Acute coronary syndrome Jiří Pařenica Coronary Care Unit Internal and Cardiology Department University Hospital Brno bohunice Detail fotografie Signs Working diagnosis ECG Troponin Diagnosis Chest pain (Dyspnoe, Cardiac arrest) Acute Coronary Syndrome ST/T abnormalities or normal ECG Persistent ST-elevation, LBBB negativ positiv Unstable AP NSTEMI STEMI Fourth Universal Definition of MI * Myocardial injury – evidence of elevated cardiac troponin. The injury is considered acute if there is a rise and/or fall cTn values. * Acute myocardial infarction (MI) - myocardial injury with clinical evidence of acute myocardial ischemia. - Symptoms of ischemia. -New significant ST-segment–T wave (ST–T) changes or LBBB, Q-waves -New regional wall motion abnormality. -Identification of an intracoronary thrombus * Type 1 MI – evidence of athero-trombosis Fourth Universal Definition of MI - e.g. coronary endothelial dysfunction, coronary artery spasm, coronary artery disease without evidence of trombosis, coronary embolism, coronary artery dissection, tachy-/brady-arrhythmias, anaemia, respiratory failure, hypotension, septic shock, and hypertension with or without LVH. Type 2 MI - secondary to an ischaemic imbalance (other than athero-trombosis) between myocardial oxygen supply and/or demand. logomuni MI type 2 - vasospasm Fourth Universal Definition of MI Type 3: Myocardial infarction resulting in death when biomarker values are unavailable Cardiac death with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes or new LBBB, but death occurring before blood samples could be obtained or before cardiac biomarker could rise. Type 4a: Myocardial infarction related to percutaneous coronary intervention (PCI) Type 4b: MI related to stent thrombosis Type 5: MI related to CABG logomuni Other causes of myocardial injury - elevated troponin Cardiac conditions Heart failure Myocarditis, Cardiomyopathy, Takotsubo syndrom Coronary revascularization procedure and other procedure, ablation, defibrilator shocks, cardiac contusion, surgery, ablation Systemic conditions Sepsis, infectious disease Chronic kidney disease Stroke, subarchnoid haemorrhage Pulmonary embolism, pulmonary hypertension Infiltrative disease, e.g. Amyloidosis, sarcoidosis Chemoterapeutic cardiotoxic agents, e.g. anthracyclines, herceptin Strenuous exercise Initial diagnosis of STEMI * Clinical symptoms - chest pain lasting 10 min and more, malignant arrhythmia, atypical chest pain, dyspnoe * ECG – ST elevation at 2 or more leads at least 0,1 mV, (presumed) new LBBB lasting > 20min, repeated ECG recording often needed * 2-D echocardiography to rule out major acute myocardial ischemia and other causes of chest pain/discomfort * Coronary angiography * Biomarkers - troponin logomuni Diagnosis of STEMI Obrázek 4 STEMI anterior wall STEMI anterior wall + RBBB STEMI inferior wall logomuni Diagnosis of STEMI - LBBB Criteria can be used to improve the diagnostic accuracy of STEMI in LBBB -Discordant ST-segment elevation > 5mm in leads with a negativ QRS -Concordant ST-segment elevation >1mm in leads with a positive QRS -Concordant ST segment depresion > 1 mm in V1-3 Consider acute echocardiography (regional akinesis) logomuni True posterior infarction - Rcx * Lasting chest pain without significant ST elevation!! * Rs V1,2 * ST segment elevation V7-V9 > 0,05 mV * ST segment depression V1-4 > 0,05 mV * Non-significant elevation ST II, III, AVF * Ischemia in Rcx can lead to acute Mi insufficiency * sejmout0001.jpg sejmout0003.jpg Ischaemia due to left main or MVD * ST depresion > 1 mm in 8 or more leads, coupled with STE in aVR and/or V1 * Severe anaemia!! logomuni Atypical ECG presentation that deserve prompt management in patients with signs and symptoms of ischemia * Ventricular paced rhytm * During RV pacing, the ECG also shows LBBB, you can aplly rules for LBBB criteria of MI * Patiens without diagnostic ST-segment elevation but with persistent ischaemic