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Unstable Angina and Non-ST elevation Myocardial Infarction. John Blair, MD. Unstable Angina / Non ST-Elevation Myocardial Infarction (UA/NSTEMI). Pathophysiology Diagnosis Initial Therapy Risk-Stratification Invasive vs Conservative Post AMI Care. UA / NSTEMI. Pathophysiology Diagnosis

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unstable angina non st elevation myocardial infarction ua nstemi
Unstable Angina / Non ST-Elevation Myocardial Infarction (UA/NSTEMI)
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
ua nstemi
UA / NSTEMI
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
sudden thrombus or thromboembolism
Sudden Thrombus or Thromboembolism

Superficial Erosion

Ruptured Fibrous Cap

Modified from Libby PCirc 104:365,2001

slide5

Hamm Lancet 358:1533,2001

Ischemic Discomfort

Presentation

Acute Coronary Syndrome

Working Dx

Davies MJ Heart 83:361, 2000

No ST Elevation

ST Elevation

ECG

NSTEMI

Biochem. Marker

Myocardial Infarction

Unstable Angina

NQMI

Qw MI

Final Dx

causes of ua nstemi
Causes of UA/NSTEMI
  • Thrombus or thromboembolism, usually arising on disrupted or eroded plaque – Most Common Cause.
  • Dynamic obstruction – coronary spasm or vasoconstriction
  • Progressive mechanical obstruction to coronary flow – ie restenosis after PCI
  • Coronary arterial inflammation
  • Coronary artery dissection
  • Secondary UA – Increasing oxygen demands in the setting of a fixed lesion.
acute coronary syndromes
Acute Coronary Syndromes
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
likelihood that signs and symptoms represent acs
Likelihood that Signs and Symptoms Represent ACS

Braunwald E, Mark DB, Jones RH NHLBI Unstable Angina 1994

algorithm for evaluation and management of patients suspected of having acs
Algorithm for Evaluation and Management of Patients Suspected of Having ACS

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

timing of release of various biomarkers after acute myocardial infarction
Timing of Release of Various Biomarkers After Acute Myocardial Infarction

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

acute coronary syndromes11
Acute Coronary Syndromes
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
treatment
Treatment
  • Increases oxygen supply to ischemic tissue
  • Start at 4L/min
  • Use caution in COPD patients
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
treatment13
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Blocks formation of thromboxane A2 and thus prevents platelet aggregation
  • Reduces mortality, reinfarction, and stroke in patients with MIs
treatment14
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Blocks catecholamines from binding to β-adrenergic receptors
  • Reduces myocardial demand by reducing HR, BP, contractility
  • Decreases incidence of primary VF
treatment15
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Dilates coronary arteries
  • Increases venous dilation and therefore decreases venous return
  • Decreases myocardial demand by decreasing preload
treatment16
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Reduces pain of ischemia and anxiety  indirect effect on catecholamines
  • May dilate coronary arteries and reduce preload  decreases myocardial oxygen demand
treatment17
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Heparins - Indirect thrombin inhibitors including LMWH
  • DTI - Direct thrombin inhibitors
  • Reduce further coagulation
treatment18
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Blocks platelet receptor so platelets cannot bind fibrinogen and form clots
  • caution in renal disease (tirofiban, ebtifbatide) and with thrombocytopenia (abciximab)
treatment19
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • Blocks the ADP receptor on platelets which also prevents fibrinogen binding and clot formation
  • Bleeding risks during CABG have limited its immediate use until coronary anatomy defined
treatment20
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • reduces peripheral vasoconstriction and blood pressure
  • Alters post-MI LV remodeling
treatment21
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • reduces fibrosis, hypokalemia, and arrhythmias
  • beneficial in high-risk post-AMI LV dysfunction
treatment22
Treatment
  • Oxygen
  • Aspirin
  • Beta-blocker
  • Nitroglycerin
  • Morphine
  • Heparins, DTIs
  • IIb/IIIa inhibitors
  • Plavix
  • ACE/ARB
  • Aldosterone Blockade
  • Statins
  • reduce LDL
  • may decrease inflammation
initial therapy
Initial Therapy
  • Anti-ischemic and Analgesic therapy
  • Anti-platelet therapy
  • Anti-coagulant therapy
anti ischemic and analgesic therapy
Anti-ischemic and Analgesic Therapy
  • Bed/chair rest – Class I, C
  • O2 for SaO2 < 90%, respiratory distress, or hypoxemia – Class I, B
  • NTG 0.4 mg sl q 5 min x 3 doses, then gtt for ongoing ischemic discomfort – Class I, C
  • NTG iv within 48h for persistent ischemia, HF, or HTN. Should not preclude use of BB – Class I, B
  • Oral BB therapy within 24h without 1) HF, 2) low output, 3) risk of shock, 4) relative contraindications – Class I, B
anti ischemic and analgesic therapy26
Anti-ischemic and Analgesic Therapy
  • CCB (nondihydropyridine) if contraindication for BB in the absence of contraindications – Class I, B
  • ACE inhibitor for LVEF <0.40 and no hypotension (SBP <100 or <30 below baseline) – Class I, A
  • ARB if intolerant to ACE inhibitor – Class I, A
  • NSAIDS should be discontinued – Class I, C
anti platelet therapy
Anti-Platelet Therapy
  • ASA – started immediately and continued indefinitely – Class I, A
  • Plavix – loading dose (300-600mg)* plus maintenance 75 mg if ASA intolerant – Class I, A
  • If h/o GIB, PPI plus anti-platelet therapy – Class I, B
  • GP IIB/IIIA therapy depends on strategy chosen (more on this later)

