Management of NonSTElevation Myocardial Infarction

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Management of Non-ST-Elevation Myocardial
Infarction

• Sandy Kimmer, MD, MPH
• Faculty Physician
• Naval Hospital Camp Pendleton

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Objectives

• STEMI--gtGet thee to a cath lab!
• Review primary prevention
• Outline the 2007 ACC/AHA Guidelines
• Discuss recent evidence
• Review secondary prevention

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Primary Prevention

• Smoking
• Hypertension
• Diet
• Dyslipidemia
• Physical inactivity
• Obesity
• Diabetes
• ASA?

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ASA No Benefit

• Heart 2001
• Food and Drug Administration 2003
• 5 primary prevention trials
• No benefit even in high-risk patients
• Did not extend labeling for primary prevention
• Womens Health Study
• Physicians Health Study
• Primary Prevention Project 2003
• POPADAD 2007

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2007 ACC/AHA Guidelines

• 2007 Focused Update Of the ACC/AHA 2004
  Guidelines for the Management of Patients With
  Non-ST-Elevation Myocardial Infarction
• A Report of the American College of
  Cardiology/American Heart Association Task Force
  on Practice Guidelines

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2007 ACC/AHA Guidelines

• Levels of Evidence
• I Rx useful/effective SHOULD BE GIVEN
• II Conflicting evidence
• III Rx NOT useful/effective SHOULD NOT BE GIVEN
• Recommendations
• A Data from multiple randomized, controlled
  trials
• B Data from limited RTCs, small patient
  numbers, non-randomized studies
• C Data from expert consensus, case studies,
  accepted standard of care

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NSTEMI Defined

• Acute Coronary SyndromeUnstable Angina, NSTEMI,
  and STEMI
• NSTEMIAnginal chest pain as the manifestation of
  decreased coronary blood flow
• Abnormal serum biomarkers
• ACS without positive markersUnstable angina

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Initial Evaluation

• Patient to call 911 if no relief of chest pain
  with ONE dose of nitroglycerine (I-C)
• Aspirin should be universally given unless ASA
  allergy (I-A)
• Increased emphasis on out-of-hospital evaluation
• 12-lead EKG (IIa-B)
• Protocol for selection of EMS destination

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Risk Stratification

• Serial EKGs (I-B)
• 15-30 minute intervals
• Facilitate prompt detection of ST change
• Biomarker Testing (I-B)
• Troponin preferred
• If negative 6 hrs post pain onset, repeat at 8-12
  hrs
• Mathematical Risk Stratification (IIa-B)
• TIMI
• GRACE
• PURSUIT

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Anti-Ischemic Therapy

• Oral ß-blocker within first 24 hrs (I-B)
• IV ß-blocker (IIa-B)
• Nitrates
• NOT if phosphodiesterace inhibitor (III-C)
• NO NSAIDs (III-C)
• Morphine (IIa-B)
• ONLY if not controlled by ß-blockerNitrates
• May increase inhospital mortality

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Initial Management

• Early invasive strategy Patients being treated
  with evidence based anti-ischemic,
  antithrombotic, and antiplatelet medications will
  undergo coronary angiography 4-24 hrs after
  admission
• Selectively invasive strategy Patients are
  taken for invasive evaluation only if they fail
  intensive medical management OR have objective
  evidence of ongoing ischemia

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Initial Management

• Early Invasive Strategy
• Patients who have an increased risk for clinical
  events (I-A)
• Refractory angina OR hemodynamic or electrical
  instability, unless significant comorbidity or
  contraindications (I-B)
• Selectively Invasive Strategy
• May be considered for patients with an increased
  risk for clinical events (IIb-B)

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Anticoagulation Therapy

• Several recent publications
• Appropriate for patients whose ACS risk is
  intermediate or higher
• Balance risk of ischemia and bleeding
• Older, female, diminished renal function, or
  anemia
• Choice is physician, cardiologist, and site
  dependent

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Anticoagulation Therapy

• SYNERGY
• Enoxaparin (I-A) UFH
• Dose interval 24 hours if CrCl lt 30 mL/min
• OASIS-5
• Fondaparinux (I-B)
• Choose in patients at increased bleeding risk
• Requires additional antithrombin Rx be given at
  PCI
• ACUITY
• Bivalirudin (I-B) for patients undergoing EIS
• If given with clopidogrel load, NO GP IIb/IIIa
  (IIa-B)

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Antiplatelet Therapy

• ASA (I-A)
• Clopidogrel (I-A)
• Load 300 mg if ASA allergic
• Hold if CABG planned 5-7 days (I-B)
• Glycoprotein IIb/IIIa Inhibitors
• Either/or (I-A)
• AND clopidogrel (IIa-B)
• Triple Therapy
• No bleeding risk and CABG unlikely

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Secondary Prevention

• Statin to achieve LDL lt 70
• Triglycerides lt 200
• HDL gt 40
• Blood pressure lt 130/80
• Beta blocker
• ACE inhibitor
• Lifestyle modifications
• HgA1c lt 7
• ASA
• Plavix

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The Bottom Line

• Serial EKGs
• Risk stratification
• Oral beta-blocker, nitrates, morphine
• Lovenox
• ASA
• Plavix and/or GPI
• Early involvement of the cardiologist

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Questions?