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Current management of
Acute Coronary Syndrome
Lokeswara Rao Sajja,
MCh, MD, FACS
Star Hospitals
Sajja Heart Foundation
Hyd...
 A spectrum of conditions compatible with acute
myocardial ischemia and/or infarction that are
usually due to an abrupt r...
Unstable Angina NSTEMI STEMI
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
Non-occlusive
thrombus
ST depr...
Decreased O2 Supply
•Flow- limiting stenosis
•Anemia
•Plaque rupture/clot
Increased O2 Demand
O2 supply/demand mismatch→Is...
 Over seven million people every year die from CAD, 12.8% of
all deaths (WHO 2011)
 1.5 million hospital admissions in t...
Comparison of ACS in developed and developing countries
Xavier D. Create Registry .Lancet 2008 : 371 ;1435-42
Syndrome
Mea...
 Young age at presentation
 ST segment elevation myocardial infarction (STEMI)
is more common in India compared to Weste...
 The ‘gold-standard’ treatment for most patients
presenting with ACS is primary percutaneous coronary
intervention (PCI) ...
 The technical advances in PCI in the setting of ACS have
relegated coronary artery bypass graft (CABG) largely to a
seco...
Recent trials for ACS
Comparing an invasive and a conservative strategy
FRISC II TACTICS-TIMI 18
RITA 3
 PCI was recommen...
Recent trials for ACS
Comparing PCI and CABG for the treatment of
ischemic heart disease
ARTS
SoSERACI II
 In a propensity- matched comparison
from the ACUITY trial, moderate- and
high-risk patients with ACS and
multivessel dis...
ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016
Appropriate Use Criteria for Coronary Revascularization in
Patients With Acute C...
Current management of Acute Coronary Syndrome
ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016
Appropriate Use Criteria for Coron...
Class I Recommendations (Level of Evidence: B)
1. acute MI in whom
 primary PCI has failed or cannot be performed
 coron...
Class I Recommendations (Level of Evidence: B)
3. Patients with cardiogenic shock and who are suitable for
CABG irrespecti...
Class IIa Recommendations (Level of Evidence: B)
1. Patients with multivessel CAD with recurrent angina or MI
within the f...
Failed PCI
 Abrupt vessel closure
 Extensive coronary artery dissection
 Incomplete revascularization
 Coronary perfor...
Recommendations Class I level of evidence B
1. Emergency CABG is recommended after failed PCI in the
presence of ongoing i...
Recommendation Class IIbLevel of Evidence: C
1. Emergency CABG might be considered after failed PCI for
hemodynamic compro...
 NSTE-ACS
In a large database analysis of unselected patients admitted for
ACS, performance of early CABG(< 48 hrs), even...
Timing of urgent CABG in patients with STEMI in
relation to use of antiplatelet agents
Aspirin should not be withheld befo...
Timing of urgent CABG in patients with STEMI in
relation to use of antiplatelet agents
Abciximab should be discontinued at...
Myocardial
oxygen demand
CPB related
inflammatory
injury
Global
ischemia
Conventional
CABG
On Pump
Beating Heart -
OPCAB -...
 Where emergency CABG is required, OPCAB is
theoretically ideal as it preserves coronary flow, avoids
global myocardial i...
Stable hemodynamic
 CA is superior in
 Shorter CPB time
 More distal anastomoses
 LCx territory grafting
 BH is super...
Off-pump coronary artery bypass can be performed safely
and effectively and should be considered in selected patients
with...
 The total arterial revascularization may further improve
long-term outcome and patients with bilateral internal
thoracic...
 The use of composite arterial grafts based upon the internal
mammary arteries eliminates the need for anastomosing
graft...
 ACS is a potentially life-threatening condition that affects
millions of individuals each year
 The initial approach to...
Initial ACS management should include
risk stratification
appropriate pharmacologic management
including
 DAPT
 Antico...
 The number of emergency CABGs is on decline
 The mortality rate associated with emergency CABG
remains high
 Off-pump ...
 Long-term management following an ACS event should
 follow evidence-based recommendations
 be individualized to each p...
