Coronary heart disease

1
???????????????????????????????????????????(Coro
nary heart disease)

• ??? ??.??. ????????? ??????????
• ???????????????????????? ??????????????????
• ??????????????????? ????????????????????
• ????????????? ??????????????????

2
Pathophysiology
Acute MI

• Platelet cascade
• Thrombus formation
• Vasospasm

Complete occlusion
Plaque rupture (55-80)
Healing plaque
Chronic stable
Spontaneous lysis
Exertion BP, HR Vasoconstriction
Incomplete occlusion Distal embolization
Unstable angina Non-Q MI
3
Pre hospital management

• Health education program
• Risk control
• Symptoms
• Call EMS earlier
• How to contact?
• When to contact?
• Early EKG on site
• ASA on site.

4
ED management

• A cardiac-specific troponin is the preferred
  biomarker in patients presenting with symptoms
  consistent with ACS.
• BNP may be added to the list of biomarkers for
  risk assessment.
• Nondiagnostic pts with possible ACS should be Rx
  and stress test stratification
• Low probability and possible ACS can be CT

5
Investigations

• Electrocardiography
• Cadiac enzyme
• Chest film
• Echocardiography
• Coronary angiography, CAG
• Other risk factors FPG, lipid profiles

6
Chest film

• Cardiac abnormality
• Determine CHF
• DDx
• Aortic dissection
• Pericardial effusion

7
Echocardiography in ACS
8
Coronary angiogram
9
TIMI risk score in STEMI

• Historical Score
• Age, y 75 3
• Age, 65-74 2
• Hx of DM, HT or angina 1
• Examination
• SBP lt 100 mmHg 3
• HR gt 100/min 2
• Killip class II-IV 2
• Weight lt 67 kg 1
• Presentation
• Ant ST elevation or LBBB 1
• Time to reperfusion gt 4 hr 1

10
TIMI risk score in NSTEMI

• Age gt 65 yr
• CAD risk gt 3
• Stenosis gt 50
• Chest pain gt 2 times in 24 hr
• ASA within 1 wk
• EKG ST diviation gt 0.5 mm
• Positive Troponin-T
• SCORE gt 4

Am Heart J 2002 143 966-70
HIGH RISK

• Heparin Rx.
• early revasculaization

Am Heart J 2002 143 966-70
J Invasive Cardiol. 2006 Dec18(12)617-39.
11
Principle of ACS management

• Early Invasive
• Primary PCI
• Facilitate PCI
• Rescue PCI
• CABG

Adjuvant Rx

• Aspirin
• Nitrates
• Mo
• Beta blockers
• ACEI
• Antithrombin
• Clopidogrel
• GPII/IIIa

• Hemodynamic
• stabilization
• Medical
• Ventilator
• IABP
• Pace maker

ACS

• Early Conservative
• Fibrinolytic drugs
• Risk stratification

Elective CAG /- PCI or CABG
12
Medication of ACS

• Fibrinolytic agents
• Antinthrombotic agents
• Anti-platelet therapy
• aspirin, ticlopidine, clopidogrel, GP IIb/IIIa
  inhibitors
• Anti-coagulant therapy
• heparin, low molecular weight heparin (LMWH)
• Antiischemic agents
• Activity, Oxygen
• Morphine, Nitrates, Beta blockers
• Others ACEIs, ARBs, Statins, Fibrates

13
Efficacy of fibrinolytic agents to mortality
Percentage mortality
0-1h 2-4 h 4-6 h
7-12 h 13-24 h
Lancet 1994343311
14
Fibrinolytic revascularization

• Indication
• Anginal in 12 hrs
• ST elevation or New LBBB
• Contraindication
• Internal bleeding
• Major operation within 2 wks
• Hemorrhagic stroke anytime or Ischemic stroke
  within 6 mo.
• Pregnancy
• Suspected aortic dissection

15
Fibrinolytic agents
Tissue Plasminogen Activator
SK t-PA r-PA TNK Dose 1.5 mu 100 mg/90
min 1010 u 30-50 mg Circulating t
1/2 20 6 18 20 Allergic reaction
Yes No No No Systemic fibrinogen depletion Se
vere Moderate Moderate Mild CNS
bleeding 0.4 0.7 0.8 0.7 Patency
rate 51 73-84 83 77-88 Live
saved/100 3 4 4 4 Cost () 290 2750 2750 27
50
Heparin
LMWH
16
????????????????????? SK

• ?????? ?
• ?????? hydrocortisone 100 mg ???? ??? SK
• ?????? ?????? ???? plasil
• ????? NSS ???? 5 D/W 100 cc drip in 1 hr
• ?????????? ???? monitor EKG ??? BP ????
• ???????????????????????? ????????????? ? ???? cut
  down ???? ??? central line ??? foley cath
  ???????????? ?

