed head or facial trauma within 3 months.

• Suspected aortic dissection.

• Any prior intracranial haemorrhage.

• Ischaemic stroke within 3 months.

• Known structural cerebral vascular lesion.

• Known malignant intracranial neoplasm.

Reference1. Dugdale DC , Chen Y-B, Zieve D, et al. Fibrinolysis – primary or secondary fibrinolysis. Available from: http://www.nlm.nih.gov/medlineplus/ency/article/000577.htm.

Accessed 7 August 2011.


Fibrinolysis

Relative contraindications

• Current use of anticoagulants.

• Non-compressible vascular punctures.

• Recent major surgery (< 3 weeks).

• Traumatic or prolonged (> 10 mins) CPR.

• Recent internal bleeding (within 4 weeks).

• Active peptic ulcer.

• History of chronic, severe, poorly controlled hypertension.

• Severe uncontrolled hypertension on presentation (systolic ≥ 180 mmHg or diastolic ≥ 110 mmHg).

• Ischaemic stroke > 3 months ago, dementia or known intracranial abnormality.

• Pregnancy.


NSTEACS – what is it?

• Non-ST-elevation ACS (NSTEACS) applies to patients with suspected ACS in the absence of other plausible causes of troponin elevation (e.g. sepsis, pulmonary embolus).

• On physical examination, patients with NSTEACS may have a ‘normal’ ECG reading, or show minor changes (occurs in up to 50% of patients).

• All patients with NSTEACS should have their risk stratified to direct management decisions.

• The management of patients with NSTEACS requires evolving risk stratification: clinical assessment, assessment of cardiac biomarkers and time.


4. Management of patients with NSTEACS

.

• Clinical assessment: careful clinical history, ECG, chest X-ray and investigations to diagnose other causes of chest pain and evaluate the likelihood of evolving ACS.

• Troponin assessment: to assess the likelihood of MI.

• Stratify risk.


Evolving risk stratification

Admit to coronary care unit or high dependency unit:

• estimate ischaemic risk, estimate bleeding risk, choose augmented antithrombotic therapy

→refer for angiography to determine surgery/PCI, or medical therapy.



Intermediate-risk NSTEACS

Recurrent ischaemia or elevated troponin?YES

• admit to CCU or high dependency unit:

estimate ischaemic risk, estimate bleeding risk, choose augmented antithrombotic therapy

→ refer for angiography to determine surgery/PCI, or medical therapy.

NO

• undertake stress test (e.g. exercise ECG):

→positive – refer for angiography to determine surgery/PCI, or medical therapy

→negative – proceed to discharge patient with urgent cardiac follow-up (on upgraded medical therapy) according to long-term management after control of myocardial ischaemia.



Appropriate period of observation. Consider if stress test (e.g. exercise ECG) needed?

Stress test (e.g. exercise ECG) using treadmill.

YES

Proceed to discharge patient with urgent cardiac follow-up (on upgraded medical therapy) according to long-term management after control of myocardial ischaemia.

NO


Antithrombotic therapy for NSTEACS

• For high-risk patients with NSTEACS, assess bleeding risk individually according to the number and severity of bleeding risk factors (Grade A).

• Assign a management strategy according to bleeding risk.

• For patients at high risk of bleeding, use a ‘priority low-bleeding’strategy.Antithrombotic agents with lower bleeding risk include:

clopidogrel in preference to prasugrel (Grade B)

fondaparinux in preference to enoxaparin (Grade B)

bivalirudin in preference to enoxaparin (Grade B).

• For patients at low risk of bleeding, use a ‘standard’ effective antiplatelet regimen (prasugrel and ticagrelor) (Grade A). (cont.)


Antithrombotic therapy for NSTEACS

• Minimise the number of agents used (Grade B).

• When additional agents are needed, substitute rather than add (Grade B).

• Consider shorter-acting or reversible agents (Grade B).

• Avoid using GP IIb/IIIa inhibitors, where possible (Grade B).


5. Long-term management Before discharging a patient:

• discharge medication regimen

• provide tailored lifestyle advice to reduce risk of further events, including:

smoking cessation

good nutrition and moderate alcohol intake

physically active lifestyle and weight management as relevant

managing depression

warning signs of a heart attack.

• Refer all patients to comprehensive cardiac rehabilitation programs.

• Provide all patients with a written action plan for chest pain, which can be downloaded from www.heartfoundation.org.au

http://www.heartfoundation.org.au/


Medication regimen

• Continued antiplatelet therapies for 12 months for all patients with stents (Grade A).

In addition:

• aspirin

• beta-blockers

• ACE inhibitors

• statins

• warfarin

• nitrates

• insulin/oral hypoglycaemics

• aldosterone antagonists.


Concluding remarks

• This presentation is designed to ensure consistency of information regarding best practice ACS management, based upon the 2011 addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006.

• Understandings of the pathophysiology of ACS have improved, together with increasingly accurate diagnostic tools, better risk stratification and improved medical and invasive treatments. However, these advances have led to an increase in the complexity of possible treatment strategies. This is evolving.

• For more information please visit www.heartfoundation.org.au.

© 2012 National Heart Foundation of Australia ABN 98 008 419 761

Disclaimer: This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The statements and recommendations it contains are, unless labelled as ‘expert opinion’, based on independent review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the Heart Foundation and its employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness. The information is obtained and developed from a variety of sources including, but not limited to, collaborations with third parties and information provided by third parties under licence. It is not an endorsement of any organisation, product or service. This material may be found in third parties’ programs or materials (including, but not limited to, show bags or advertising kits). This does not imply an endorsement or recommendation by the National Heart Foundation of Australia for such third parties’ organisations, products or services, including their materials or information. Any use of National Heart Foundation of Australia materials or information by another person or organisation is at the user's own risk. The entire contents of this material are subject to copyright protection.




©2012 national heart foundation of australia management of acute coronary syndromes (acs) this...

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