Case presentation : STEMI

Outline Introduction of coronary artery disease Definition

of acute coronary syndrome Pathophysiology Management Patient SOAP

Case presentationprofile

Chronic Angina

Coronary Artery Disease ( CAD )Stable

Acute Coronary Syndrome ( coronary arteries ) Rest angina New-onset angina

Causes of ACS 1. Occlusive or non-occlusive thrombus on preexisting plaque: ACS atherosclerosis plaque thrombus formation 2. Dynamic obstruction (coronary spasm): vasospasm hypercontractility vascular smooth muscle endothelial dysfunction 3. Progressive mechanical obstruction : atherosclerosis progressive/worsening angina

Cause of ACS Occlusive Thrombus

Vascular disease : A generalized and progressive process

common pathophysiology of a disrupted atheroslerotic plaqueCirculation 1995;92:1355-1347.

Pathophysiology Lipid-rich plaque Vulnerable artherosclerotic plaque Thin protective fibrous cap Plaque rupture Thrombus formation Artery occlusion STEMI

Pathophysiology

Lipid-rich plaque Vulnerable artherosclerotic plaque fibrous cap collagen

interferon-gamma ( foam cell metalloprotienase enzyme collagen) vulnerable plaque thrombus (complete occlusion) STEMI

Type of Acute coronary syndrome ( ACS )Unstable angina ( UA )

STEMI (ST-segment Elevation Myocardial Infarction)

NSTEMI (Non-ST-segment Elevation Myocardial Infarction)

Normal ECG

ST Elevatio

ST Depression

T wave inversi

STEMI vs NSTEMI vs Unstable anginaSTEMIComplete occlusion Thrombolytic therapy Cardiac catheterization

NSTEMIPartial occlusion Cardiac catheterization

Unstable angina Partial

occlusion Cardiac catheterization

EKG

EKG

The Acute Coronary Syndrome

RiskAsymptomatic Angina Unstable Myocardial Infarction

Plaque Rupture

tracoronary Thrombus

educed Blood Flow

ocardial IschemiaECG CK - MB ,

ocardial Necrosis Diagnostic Focus

Diagnosis and Investigation

Diagnosis - 1 . Risk Factors Age, sex, family history, race Smoking Lipid profiles Elevated blood pressure Low exercise Obesity DM

Cardiovascular risk factorsHypertension Age (older than 55 years for men, 65 years for women) Diabetes mellitus Elevated LDL (or total) cholesterol, or low HDL cholesterol Estimated GFR > Risk Treatment should be performed v Class IIa Benefit >> Risk Reasonable to perform vClass IIb Benefit > Risk Treatment may be considered vClass III Risk > Benefit Treatment should not be perform

ManagementRoutine Measure 1 . Oxygen : keep SaO2 > 90 % 2 . Nitroglycerin : Nitroglycerine SL q 5 min , total 3 dose 3 . Analgesia : Morphine 4 . Aspirin 5 . Beta - Blocker

Analgesia

Aspirin

Beta - Blockers

Reperfusion therapy

Reperfusion therapy

- General Concepts - Selection of Reperfusion Strategy - Pharmacological Reperfusion - Percutaneous Coronary Intervention ( PCI ) - Ancillary Therapy

Reperfusion therapy Thrombolytic agent Percutaneous Coronary Intervention (PCI) Coronary artery bypass graft (CABG)

Selection of Reperfusion Strategy

Total ischemic time : Within 180 min

Reperfusion Options for STEMI Patients

VS

Time is muscle !! - Faster as you can

Thrombolytic agent

Pharmacological Reperfusion

Pharmacological Reperfusion

Percutaneous Coronary Intervention ( PCI )

Coronary Angiography Stent

http://www.youtube.com/watch?v=kY5gKdFWT3

http://www.youtube.com/watch?v=S9AqBd4REx

Acute Surgical Reperfusion

CABG http :// www . youtube . com / wa

ANCILLARY THERAPY . Unfractionated heparin ( UFH ) Low - molecular - weight heparin ( LMWH ) Direct antithrombins Aspirin Thienopyridines Glycoprotein IIb / IIIa inhibitors ( GP IIb / IIIa inhibitors )

Antiplatel et

Anticoagulants

cascade

UFH

cascade

LMWH

cascade

Fondaparinux

cascade

Direct thrombin inhibitor

UFH

LMWH

Direct antithrombins : Bivalirudin

Glycoprotein IIb / IIIa inhibitors

Post MI pharmacotherapy Patient Education Before Discharge ( ) Lipid Management : statin Smoking Cessation Weight Management Beta - Blockers Blood Pressure Control Diabetes Management Hormone Therapy Physical Activity Antioxidants Influenza

Antiplatelet Therapy

Aspirin

stent aspirin bleeding aspirin 162 mg 325 mg 1 BMS implantation 3 sirolimus - eluting stent implantation

Aspirin

Antiplatelet Therapy

Clopidogrel

PCI DES clopidogrel 75 mg 12 bleeding PCI BMS clopidogrel 1 12 bleeding minimum 2 weeks ) stent clopidogrel

Post stent therapy Bare metal stent : clopidogrel at least 1 mo up to 1 yr Drug eluting stent : Withhold clopidogrel at least 1 mo

Thienopyridines

clopidrogrel for at least 5 days

Warfarin

Antiplatelet Therapy

post-MI atrial fibrillation, left ventricular thrombus Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. In patients requiring warfarin, clopidogrel, and aspirin therapy, an INR of 2.0 to 2.5 is recommended with low dose aspirin (75 mg to 81 mg) and a 75 mg dose of clopidogrel.