Thank you
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Acute Coronary Syndrome by Lokeswara Rao Sajja - STAR Hospitals

Acute Coronary Syndrome by Lokeswara Rao Sajja - STAR Hospitals

Lokeswara Rao Sajja, MS, MCh, MD, FACS.
Senior Consultant Cardiac Surgeon, STAR Hospitals, and Sajja Heart Foundation, Hyderabad, India.

63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru

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Acute Coronary Syndrome by Lokeswara Rao Sajja - STAR Hospitals

  1. 1. Current management of Acute Coronary Syndrome Lokeswara Rao Sajja, MCh, MD, FACS Star Hospitals Sajja Heart Foundation Hyderabad, India 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  2. 2.  A spectrum of conditions compatible with acute myocardial ischemia and/or infarction that are usually due to an abrupt reduction in coronary blood flow Acute coronary syndrome Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru  The spectrum of acute ischemia related syndromes ranging from [----UA-------NSTEMI--------STEMI----] that are secondary to acute plaque rupture or plaque erosion
  3. 3. Unstable Angina NSTEMI STEMI Non occlusive thrombus Non specific ECG Normal cardiac enzymes Non-occlusive thrombus ST depression +/- T wave inversion on ECG Elevated cardiac enzymes Complete thrombus Occlusion ST elevations on ECG or new LBBB Elevated cardiac Enzymes More severe symptoms Acute Coronary Syndrome (ACS) Current management of Acute Coronary Syndrome
  4. 4. Decreased O2 Supply •Flow- limiting stenosis •Anemia •Plaque rupture/clot Increased O2 Demand O2 supply/demand mismatch→Ischemia Myocardial ischemia→necrosis Pathophysiology ACS Asymptomatic/ stableangina UnstableAngina MyocardialInfarction Pathophysiology of Stable Angina and ACS Stable angina Current management of Acute Coronary Syndrome
  5. 5.  Over seven million people every year die from CAD, 12.8% of all deaths (WHO 2011)  1.5 million hospital admissions in the U.S. annually: Approximately 70% - NSTE-ACS (Heart Disease and Stroke Statistics-2014 Update from AHA)  In the Europe (incidence per 100,000/year) :  77 STEMI  132 non-STEMI (ESC guideline 2012)  India has the highest burden of ACS in the world  (Treatment and outcomes of ACS in India (CREATE S)- a prospective analysis of registry data Epidemiology Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  6. 6. Comparison of ACS in developed and developing countries Xavier D. Create Registry .Lancet 2008 : 371 ;1435-42 Syndrome Mean Age (Yrs) Time (min) Practice 30 day mortality STEMI NSTEMI Onset of symptoms to admission hospital Admission to thromboly sis Primary PCI (STEMI vs NSTEMI) Thrombolytic treatment ( Proportion streptokinase) STEMI NSTEMI CREATE Indian Registry 61% 39% 57 300 50 8% vs 7% 59% 9% 4% Global registry of ACS 31- 40% 60-70% 64-69 140 - 40% vs 28% 47% 8% 3% European heart Survey 42% 51% 63 170 40 40% vs 25% 37% 7% 1% US National registry of MI - - 68 128 32-38 36% 21% 8% -
  7. 7.  Young age at presentation  ST segment elevation myocardial infarction (STEMI) is more common in India compared to Western Countries  Majority of patients receive thrombolysis  30-day mortality is higher in India compared to Western Countries The unique features of ACS in Indians Mansoor AH, Kaul U. Prehospital Thrombolysis. Indian Heart J. 2009; 61:433-436 Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  8. 8.  The ‘gold-standard’ treatment for most patients presenting with ACS is primary percutaneous coronary intervention (PCI) of the culprit coronary vessel  Currently, the optimal treatment of STEMI is the primary PCI or systemic thrombolysis  The initial approach to the patient with non-ST segment elevation ACS is pharmacological stabilization followed by risk stratification Treatment Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  9. 9.  The technical advances in PCI in the setting of ACS have relegated coronary artery bypass graft (CABG) largely to a secondary position in most cases  Conventional surgical revascularizatio achieves a combined prospect of an excellent long term outcomes and an average risk of < 3% which can be further reduced using off-pump CABG , particularly in high risk patients
  10. 10. Recent trials for ACS Comparing an invasive and a conservative strategy FRISC II TACTICS-TIMI 18 RITA 3  PCI was recommended for one vessel or two vessel disease and CABG for three vessel disease or left main stenosis  higher repeat revascularisation rate for PCI (14.8%) than CABG (6.9%)
  11. 11. Recent trials for ACS Comparing PCI and CABG for the treatment of ischemic heart disease ARTS SoSERACI II