17
Antiplatelets ASA

• ASA should be administered to patients with ACS
  as soon as possible (unless contraindicated) and
  continued lifelong.
• ASA 162-323 mg/day at least 1 mo for bare stent
  and 3-6 mo for drugs eluting stent.
• ASA 75-162 mg/day for maintenance or in high risk
  bleeding.

18
Antiplatelets Clopidogrel

• All STEMI with or without fibrinolytic Rx must be
  use Clopidogrel and ASA at least 14 days.
• Loading Clopidogrel is 300 mg.
• All post PCI patients
• No stent No recommendation but Clopidogrel
  should be Rx at least 1 mo.
• BMS Clopidogrel at least 1 mo and ideally up to
  12 mo (unless the patient is at increased risk of
  bleeding then it should be given for a minimum
  of 2 weeks).
• DES Clopidogrel at least 12 mo.

19
CLARITY-TIMI 28 Primary EndpointOccluded Artery
(or D/MI thru Angio/HD)
Odds Ratio 0.64(95 CI 0.53-0.76)
36 Odds Reduction
21.7
25
P0.00000036
20
15.0
15
10
Occluded Artery or Death/MI ()
5
1.0
0.4
0.6
0.8
1.2
1.6
n1752
n1739
0
Clopidogrel better
Placebo better
Placebo
ClopidogrelLD 300 mgMD 75 mg
STEMI, Age 18-75
Sabatine N Eng J Med 20053521179.
20
COMMIT Effect of CLOPIDOGREL on Death In
Hospital
Placebo ASA 1,846 deaths (8.1)
Clopidogrel ASA 1,728 deaths (7.5)
0.6 ARD7 RRR P 0.03
Dead ()
N 45,852 No Age limit 26 gt 70 y Lytic Rx
50 No LD given
Chen ZM, et al. Lancet. 20053661607.
Days Since Randomization (up to 28 days)
21
Antiplatelets GPIIb/IIIa

• All patients receiving intravenous GP IIb/IIIa
  inhibitors must also receive concomitant UFH or
  another antithrombotic agent.

22
Heparin

• Antithrombin
• Indication
• UFH in AMI with PCI or CABG
• UFH with fibrin selective firinolytic Rx
• UFH in high risk of systemic emboli patient
• UFH in NSTEMI or UA high risk.
• Adjusted aPTT 1.5-2
• LMWH may be substituted to UFH (IIb)
• SK may be combine to LMWH
• Caution Heparin induce thrombocytopenia

23
Am Heart J 2002 143 966-70
24
ExTRACT-TIMI 25 Primary End Point (ITT) Death or
Nonfatal MI
UFH
12.0
17 RRR
9.9
Enoxaparin
Primary End Point ()
Relative Risk0.83 (95 CI, 0.77 to 0.90)Plt.001
Lost to follow-up 3
Days after Randomization
Adapted with permission from Antman EM, et al. N
Engl J Med. 20063541477-1488.
25
OASIS 5 Cumulative Risk of Death, MI, or
Refractory Ischemia
10
9.0
9
8
7.3
7
Enoxaparin
5.8
5.7
6
Fondaparinux
5
4.1
4
3
2.2
2
1
0
OASIS 5 Death, MI, or refractory
OASIS 5 Major bleeding at 9
OASIS 5 Composite primary
ischemia at 9 days
days
outcome and major bleeding at 9 days
Absolute Risk Reduction -0.1 1.9 1.7 Hazard
Ratio 1.01 0.52 0.81 Confidence
Interval 0.901.13 0.440.61 0.730.89 p 0.007
lt 0.001 lt 0.001
p for noninferiority p for superiority. Yusuf
S, et al. N Engl J Med 2006354146476.
26
Anticoagulants NSTEMI

• Conservative therapy
• Fondaparinux, enoxaparin (for 8 days or duration
  of hospitalization) or
• Unfractionated heparin (UFH) (for 48 hours) (in
  that order).
• Invasive therapy
• enoxaparin or UFH-based regimens have the most
  supporting evidence.
• Bivalirudin can be use in PCI.

