What’s the Updated Guidelines for ACS Management?

A Cardiologist perspective

Isman Firdaus, MD

FIHA, FAPSIC, FAsCC, FESC, FSCAI

National Cardiovascular Center, Harapan Kita Hospital

Departement of Cardiology and Vascular Medicine, University of Indonesia

Spectrum of Pathology and Clinical IHD

Stable angina NSTEMI STEMI

IHD= Ischaemic heart diseaseNSTEMI= Non ST segment elevation myocardial infarctionSTEMI= ST segment elevation acute myocardial infarctionACS= Acute coronary syndrome

ACS

Adapted from Morrow DA, et al. N Engl J Med 2017;376:2053-64.

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• Sebuah sumbatan di arteridapat menghalangi oksigenmenuju jaringan distal miokardium, hal ini disebutiskemia

• Iskemia dapat teratasi jika alirandarah dikembalikan, tetapi jikaiskemia tidak ditangani secaratepat, dapat menyebabkankerusakan maupun kematianjaringan (infark)

Apa Saja Akibat dari Pembentukan Trombus?

Sebuah trombus dapat menghambat aliran darah sepenuhnya

maupun sebagian, menyebabkan iskemia atau infark.

http://www.nlm.nih.gov/medlineplus/ency/article/001124.htm. Accessed 9/20/12.

Image: NIH3

Kematian otot jantungdi bawah aliranyang tersumbat

PLATELET Plays Important Role in Thrombus Formation

Schafer AL. Am j Med.1996;101(2):199-209

Jakarta Acute Coronary Syndrome Registry (JAC Registry)

• Single center registry

• National referral hospital

• 24/7 PCI capable hospital

• Interventional cardiologist and staff capable of arriving at the laboratory within 30 minute

• 9000 cathlab procedures

• 700 PPCI procedures

Percentage of patient diagnosed with ACS admitted to emergency room

8060

1499

(18,6%)

8306

1678

(20,2%)

8007

1882

(23,5%)

8661

2332

(30,4%)

9634

3402

10188

2832

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

Pa

tien

t

2005 2006 2007 2008 2009 2010

YearTotal patient admitted to ER Number of ACS patient

(35%)28%

Source: Jakarta Acute Coronary Syndrome Registry data base 2012, Emergency Unit NCCHK

ACS registry’s patient distribution

Consecutive ACS

N=2797

STEMI

N= 869 (31,1%)NSTEMI

N= 789 (28,2%)

Fibrinolytic

N= 96 (11%)

Primary PCI

N= 263 (30%)

No reperfusion

N= 510 (59%)

UAP

N= 1139 (40,7%)

Source: JAC registry data base 2010, NCCHK

(Dharma S, et al. Neth Heart J 2012;20: 254-259)

STEMI: description data (N=869)

Variabel Description

Location of STEMI, n (%)Anterior 530 (61,0)Non anterior 339 (39,0)

Killip class, n(%)I 598 (68,8)II 223 (25,7)III 25 (2,9)IV 18 (2,1)

Onset time, n(%)

< 12 hour 422 (49)> 12 hour 442 (51)

Door to needle (min) 39 (5 – 333)

Door to balloon (min) 91 (16-681)

Continous data were presented as median;minimal-maximal

(Dharma S, Firdaus I, et al. Neth Heart J 2012;20: 254-259)

Acute reperfusion therapy in STEMI

0

500

1000

1500

2000

2500

2002 2003 2004 2005 2006 2007 2008 2009 2010

PPCI

PCI

Year

N

Source: Jakarta Acute Coronary Syndrome Registry data base 2012, Emergency Unit NCCHK

In-hospital mortality

Percentage

(%)

PPCI Fibrinolytic No reperfusion

5,36,2

13,3

P<0.001

P<0.03

(Dharma S, et al. Neth Heart J 2012;20: 254-259)

Cath lab in ED pictures

Alarm center ED pictures with internet service ECG transmission

Source: www.google.co.id

Common cause of time delay in Jakarta

JAKARTA ACUTE CARDIOVASCULAR CARE

NETWORK SYSTEM

General Physician/ Hospital Call Ambulance

AmbulanceHotline

A PATIENT WITH CHEST PAIN

REPERFUSION

Heartline

Global STEMI & NCC-HK Meeting

Jakarta ACS Registry (2008-2010)

24 hours Call center –NCC Harapan Kita 2008

Low reperfusion rate: 41%

Late presenter (> 12 hours) : 53.1%

Inter-hospital Referral: 61%

Dharma S, Juzar DA, Firdaus I et al. Neth Heart J 2012;20: 254-259)

April 2014

West Jakarta Population: 2,260,825Area: 127.11 km2

• AMI Incidence Rate 222.3/100.000 per-year= 2.260.825/100.000 x 222,3 = 5026

•Approximately 5026 AMI case per-year

Preliminary Survey- Jakarta Area: 740.3 km2 /Population: 11 million (15.000/km2)

Ref: Singapore Myocardial Infarction Registry Report No.2, Trends in Acute Myocardial Infarction in Singapore 2007-2012

Estimated AMI in Jakarta 24,453 case per-year

EMS / SPGDT

NATIONAL HEALTH COVERAGE REIMBURSEMENT REIMBURSEMENT DEPEND ON CASE SEVERITY AND HOSPITAL LEVEL OF

SERVICES

Primary PCI

Reimbursement

(Procedure &

Admission)