* Risk/benefit to higher loading dose regimens is yet to be determined

anti coagulant therapy
Anti-Coagulant Therapy
  • Anticoagulant Therapy should be added to antiplatelet therapy as soon as possible after presentation
  • Choice of anticoagulant depends on the strategy chosen (more on this later)
there is an incremental benefit to asa ufh lmwh and gpiib iiia therapy
There is an Incremental Benefit to ASA, UFH/LMWH, and GPIIb/IIIa Therapy

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

acute coronary syndromes30
Acute Coronary Syndromes
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
kaplan meier estimates of probability of death based on admission electrocardiogram
Kaplan-Meier Estimates of Probability of Death Based on Admission Electrocardiogram

Savonitto S, Ardissino D, Granger CB, et al. JAMA 1999;281:707–13 (127)

troponin i levels to predict the risk of mortality in acute coronary syndromes
Troponin I Levels to Predict the Risk of Mortality in Acute Coronary Syndromes

Antman EM, Tanasijevic MJ, Thompson B, et al. N Engl J Med 1996;335:1342–9 (201)

grace prediction score all cause mortality within 6 months of discharge
GRACE Prediction Score – All-cause Mortality Within 6 Months of Discharge

Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727-33(168)

what is elevated risk
What is Elevated Risk?

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

acute coronary syndromes36
Acute Coronary Syndromes
  • Pathophysiology
  • Diagnosis
  • Initial Therapy
  • Risk-Stratification
  • Invasive vs Conservative
  • Post AMI Care
choose a strategy
Choose A Strategy
  • Initial Conservative – Angiography only if patient fails medical management (refractory or resting angina) or has objective evidence of ischemia (stress testing)
  • Initial Invasive – Angiography before failure of medical management or stress testing
    • Immediate angiography (ISAR-COOL) or
    • Deferred Angiography (all other trials – 12-48h)
choose a strategy rationale
Choose A Strategy - Rationale
  • Initial Conservative
    • Early trials demonstrate similar efficacy (TIMI IIIB, MATE, VANQWISH, RITA-2)
    • Aggressive antiplatelet and anticoagulant therapy has reduced events
  • Initial Invasive
    • Rapidly identify the 10-20% with nonocclusive CAD and the 20% with 3v CAD
less events in early invasive strategy
Less Events in Early Invasive Strategy

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

choose a strategy guidelines
Choose A Strategy – Guidelines
  • Initial invasive
    • Refractory angina or hemodynamic/electrical instability (Class I, B)
    • Initially stabilized patients without contraindications and with elevated risk for events (Class I, A)
  • Initial Conservative
    • May be considered in patients with elevated risk (Class IIb,B)
    • May consider physician or patient preference (Class IIb,C)
    • Women with low-risk features (Class I, B)
important points in hospital care
Important Points in Hospital Care
  • Stress test before discharge for assessment of ischemia in initial conservative strategy. Must be free of resting ischemia or HF for 12-24h – Class I, C
  • If not classified as low risk, angiography should be performed – Class I, A
  • Fasting lipid panel within 24 hours – Class I, C
  • Statin regardless of baseline LDL-C pre-discharge
  • Echo or MUGA must be done if no plan for left ventriculography by angiogram – Class I, B
acute coronary syndromes44
Acute Coronary Syndromes
  • Pathophysiology
  • Diagnosis
  • Triage
  • Initial Therapy
  • Invasive vs Conservative
  • Post AMI Care
post ami care
Post-AMI Care
  • Similar to care after STEMI
  • Focus on secondary prevention of coronary events…
    • ASA
    • Statin
    • BB
    • BP control
    • Smoking Cessation
    • Healthy Lifestyle
  • …And treatment of LV systolic Dysfunction (EF<40)
    • ACE inhibitor
    • ARB if ACE inhibitor intolerant
    • Eplerenone if HF or DM, and eGFR > 30, and K < 5
when to stop plavix
When to Stop Plavix

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157