Inhibition of RAAS ACE inhibitor HF MI ; hypertension aldosterone blockade MI diabetes HF ARB ACE inhibitor ( Valsartan candesartan)

RAAS inhibitors

Beta - Blockers 2-3 STEMI

Calcium Channel Blockers

Blood Pressure Control

Less than 140/90 mm Hg or less than 130/80 if patient has diabetes or chronic kidney disease

Most patients treating initially with beta-blockers and/or ACE inhibitors, with the addition of other drugs such as thiazides as needed to achieve goal blood pressure

Lipid Management

:

LDL-C < 100 mg/dL LDL-C 100 mg/dL ( statin) LDL-C 100 mg/dL combination LDL-C 70 - 100 mg/dL LDL-C < 70 mg /dL triglycerides 200 mg/dL nonHDL-C < 130 mg/dL triglycerides 150 mg/dL HDL-C < 40 mg/dL

Lipid Management

Therapeutic options to reduce nonHDL-C include: LDL-Clowering therapy

therapy triglycerides 500 mg/dL fibrate niacin LDL-lowering therapy pancreatitis

Niacin Fibrate

Weight Management BMI: 18.5 to 24.9 Diabetes kg/m2 Management 30

Goal: HbA1c less than 7%

Physical Activity

5

Antioxidants vitamin E E

vitamin

1 . Hemodynamic Assessment

Hemodynamic Disturbances

Class I

1 . Pulmonary artery catheter monitoring should be performed for the following : a. Progressive hypotension, when unresponsive tofluid administration or when fluid administration may be contraindicated. b. Suspected mechanical complications of STEMI, (i.e., VSR, papillary muscle rupture, or free wall rupture with pericardial tamponade) if an echocardiogram has not been performed 2 . Intra - arterial pressure

Hemodynamic Disturbances

Case presentation

Patient s Information 50 . . .

3 .. 53

CC : HPI

: 1 PTA: 30 3 PTA : ( 6.00 .)

7

:

PMH : ( ??) FH : 71 ( ER: ),

SH : 13 30 (pack/years=), , 1 , , 4-5 Drug allergy : NKDA Medication PTA : , , / /

Physical examination: CXR: EKG: CAG: PCI stent stent V/S

CB C

Laboratory Test3 / 11 / 53 14.1 41.0 11,380 78 . 4 16 . 7 4.1 0.4 0.4 314,000 88.9 6 / 11 / 53 11 . 3 33 . 2 9,660 63.6 28.4 3.9 3.7 0.4 244,000 -

Hb (12-18 d/dl) Hct (37-52%) WBC (4-11x103/uL) N (40-74%) L (19-48%) M (3.4-9.0%) E (0-7%) B (0-1.5%) Platelets (150440x103 /uL) MCV

Chemistry ( CrCl ) AG Mg HCO (9 2 Cl 55 1 9 K 17 5mmol Na 9821-.5 Cr( 135107 BUN(0702034 FBS3.(.----110 /L) 3./6 / 53 3./5 / 53 2311 102 138 18 83 16 20 101 4 137 - 11mmol/L 145mmol mg/dL) ) /L)3

( 09 . 06 .)

( 18 . 28 .)

20 103 136 11 22 9311 4./2 / 53 6./29 / 53 22 107 4 139 1 . 1511 - 7 ( 05 . 40 .)

Glucose 6 34 Mg Anion Troponin 3./02 / 53 3 / 11 / 53 4./77 / 53 5./6 / 53 6./57 / 53 CK-MB 1 . 1311 0 80 16 93 13 6 .99 4911 2 14 - 11 - 93 1011 gap T ( 09 . 06 ( 18 . 28. ( 05 . 39 ( 06 . 11 ( 06 . 09 .) ) .) .) .)

Cardiac enzyme ( )

PT aPTT ratio

12 - 6 27.5 3 / 11 / 53 ( 09 . 06 .)

12 9 1 .1 3111 3./18 / 53 ( 15 . 49 .)

2 .6 5711 3./19 / 53 ( 22 . 32 .)

ipid profile3 / 11 / 53 3 / 11 / 53 ( 09 . 06. ( 18 . 28. ) Cholester) ol ( 240mg/dL ; LDL-C >160mg/dL) 3. HDL-C (