  12. 12.  In a propensity- matched comparison from the ACUITY trial, moderate- and high-risk patients with ACS and multivessel disease treated with PCI rather than CABG had lower rates of peri-procedural stroke, MI, major bleeding, and renal injury, with comparable 1-month and 1-year rates of mortality  but more frequently developed recurrent ischemia requiring repeat revascularization procedures during follow-up
  13. 13. ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  14. 14. Current management of Acute Coronary Syndrome ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  15. 15. Class I Recommendations (Level of Evidence: B) 1. acute MI in whom  primary PCI has failed or cannot be performed  coronary anatomy is suitable for CABG, and  persistent ischemia of a significant area of myocardium at rest and/or hemodynamic instability refractory to nonsurgical therapy is present 2. Patients undergoing surgical repair of a post infarction mechanical complicationof MI  ventricular septal rupture  mitral valve insufficiency because of papillary muscle infarction and/or rupture  free wall rupture Hillis et al 2011 ACCF/AHA CABG Guideline Indications for CABG (ACCF/AHA CABG Guideline) Current management of Acute Coronary Syndrome
  16. 16. Class I Recommendations (Level of Evidence: B) 3. Patients with cardiogenic shock and who are suitable for CABG irrespective of the time interval from MI to onset of shock and time from MI to CABG Class I Recommendations (Level of Evidence: C) 4. Patients with life-threatening ventricular arrhythmias(believed to be ischemic in origin) in the presence of left main stenosis greater than or equal to 50% and/or 3-vessel CAD Hillis et al 2011 ACCF/AHA CABG Guideline Current management of Acute Coronary Syndrome Indications for CABG (ACCF/AHA CABG Guideline) 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  17. 17. Class IIa Recommendations (Level of Evidence: B) 1. Patients with multivessel CAD with recurrent angina or MI within the first 48 hours of STEMI presentation as an alternative to a more delayed strategy Class III Recommendations (Level of Evidence: C) 1. Emergency CABG should not be performed in patients with persistent angina and a small area of viable myocardium who are stable hemodynamically 2. Emergency CABG should not be performed in patients with no reflow (successful epicardial reperfusion with unsuccessful microvascular reperfusion) Hillis et al 2011 ACCF/AHA CABG Guideline Current management of Acute Coronary Syndrome Indications for CABG (ACCF/AHA CABG Guideline)
  18. 18. Failed PCI  Abrupt vessel closure  Extensive coronary artery dissection  Incomplete revascularization  Coronary perforation  Unsuccessful dilation  Other situations resulting in hemodynamic instability and requiring surgical intervention Emergency CABG After Failed PCI Current management of Acute Coronary Syndrome Yang et al. 2005 JACC Vol. 46, No. 11 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  19. 19. Recommendations Class I level of evidence B 1. Emergency CABG is recommended after failed PCI in the presence of ongoing ischemia or threatened occlusion with substantial myocardium at risk 2. Emergency CABG is recommended after failed PCI for hemodynamic compromise in patients without impairment of the coagulation system and with out a previous sternotomy Recommendations Class IIa level of evidence C 1. Emergency CABG is reasonable after failed PCI for retrieval of a foreign body (most likely a fractured guide wire or stent) in a crucial anatomic location 2. Emergency CABG can be beneficial after failed PCI for hemodynamic compromise in patients with impairment of the coagulation system and without previous sternotomy Emergency CABG After Failed PCICurrent management of Acute Coronary Syndrome
  20. 20. Recommendation Class IIbLevel of Evidence: C 1. Emergency CABG might be considered after failed PCI for hemodynamic compromise in patients with previous sternotomy Recommendation Class III Level of Evidence: C 1. Emergency CABG should not be performed after failed PCI in the absence of ischemia or threatened occlusion 2. Emergency CABG should not be performed after failed PCI if revascularization is impossible because of target anatomy or a no- reflow state Emergency CABG After Failed PCI Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  21. 21.  NSTE-ACS In a large database analysis of unselected patients admitted for ACS, performance of early CABG(< 48 hrs), even in higher-risk patients, was associated with low in-hospital mortality. (MonteiroP. Circulation2006;114), (Parikh SV. JACC CardiovascInterv2010;3(4)  STEMI When possible, in the absence of persistent pain or haemodynamic deterioration, a waiting period of 3–7 days appears the best compromise (Weiss ES,J ThoracCardiovascSurg2008;135(3)  In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding complications Class I recommendation (Hillis et al 2011 ACCF/AHA CABG Guideline) Timing of CABG Current management of Acute Coronary Syndrome