27
Oxygen 2008

• Supplemental oxygen should be administered to pts
  with oxygen sat lt 90 (I)
• Supplemental oxygen to all pts with uncomplicated
  ACS during the first 6 hrs (IIa)

28
NTG

• Nitroglycerin changed to 0.4 mg SL every 5
  minutes (no maximum dose) until patient is
  pain-free or hypotension prevents further doses
• Normal Saline fluid bolus of 250 cc will be used
  if hypotension occurs (w/o Base Hospital
  Physician order) and may be repeated once
• Morphine is now by Base Hospital Physician order
  only

29
Analgesia

• Morphine downgraded from I to IIa in NSTEMI and I
  in STEMI but should be caution because may
  increase adverse events in UA/NSTEMI.
• NSAIDS other than ASA should be discontinued on
  admission because increase mortality,
  reinfarctin, and HF in proportion to degree of
  COX-2 selectivity.
• Do not initiate during acute phase of management

30
Why does Morphine lead to poor outcomes?

• Masks myocardial ischemia
• Reduces preload
• May increase ischemia in preload dependent hearts
• May depress heart rate, blood pressure,
• and oxygen delivery

31
Beta-Blockers

• Oral BB within first 24 hrs who do not have
  contraindications.
• IV BB should only for hypertension who do not
  have contraindications.
• Contraindications
• Signs of heart failure
• Evidence of a low output state
• Increased risk for cardiogenic shock age gt 70
  yr, SBP lt 120 mmHg, HR lt 60 t/min, HR 110
  t/min.
• Other relative contraindications to beta blockade
  
• PR interval gt 0.24 seconds
• Second- or third-degree heart block
• Active asthma or reactive airway disease

32
Calcium Channel Blockers

• Class I indications none
• Number of studies showing mortality reduction in
  AMI none
• Class IIb indications
• Diltiazem (Cardizem) for NSTEMI
• If no LV dysfunction or pulmonary congestion
• (41 increase in cardiac events, if present)
• After first 24 hr, up to 1 yr
• Class III indications
• Short acting Nifedipine
• Diltiazem and Verapamil if LV dysfunction is
  present

Multicenter Diltiazem Reinfarction Trial NEJM
1988, 319385-392.
33
ACEI

• Indicate in all patents with ACS (all
  atherosclerosis or atherosclerosis risk
  equivalents)
• Oral ACEI should be start within 24 hrs (without
  contraindication) in the conditions of CHF and
  poor EF (40)
• ARB can be use if ACEI in tolerate.
• IV ACEI is contraindicate within 24 hrs of ACS
  except refractory hypertension

34
How to selection of Rx NSTEMI

• Conservative
• Based on physician and patient preference.
• In patients who are stable for 12-24 hours on
  conservative therapy, noninvasive stress testing
  should be performed prior to discharge.

• Early Late invasive
• High-risk score patients with ongoing symptoms
• Hemodynamic instability
• Sustain VT
• CHF or new or worsening MR
• Elevated cardiac biomarkers
• PCI within 6 mo.
• Prior CABG
• Poor LVEF lt 40

35
How to selection of Rx STEMI

• Invasive Rx.
• PCI capability should be treated with primary PCI
  within 90 minutes of first medical contact as a
  systems goal.

• Noninvasive Rx.
• who cannot be transferred to a PCI center and
  undergo PCI within 90 minutes of first medical
  contact should be treated with fibrinolytic
  therapy within 30 minutes of hospital
  presentation as a systems goal unless
  fibrinolytic therapy is contraindicated.

36
Percutaneous coronary angioplasty
37
Primary PCI and Lytic Therapy



Death Reinfarction
Death Reinfarction 30
days
6 months
Grines CL. Circulation 1999
38
Indication of Primary PCI

• Angina within 3 hrs and expected
• DTB DTN less than 1 hr
• Angina after 3 hrs
• Severe CHF within 12 hrs of angina (I) or 12-24
  hrs of angina (IIa)
• Shock within 36 hrs of angina (I) and recommend
  PCI within 18 hrs of shock

39
Coronary Arterial Bypass Graft
40
Indication for CABG

• Fail or contraindication to PCI or? Fibrinolytic
  drugs
• Lesion is not suitable to PCI
• LM disease
• Triple disease
• Complicated AMI
• acute severe MR
• Rupture LV, VSD

41
Indications for Refer

• STEMI with candidate thrombolysis. (center is not
  available)
• STEMI with contraindicate to thrombloysis.
• ACS with complications.
• Shock
• Intractable arrhythmia CHB, VT, VF
• Intractable heart failure
• Mechanical complications VSD, MR, Pericardial
  effusion, Perforate heart.