symptoms logomuni Pre-hospital Management of STEMI * Pre-hospital mortality – sudden death 10-20%? * Preinfarction unstable AP – 50% of STEMI * First medical contact (FMC) - working diagnosis of STEMI must be done by staff of emergency ambulance - based on ECG (lifenet is helpfull) and chest pain * FMC – 12-lead ECG must be obtained within 10min * Primary transport to PCI-center (max. 90 min) logomuni ESC_AMI-STEMI_2017_for TF_18-08-17-V2final_JPG some slides 200817 - Copy0021.jpg ESC_AMI-STEMI_2017_for TF_18-08-17-V2final_JPG some slides 200817 - Copy0022.jpg Fibrinolytic therapy * In STEMI patients with early presentation < 3 h and an expected time ECG- PCI >2 h * If primary PCI cannot be performed timely after STEMI diagnosis, fibrinolytic therapy is indicated within 12 hours of symptom onset * A fibrin-specific agent (alteplase 15 mg iv. bolus, 50 mg/30 min, 35 mg/60 min), reteplase, tenecteplase * Co-therapy – aspirin + clopidogrel * Heparin 60 IU/kg iv bolus and infusion 12 IU/kg (aPTT 50-70 s) or Enoxaparin i.v. * Coronary angiography 2-24 hours after fibrinolytic treatment * Rescue PCI – after failed fibrinolysis * Contra-indication to fibrinolytic therapy * Previous intracranial haemorrhage or stroke of unknown origin * Ischaemic stroke in the preceding 6 M * Central nervous system damage, neoplasm, arteriovenous malformation * Recent major trauma/surgery/head injury (within month) * Gastrointestinal bleeding within month * Known bleeding disorder * Aortic dissection * Non-compressible punctures in the past 24 hours •Relative CI – TIA 6M, oral anticoagulant therapy, pregnancy or 1 week postpartum, refractory hypertension (SBD>180 mmHg), active peptic ulcer, advanced liver disease, prolonged/traumatic resuscitation. Pre-hospital treatment * Relieve pain and anxiety (Fentanyl 2 ml i.v., morphin 2-8 mg i.v., Diazepam 5-10 mg i.v.) * Antithrombotic therapy * ASA 250-500 mg i.v. bolus (150-300 mg soluble -no enteric-coated forms) * Heparin 100 IU/kg (enoxaparin 0,5 mg/kg iv bolus) * Bivalirudin i.v. * Beta-blockers Metoprolol 2-5 mg i.v. only in Killip I without bradycardia or hypotension Pre-hospital treatment of acute heart failure * 02 (2-4 L/min) by mask only in patients with hypoxaemia (SaO2<90% or PaO2<60mmHg) * Diuretics (Furosemide 40-80 mg – cave hypovolemia) * Nitrates (if no hypotension) * Opioids (Fentanyl 2 ml i.v., morphin 2-8 mg i.v) to relieve pain * Invasive pulmonary ventilation (Killip III-IV) should be considered early * * * In a patient with inferior STEMI and proximal occlusion of RCA * Diagnosis – ST-segment elevation in V4R * Right ventricular infarction may be suspected by hypontension, clear lung fields, raised jugular venous pressure * Echocardiography may confirm the diagnosis * Often complicated by AF – should be corrected * Primary PCI may result in haemodynamic improvement * Therapy 1000-2000 ml of fluids during first hours, then 100-200 ml/h until hemodynamic stabilization (PCWP 15-18 mmHg) with carefull heamodynamic monitoring – cave HF * Noradrenaline could be considered * Cave nitrates, diuretics, ACEI/ARB Right ventricular infarction Antiplatelet therapy * ASA 75-100 mg long term * Prasugrel 60mg/10mg (CI after stroke, > 75 y) * Ticagrelor 180/90 BID * Clopidogrel 600 mg/75 mg * (6-) 12 month * LWMH (enoxaparin 24 h after PCI, then only as thromboembolic prophylaxis as needed) * Oral anticoagulation INR 2-3 in patients who do not tolerate aspirin/clopidogrel/Ticagrelor/ Prasugrel Medical treatment after MI * BB (early use with the aim of HR 60-70/min and BPs 120 mmHg, in patients with HF – carvedilol, metoprolol, bisoprolol) * Statins – early use since the first day (LDL < 1.4 mmol/l) * ACEI – should be started in the first 24 h * ARB – in patients, who do not tolerate ACEI * Spironolactone, eplerenone – EF LV≤ 40% * Smoking cessation * Physical activity – moderate intensity aerobic exercise at least 4 times a week * Diabetes management – HbA1C < 6,5% * Weight reduction (BMI ≤ 30 kg/m2) * BP control - 130/80 * Lipid control - LDL< 1,4 mmol/l * Management of HF or LV dysfunction – medical treatment; CRT in patients with < 35%, LVDd >55 mm and QRS>120ms who remain in NYHA III-IV in spite of optimal medical therapy * Prevention of sudden death • ICD if EV≤35% and NYHA II-II at least 40 days after MI Long term management of specific coronary risk factors and LV dysfunction •ACS 20-40% •Aortic dissection, aneurysma •Pulmonary embolism 5% •Pericarditis, myocarditis, Tako-tsubo •Anemia •Pleuritis •Pneumothorax •Herpes zoster •Ulcus ventriculi, pancreatitis •Reflux esophagitis •Neurasthenia 5-10% •Vertebrogenic pain 14-43% •Tietze syndrome NSTEMI -Differential diagnosis of chest pain Algorithm rule-out/rule-in at 0-1 h (hs-cTnT) * ˃ 3 hours after onset of chestpain Further testing at 3-6 h, when is ACS suspected and first 2 samples are negative Boeddinghaus J et al., Clinical Chemistry 2018 Acute Chest Pain 0h<12 ng/l 0h<5 ng/l* or and ∆0-1h<3 ng/l Other 0h ≥ 52 ng/l or ∆0-1h ≥ 5 ng/l Rule-out Observe Rule-in Risk of MI 0–1 % Risk of MI 11 % Risk of MI 73 % logomuni Prognosis Reichlin, Mueller et al, CMAJ, 2015 May 19; 187(8): E243–E252 Cardiac magnetic resonance imaging NSTEMI – recommendation for invasive evaluation •Urgent < 2h – with refractory angina, AHF, life-threatening ventricular arrhythmias or hemodynamic instability, RBBB •An early invasive strategy < 24h is recommended in patients with a GRACE score >140, T-wave dynamic changes •An invasive strategy (within 72h) in all patients with recurrent symptoms or with high-risk criterion segment with at least one primary high risk criterion (DM, renal insufficiency, EF< 40%, early post infarction AP, recent PCI, prior CABG, intermediate to high GRACE risk score) Acute heart failure Killip Definition 30D and 12M mortality I (without HF) Without pulmonary congestion 2,8 % a 6,9 % II (mild HF) Rales < 50% of lung and/or gallop 10,9 % a 20,1 % III (pulmonary oedema) Rales ≥ 50% of lung 20,6 % a 41,3 % IV (cardiogenic shock) Hypotension, tissue hypoperfusion, anuria 38,0 % a 62,4 % * The stage in which profound reduction of effective tissue perfusion leads first to reversible, and then if prolonged, to irreversible cellular injury * Persistent (>30 min) hypotension with systolic BP bellow 80-90 mmHg (in normotensive patient) and a mostly marked reduction of cardiac index (<1,8 L/min/m2) in face of elevated left ventricular filling pressure (PCWP > 18 mmHg) or need of vasopressors to achieve BPs >90 mmHg because of HF. * Evidence of organ hypoperfusion – oliguria (bellow 20 ml/h), peripheral hypoperfusion (mottled, wet and cool skin), encephalopathy (confusion), acidosis. * * Cardiogenic shock- Killip IV • * 1. Severe left ventricle dysfunction (EF 20%) – usually involves left main or left anterior descending obstruction or 3VD, low cardiac output, compensatory systemic vasoconstriction * 2. Moderately severe depression of LV function of 30% and SIRS (systemic inflammatory response syndrome – fever, elevated white blood cell count, CRP, low SVR) * 3. Mechanical causes of heart failure (free wall rupture, rupture of IVS, rupture of papillary muscle) * 4. Right ventricle MI and CS * 5. Iatrogenic (hypovolemia, BB) • Cardiogenic Shock – ACS * Invasive pulmonary ventilation according to state and blood gases * Inotropic agents + vasopressors (dobutamin 5-20 ug/kg/min+ NA 0,5-30 ug/min, levosimendan, adrenaline cont., vasopresin, terlipresine) * Hypotension – consider i.v. fluids 250-500 ml or more to achieve PCWP 18-20 mmHg * IABC (in hemodynamic unstable patients despite optimal farmacologic treatment and mechanical complication, no routine use is recommended), ECMO, LVAD * Emergent revascularization by primary PCI or CABG * Pulmonary artery catheter (CO, PCWP, VR, +/- RVEF, oximetry of pulmonary venous blood – 60-65%) Cardiogenic shock - management Thank you for your attention srdce5