  22. 22. Timing of urgent CABG in patients with STEMI in relation to use of antiplatelet agents Aspirin should not be withheld before urgent CABG Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible I IIaIIb III I IIaIIb III I IIa IIb III Current management of Acute Coronary Syndrome
  23. 23. Timing of urgent CABG in patients with STEMI in relation to use of antiplatelet agents Abciximab should be discontinued at least 12 hours before urgent CABG Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding I IIaIIb III I IIaIIb III I IIaIIb III Current management of Acute Coronary Syndrome
  24. 24. Myocardial oxygen demand CPB related inflammatory injury Global ischemia Conventional CABG On Pump Beating Heart - OPCAB - - - Surgical technique Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru 38% of patients need Intra aortic balloon pump
  25. 25.  Where emergency CABG is required, OPCAB is theoretically ideal as it preserves coronary flow, avoids global myocardial ischaemia and reduces ischaemia- reperfusion injury  OPCAB may have offer some benefits by avoiding full heparinization and avoiding the inflammatory response associated with cardiopulmonary bypass
  26. 26. Stable hemodynamic  CA is superior in  Shorter CPB time  More distal anastomoses  LCx territory grafting  BH is superior in  Time to culprit lesion revascularization Rastanet al .Beating Heart CABG in Emergency ACS, Circulation 2006  638 (3.3%) (stable 531, CS 107)  240 Beating heart operation 124 OPCAB  116 on pump beating heart 398 conventional CPB/CA BH is superior in •less Inotrope •less bleeding •less hospital stay
  27. 27. Off-pump coronary artery bypass can be performed safely and effectively and should be considered in selected patients with acceptable hemodynamics undergoing emergency coronary revascularization
  28. 28.  The total arterial revascularization may further improve long-term outcome and patients with bilateral internal thoracic artery grafts had significantly better freedom from readmission for ACS
  29. 29.  The use of composite arterial grafts based upon the internal mammary arteries eliminates the need for anastomosing grafts to the aorta, permitting a true “no touch” aortic technique, further reducing the risk of stroke
  30. 30.  ACS is a potentially life-threatening condition that affects millions of individuals each year  The initial approach to the patient with non-ST segment elevation ACS is pharmacological stabilization followed by risk stratification  The consensus is rapidly evolving for the treatment of NSTEMI and unstable angina based on a system of risk stratification includes multiple clinical, demographic and ECG variables in addition to the use of serum biomarkers Conclusions Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  31. 31. Initial ACS management should include risk stratification appropriate pharmacologic management including  DAPT  Anticoagulation and  Appropriate adjuvant therapies decision to pursue an early invasive or conventional treatment strategy Conclusions Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  32. 32.  The number of emergency CABGs is on decline  The mortality rate associated with emergency CABG remains high  Off-pump coronary artery bypass graft may improve the outcome but may not suitable for the unstable patients and LM disease  Initial stabilization followed by CABG is the preferred mode of treatment for patients with ACS and multivessel CAD Conclusions Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru
  33. 33.  Long-term management following an ACS event should  follow evidence-based recommendations  be individualized to each patient.  Secondary prevention with antiplatelet therapy, beta blockade, lipid lowering therapy, and ACE inhibitors or ARBs is critical to the long term success of revascularization Conclusions Current management of Acute Coronary Syndrome 63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru Decision of treatment by the Heart Team is the trend in the Current Management of ACS
  34. 34. Thank you

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