“ if physicians would read two articles per day out of the six million medical articles published...
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“If physicians would read two articles per day out of the six million medical articles published annually, in one year, they would fall 82 centuries behind in their reading.”
Miser WF, Critical Appraisal of the Literature. J Am Board Fam Pract, 12(4):315-333, 1999.
Acute Coronary Syndromes
Coronary artery disease is the leading cause of death in the United States.
Acute Coronary Syndrome (ACS) includes any constellation of symptoms compatible with acute myocardial ischemia:
Acute MI (AMI) with ST-segment elevation and depression Q-wave and non-Q wave Unstable Angina (UA)
The implication of ACS is for early diagnosis for appropriate clinical management, and placement in an environment with continuous EKG and defibrillation capability, where an EKG can be obtained and immediately interpreted.
Priority is to identify patients with AMI to be considered for immediate reperfusion Rx, and recognize other potential catastrophic causes of sudden decompensation such as aortic dissection.
ST-Elevation Myocardial Infarction (STEMI)
Pre-hospital Management
Initial Management in the ER
Reperfusion Therapy
Initial Adjunctive Treatments
Risk Stratification after MI
Pre-hospital Management
Time is myocardium, regardless of the strategy to reperfusion.
Prompt reperfusion: limits myocardial necrosisPreserves LV functionReduces mortality
Pre-hospital Management
Most pts don’t seek care for 2 or more hours
Pts should promptly administer ASA
Dial 911
EMS should take pt to facility that can do PCI
16% reduction in mortality in pts given thrombolytic Rx before hospitalization
? Safety of Rx before correct dx & selection
Initial Management in the ER
STEMI Protocols in the ER result in rapid ID and RxInitial diagnostic tests:
EKGcontinuous monitoring of rhythm, HR & BP targeted Hx and PEstat blood for cardiac markers, heme, chemistry
clotting and lipidschest X-ray
Reperfusion Therapy
Success depends on time to therapy
< 30 minutes for thrombolytic rx > < 90 minutes for primary PCI
Both are effective for achieving reperfusion
PCI in STEMI
If it can be done rapidly, less risk of recurrent MI
Stents better than POBA: < restenosis, better success rates
PCI not AvailableOr Long Door to Balloon (DB) Time
Peripheral Hospital
> mortality if DB time is > 2 hours
If DB time > 1 hour, PCI is no better than fibrinolytic Rx
Initial Adjunctive Treatments
Platelet activation and aggregation are important in STEMI causing persistence of thrombotic occlusions and resistance to fibrinolytic Rx and risk of reocclusion.
Pathways leading to platelet activation and aggregation are thus targets of therapy.
Initial Adjunctive Treatments
ASA given to all (160 – 325mg)Plavix in pts allergic to ASAGlycoprotein IIb/IIIa inhibitors for all undergoing PCIThrombin Inhibitors (UFH or LMWH)O2
NTGIV B-blockersACE-IAnalgesia
Ischemic Risk
Identifying residual ischemia is to identify high-risk pts who will benefit from revascularization.
Post MI stress test – not necessary in pts who had PCI
LV Function
LV function and Valvular disease usually assessed with echocardiography
Myocardial stunning may persist for 2 weeks
Assessment of Risk for Arrhythmia
Important to assess risk or early or late arrhythmic deaths is important after STEMI
ICD implants in pts with low LVEF after MI reduces mortality
Accuracy of prediction is not good
UA and NSTEMI
1.5 million patients annually admitted to hospitals in US
Many advances in last few years:Antiplatelet therapiesCholesterol loweringB-blockade
Antiplatement Therapy
ASA reduces events by 50% to 70% compared with placebo. (160-325mg in hospital, 81mg at discharge).
Plavix (Clopidogrel) in patients who cannot take ASA.
Antiplatement Therapy
Clopidogrel is a class I recommendation in addition to ASA
CURE Trial Clopidogrel + ASA had 20% reduction of CV death, MI and stroke vs ASA alone in both high and low risk pts with UA/NSTEMI.
The benefits were seen at 2 hours and 1 year. 31% reduction in cardiac events at 1 and 12 months
Glycoprotein IIb/IIIa Inhibitors
Upstream Management with Integrilin (eptifibatide) shows clear benefit, Reopro (abciximab) none in pts treated conservativelyAciximab is strongly beneficial in pts undergoing PCIPts at high risk benefit from GP IIb/IIIa inhibitors
UFH and LMWH
All pts with US/NSTEMI
Incremental benefit over ASA alone
Lovenox (enoxaparin) (LMWH) superior to UFH in reducing recurrent cardiac events
Beware of pts with bleeding histories
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