ACUTE CORONARY SYNDROME DR CHEVAAN HENDRICKSE INTERVENTIONAL - - PowerPoint PPT Presentation

▶
acute coronary syndrome
SMART_READER_LITE
LIVE PREVIEW

ACUTE CORONARY SYNDROME DR CHEVAAN HENDRICKSE INTERVENTIONAL - - PowerPoint PPT Presentation

Jan 01, 2023 387 likes •1.23k views

ACUTE CORONARY SYNDROME DR CHEVAAN HENDRICKSE INTERVENTIONAL CARDIOLOGIST Conflicts of interest None ACUTE CORONARY SYNDROMES CHRONIC CORONARY SYNDROMES (2019) CASE STUDY 50 YEAR OLD Risk factors : Hypertension, Smoker Central,

slide-1
SLIDE 1

ACUTE CORONARY SYNDROME

DR CHEVAAN HENDRICKSE INTERVENTIONAL CARDIOLOGIST

slide-2
SLIDE 2

Conflicts of interest

None

slide-3
SLIDE 3

ACUTE CORONARY SYNDROMES

slide-4
SLIDE 4

CHRONIC CORONARY SYNDROMES (2019)

slide-5
SLIDE 5
slide-6
SLIDE 6

CASE STUDY

  • 50 YEAR OLD
  • Risk factors: Hypertension, Smoker
  • Central, dull chest pain when playing touch rugby. @ 15 min into the
  • game. Pain occurring more frequently. Other atypical pain syndromes.
  • Presentation via his GP with unstable angina
  • Reported to my rooms: Electrocardiogram within 10 min
slide-7
SLIDE 7

ELECTROCARDIOGRAM

slide-8
SLIDE 8

1. TROPONIN I < 30 ng/L repeat at 2 hours < 30 ng/ L 2. Mild dyslipidaemia: t chol 5.8, LDL 3.4, HDL 0.9, TG 0.75 3. Normal echocardiogram 4. Normal CXR

slide-9
SLIDE 9

Differential diagnosis

slide-10
SLIDE 10
slide-11
SLIDE 11

Unstable angina

  • 1. New onset angina over 2 months (central,

constricting, radiation)

  • 2. Accelerating tempo (crescendo) of symptoms over 48

hrs

  • 3. Resting angina (pain> 20 min)
  • 4. Nocturnal angina
  • 5. Post-infarct angina
  • 6. Post-intervention
slide-12
SLIDE 12

What should we do next?

  • 1. INVASIVE ANGIOGRAPHY ?
  • 2. EXERCISE STRESS TESTING ?
  • 3. STRESS ECHOCARDIOGRAPHY ?
  • 4. CT CORONARY ANGIOGRAPHY ?
  • 5. MYOCARDIAL PERFUSION STUDIES ?
  • 6. CARDIAC MRI ?
slide-13
SLIDE 13

TREATMENT FOR HEART FAILURE

slide-14
SLIDE 14
slide-15
SLIDE 15

Electrocardiogram

slide-16
SLIDE 16

Exercise stress test

slide-17
SLIDE 17

Invasive coronary angiography and percutaneous coronary intervention

slide-18
SLIDE 18

MYOCARDIAL INFARCTION

THEORETICAL CONCEPTS

slide-19
SLIDE 19
slide-20
SLIDE 20
  • 1. Myocardial infarction Type (Type 1-5)
  • 2. Myocardial infarction vs myocardial injury
  • 3. Troponin
  • 4. hs troponin
slide-21
SLIDE 21
slide-22
SLIDE 22
slide-23
SLIDE 23
slide-24
SLIDE 24
slide-25
SLIDE 25
slide-26
SLIDE 26
slide-27
SLIDE 27

Non ST elevation MI (NSTEMI) ST elevation MI (STEMI)

PRICIPLES OF MANAGEMENT

slide-28
SLIDE 28
slide-29
SLIDE 29

The greatest challenge is the integration of clinical presentation with information derived from ECG, troponin assessment and imaging modalities into a standardised management strategy

GRACE SCORE: Accurate stratification of risk both on admission and at discharge. (GRACE 2.0 risk calculator) > 120 TIMI risk score CRUSADE SCORE: HASBLED SCORE

BLEEDING RISK

slide-30
SLIDE 30
slide-31
SLIDE 31

RISK STRATIFICATION FOR UAP/NSTEMI

GRACE

  • AGE
  • HEART RATE
  • BLOOD PRESSURE
  • SERUM CREAT
  • KILLIP HF CLASS
  • CARDIAC ARREST
  • INITIAL ENZYMES
  • ST DEVIATION

TIMI

  • AGE</> 65
  • RISK FACTORS
  • >0.5 MM ST DEVIATION
  • CHEST PAIN<24 HRS AGO
  • POSITIVE BIOMARKER
  • USE OF ASPRIN IN LAST 7 DAYS
slide-32
SLIDE 32

IMMEDIATE INTERVENTION

slide-33
SLIDE 33

EARLY INTERVENTION WITHIN 24-28 HRS

slide-34
SLIDE 34

INTERVENTION WITHIN 72 HOURS

slide-35
SLIDE 35
slide-36
SLIDE 36

WHAT IS THE ROLE OF THE GENERAL PRACTITIONER ?