National

Cardio-

vascular

Center

Type B

Private

Hospital

Minimum

Reimbursement

3,414

USD

2,555

USD

Maximum

Reimbursement

7,343

USD

3,476

USD

Permenkes 59/2014 on the Healthcare Standard Tariff, Universal Health Coverage/National Health Insurance (JKN)

Indonesia Case Based Groups (INA-CBGs), Social Security Management Agency (BPJS)

PCI: Percutaneous Coronary Intervention

Fibrinolysis

Reimbursement

(Procedure &

Hospitalization)

National

Cardio-

vascular

Center

Type B

Private

Hospital

Type C

Private

Hospital

Type D

Private

Hospital

Minimum

Reimbursement829 USD 481 USD

414

USD249 USD

Maximum

Reimbursement

1,629

USD

1,025

USD

644

USD493 USD

Streptokinase (drug only): 280 USD; Alteplase (drug only): 560 USD

Primary PCI Fibrinolytics

Case Number Cost (USD) Disease

UNIVERSAL HEALTH COVERAGE IN INDONESIANumber of Cases and Cost of Catastrophic Diseases:

Inpatient January-June 2014 (6 months)

Catastrophic Inpatient

735,827 case

232,010 134,821,667

172,303 55,600,810

138,779 55,600,810

70,584 23,232,524

56,033 23,192,193

53,948 12,951,916

12,170 5,277,811 18

Cardiac

Stroke

Kidney

Diabetes

Cancer

Thalassemia

Hemophilia

Main NCD

6 billion USD/year

Initial Assessment Suspected ACS

KMP : Fasilitas IKP

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

2018

LMD - Layanan Medis DaruratKMP – Kontak Medis PertamaIKP – Intervensi Koroner Perkutan

TIME and Myocardial Salvage

TIME IS MUSCLE

Timing and logistical factors influence choice of reperfusion strategy

• 1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3. Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation 2004;110:1909–1915; 6. Henriques JPS et al. J Am Coll Cardiol 2003;41:2138–2142

• PCI vs non-PCI capable hospitals1–3

• Dependence on operator expertise/volume3

• Availability of a 24/7 service1,3*

• Availability of a pre-hospital system for diagnosis and treatment3,4,5

• Patient ability to recognize symptoms1,2

•Mode of transportation to the hospital (self-presentation vs EMS)1,2

• Inter-hospital transfer challenges (distance, traffic patterns, climatic conditions etc)2,3

Time to reperfusion Healthcare resource

24

INITIAL TREATMENT

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

ASPIRIN

Loading

160 – 320mg

Ticagrelor

or

clopidogrel*

O2

NTG / ISDN

2018

M

O

N

A • 180 mg loading dose + 90 mg BID• 300 mg loading dose + 75 mg OD if

ticagrelor is not available or contraindicated

Morphine

sulfate iv

1-5 mg

• Can be repeated per 10 – 30 min, for patient who not responsive

• when SaO2 < 90% or PaO < 60

• If ongoing chest pain by the time admitted at ER

25

Adjunctive treatment in Primary PCI and Fibrinolytic Therapy

• Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

Primary PCI Fibrinolytic

Antiplatelet • Ticagrelor 180 mg + 90 mg BID• Clopidogrel 600 mg + 75 mg

OD if ticagrelor is not available or contraindicated

• Clopidogrel** If patient undergoing PCI after fibrinolytic may considered to switch to ticagrelor

Anticoagulant • UFH if patient can not received bivalirudin or enoxaparin

• Enoxaparin

• Enoxaparin sc• UFH iv• Fondaparinux bolus + sc for

24 hours - streptokinase

GPIIbIIIa Only for no reflow or thrombotic complication

2018

NSTEACS : Pathophysiology

Chang H, et al. Circ Cardiovasc Imaging2012;5:536-546.

NSTE-ACS patients have varying degrees of coronary obstruction, undergo more heterogeneous management, and have worse long-term

outcomes

NSTEACS Management strategy

27

Step 1. initial evaluation

Step 2. Diagnosis validation, risk assessment and rhythm monitoring

Step 3. invasive strategy

Step 5. hospital dischargeand post-discharge management

Step 4. revascularization modalities

Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

2018

1. ESC Guidelines NSTEACS 2015 ; 2. Pedoman Tatalaksana Sindroma Koroner Akut PERKI 2018

Initial Treatment in NSTEACS

Discharge Treatment in NSTEACS

P2Y12 inhibitors

Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054

Both groups included aspirin.

*NNT at one year.

No. at risk

Clopidogrel 9,291

9,333

Months After Randomization0 2 4 6 8 10 12

Wallentin L, et al. N Engl J Med. 2009;361:1045–1057.

8,521

8,628

8,362

8,460

8,124 6,650

6,743

5,096

5,161

4,047

4,1478,219

11.7 Clopidogrel

9.8 Ticagrelor

ARR=1.9%

RRR=16%

NNT=54*

P<0.001

HR: 0.84 (95% CI, 0.77–0.92)

0–12 Months

PLATO: Primary Efficacy Endpoint(Composite of CV Death, MI, or Stroke)

12

11

10

9

8

7

6

5

4

3

2

1

0

13

Cu

mu

lati

ve I

ncid

en

ce (

%)

Ticagrelor

Summary• Acute Coronary Syndrome: major cause of mortality

• STEMI – Reperfusion strategy ; NSTEACS – risk stratification

• High mortality of ACS patient treated non invasively vs invasive strategy

• Platelet plays important role in thrombus formation

• Dual antiplatelet treatment as standard care of ACS treatment has proven to improve patient CV outcomes

• Ticagrelor is preferred P2Y12 inhibitor in STEMI Primary PCI and NSTEACS management