“ 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.

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Page 1: “ 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.

“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.

Page 2: “ 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.

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)

Page 3: “ 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.
Page 4: “ 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.

Acute Coronary Syndromes

Can also be divided into:

STEMI

UA

NSTEMI

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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.

Page 6: “ 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.

ST-Elevation Myocardial Infarction (STEMI)

Pre-hospital Management

Initial Management in the ER

Reperfusion Therapy

Initial Adjunctive Treatments

Risk Stratification after MI

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Pre-hospital Management

Time is myocardium, regardless of the strategy to reperfusion.

Prompt reperfusion: limits myocardial necrosisPreserves LV functionReduces mortality

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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

Page 9: “ 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.

Initial Management in the ER

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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

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Selecting Optimal Reperfusion Rx for Pts with STEMI

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Page 13: “ 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.

Reperfusion Therapy

Success depends on time to therapy

＜ 30 minutes for thrombolytic rx ＞ ＜ 90 minutes for primary PCI

Both are effective for achieving reperfusion

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PCI in STEMI

If it can be done rapidly, less risk of recurrent MI

Stents better than POBA: ＜ restenosis, better success rates

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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

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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.

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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

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Risk Stratification after MI

Ischemic Risk

LV Function

Arrhythmic Substrate

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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

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LV Function

LV function and Valvular disease usually assessed with echocardiography

Myocardial stunning may persist for 2 weeks

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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

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Page 23: “ 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.

Unstable Angina and Non--ST-Segment Elevation MI

UA and NSTEMI

Page 24: “ 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.
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UA and NSTEMI

1.5 million patients annually admitted to hospitals in US

Many advances in last few years:Antiplatelet therapiesCholesterol loweringB-blockade

Page 26: “ 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.

ACC/AHA

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Overview of Guidelines

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Features with Higher Liklihood of ACS

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TIMI Risk Score for UA/NSTEMIPredicts Risk of Death, MI, or Recurrent

Ischemia

Page 30: “ 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.

Effects of Plavix Stratified by TIMI Risk Score at 12 Months

Page 31: “ 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.

Benefit of IIb/IIIa Inhibitors in UA/NSTEMI by Troponin

Page 32: “ 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.

Antiplatelet Treatment

Antiplatelet Therapy is the Cornerstone in the Management of UA/NSTEMI

Page 33: “ 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.

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.

Page 34: “ 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.

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

Page 35: “ 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.

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

Page 36: “ 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.

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

Page 37: “ 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.
Page 38: “ 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.
Page 39: “ 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.

Invasive vs Conservative Strategy

Especially in high risk pts (ST changes and Tp positive

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An early invasive strategy is cost-effective with a cost of $17,500 per life saved

Page 41: “ 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.
Page 42: “ 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.

Summary of Hospital Strategy

Page 43: “ 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.

Summary of Invasive Strategy

Page 44: “ 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.

Long Term Therapy

Page 45: “ 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.
Page 46: “ 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.
Page 47: “ 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.

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