  • 1. DIAGNOSIS
  • 2. INITIAL RISK STRATIFICATION
  • 3. STABALIZATION
  • 4. INITIATION OF MEDICAL THERAPY
slide-37
SLIDE 37

ANTI-THROMBOTIC THERAPY

1) ANTIPLATELET AGENTS (DUAL ANTIPLATELET THERAPY) ASPRIN + P2Y12 INHBITOR 2) ANTICOAGULATION 3) INTRAVENOUS ANTIPLATELET THERAPY (ANTI-IIb/IIIa)

slide-38
SLIDE 38
slide-39
SLIDE 39

ANTIPLATELET TRIALS

slide-40
SLIDE 40
slide-41
SLIDE 41
slide-42
SLIDE 42
slide-43
SLIDE 43

DO NOT SWITCH ANTICOAGULATION BEFORE PCI Arixtra 2.5 mg SC daily FONDAPARINUX VS CLEXANE

OASIS-5 TRIAL

ANTICOAGULATIO N

slide-44
SLIDE 44
slide-45
SLIDE 45

CORONARY ANGIOGRAPHY

slide-46
SLIDE 46

PERCUTANEOUS CORONARY INTERVENTION

slide-47
SLIDE 47

WHAT ABOUT PATIENTS ON ORAL ANTICOAGULANTS ?

slide-48
SLIDE 48
slide-49
SLIDE 49

Suggested strategies to reduce bleeding risk related to PCI

1) RADIAL APPROACH 2) ADD A PROTON PUMP INHIBITOR

slide-50
SLIDE 50

EVIDENCE-BASEDPERFORMANCE MEASURES

slide-51
SLIDE 51

ST ELEVATION MYOCARDIAL INFARCTION

  • 1. ST-segment elevation 2.5mm in men < 40 years, in leads V2–

V3

  • 2. 2mm in men > 40 years in leads V2–V3
  • 3. 1.5mm in women in leads V2–V3
  • 4. 1mm in the other leads [in the absence of left ventricular (LV)

hypertrophy or left bundle branch block LBBB)].

slide-52
SLIDE 52
slide-53
SLIDE 53
slide-54
SLIDE 54
slide-55
SLIDE 55
slide-56
SLIDE 56
slide-57
SLIDE 57
slide-58
SLIDE 58
slide-59
SLIDE 59

ER MANAGEMENT (ACLS/ABC)

slide-60
SLIDE 60
slide-61
SLIDE 61
slide-62
SLIDE 62
slide-63
SLIDE 63

WHEN ANTICIPATING PRIMARY PCI

slide-64
SLIDE 64

IF NO PRIMARY PCI

slide-65
SLIDE 65
  • Discovered in 1930
  • 1945: VTE Rx
  • 1980’s: AMI
  • ISIS TRIALS
  • ASA RR 25%
  • STREP RR 25%
slide-66
SLIDE 66

FIBRINOLYTICS

tenecteplase tissue plasminogen activator (TNK-tPA) is equivalent to accelerated tPA in reducing 30 day mortality, but is safer in preventing non-cerebral bleeds and blood transfusion, and is easier to use in the pre-hospital setting

slide-67
SLIDE 67
  • 1. Tenecteplase tissue plasminogen activator (TNK-

tPA) is equivalent to accelerated tPA in reducing 30 day mortality,

  • 2. TNK is safer compared to TPA in preventing non-

cerebral bleeds and blood transfusion, and is easier to use in the pre-hospital setting

slide-68
SLIDE 68

ANTICOAGULANT CO-THERAPIES

slide-69
SLIDE 69

CONTRAINDICATIONS

slide-70
SLIDE 70

EARLY ANGIOGRAPHY AND PCI AFTER FIBRINOLYSIS

  • 1. PCI RECOMMENDED BETWEEN 2-24 HRS
slide-71
SLIDE 71

PERCUTANEOUS INTERVENTION

slide-72
SLIDE 72

ANTICIPATE AN ADMISSION FOR 48-72 HRS TO SCREEN FOR COMPLICATIONS

  • 1. MYOCARDIAL DYSFUNCTION AND CARDIAC FAILURE
  • 2. MECHANICAL COMPLICATIONS (FREE WALL RUPTURE,

PAPILLARY MUSCLE RUPTURE, VSD)

  • 3. ARRHYTHMIAS (VT, AF, VF)
  • 4. PERICARDITIS
slide-73
SLIDE 73

MYOCARDIAL INFARCTION WITH NON- OBSTRUCTED CORONARY ARTERIES

slide-74
SLIDE 74
slide-75
SLIDE 75

MEDICAL THERAPY

Dual Antiplatelet Therapy FOR 12 MONTHS

slide-76
SLIDE 76

STRATEGIES OF MEDICAL MANAGEMENT

slide-77
SLIDE 77
slide-78
SLIDE 78
slide-79
SLIDE 79
slide-80
SLIDE 80
slide-81
SLIDE 81

IN SUMMARY

  • 1. Have an institutional approach to chest pain
  • 2. Exclude other possible fatal causes
  • ACS and the differential diagnosis as discussed
  • 3. Electrocardiogram within 10m minutes of arrival
  • 4. Biomarkers and repeat at 3 hours to confirm or exclude a

rise/fall.

  • 5. If unsure, then pick up the phone and call
  • 6. If suspecting an ACS, commence AspIrin loading and

activate the ACS network

  • 7. STEMI: time is muscle. If no PCI Lysis
slide-82
SLIDE 82

References

  • Uptodate
  • ESC guidelines
  • ESC textbook of cardiovascular medicine 2019
  • NEJM
  • JACC
  • Brawnwald’s Cardiovascular disease: ninth edition
  • Personal experience (Life)
  • Google images