42
RV infarction

• Associated to inferior wall MI
• High mortality
• Physical examination
• NV engorged and no sign of CHF
• Volume sensitive MI
• Diagnosis criteria
• ECG Inferior MI ST-T elevation in V3,4R
• High RA pressure (RAPgt10mmHg) and normal PWP
  (RAP/PWP ratio gt 0.8)

43
Right Ventricular Infarction
44
Principle of RV Infarction management

• Reduce infarction area
• Adequate volume expansion
• invasive monitoring CVP, PCWP
• Caution of vasodilation, morphine and diuretic
• Inotropic agents
• IABP
• AV synchrony
• DC shock AF, SVT
• Pacing Heart block

45
Complicated AMI

• Congestive heart failure
• Cardiogenic shock
• Acute mitral regurgitation
• Acute VSD
• LV perforation
• VF, Heart block

46
Congestive heart failure

• Mechanism
• Diastolic failure
• Systolic failure (area infarction gt 40)
• Arrhythmia
• Principle of management
• Reduced infarct area
• Reduced preload
• Reduced afterload
• Increase contractility
• Medication Diuretic, Inotropic agents,
  Vasodilator
• Nonmedical Mx. Ventilator, IABP, Pacing

47
Shock

• Mechanism
• RV infarction (Volume responsive)
• LV infarction (impair systolic function)
• Arrhythmia (Bradycardia.
• Principle of management
• Reduce infarct size
• Adequate volume
• Invasive monitoring ???? PCWP, A-line
• Vasopressive agent
• Nonmedical Mx IABP, Pacing

48
Acute mitral regurgitation

• Mechanism
• Papillary m. ischemia
• Dysfunction
• Rupture
• LV dysfunction
• Increase LVEDP
• Annulus dilatation

• Principle of management
• Reduced infarct size
• Reduced afterload
• Medical
• IABP
• Increase contraction

49
VSD or LV rupture

• Mechanism
• Large infarction
• Principle of management
• Reduced infarct size
• Early surgery in free wall rupture
• VSD with hemodynamic stable, elective CABG with
  VSD closure should be perform in 2 wks

50
VF, Heart block

• Mechanism
• Ischemia induce irritability of myocardium
• Principle of management
• ??????????????????????????????????
• ?? afterload ?????? ???? IABP
• Early defibrillation in primary VT/VF
• Antiarrhythmic in secondary VT/VF
• Pacing according indications

51
Primary Prevention
52
Identification Pts Risk

• Evaluate the presence and status of control of
  major risk for CAD for all pts at regular
  interval (every 3-5 yrs)
• Ten yrs risk should be calculated for all pts who
  have 2 or more major risk factors to assess the
  need for 1 prevention.
• CAD pts and pts with CAD risk equivalent should
  be identified intensive 2 prevention.
• DM, CKD or 10 yr risk greater than 20 are the
  CAD risk equivalent

53
Secondary Prevention and Long-Term Management
54
Risk Factor Modification

• Smoking Cessation
• 2.5 increased mortality risk reduced if quit
• Diet modification
• Low fat, low cholesterol
• Hypertension
• Poorly controlled BP increases mortality risk
• Diabetes
• Tight control, metformin if obese
• Cardiac rehab (with exercise)
• Mortality benefits, Quality of Life

55
Secondary Prevention

• Aspirin
• Continue indefinitely
• Benefits established to 27 months (death,
  non-fatal MI/stroke - ARR 4)
• Betablockers
• Continue indefinitely
• Long-term mortality benefits shown BHAT, ISIS-1
• Titrate dose (according to BP) to HR of 60bpm

56
Secondary Prevention (continued)

• ACE Inhibitors
• LVF patients mortality reduction at 1 to 5 yrs
• Patients without LVF ? reduction in mortality,
  MI, stroke (often initiated months after MI)
  HOPE
• Lipid therapy
• Statins have shown long-term mortality benefits
• Targets
• LDL lt 70 mg/dl

57
Medications Post-surgical Intervention

• CABG (Coronary Artery Bypass Graft)
• anti-anginal medications usually ceased
• continue secondary prevention medications
• PTCA (Percutaneous Transluminal Coronary
  Angioplasty) Stent Insertion
• continue clopidogrel and higher dose (300mg)
  aspirin daily for 9 month post-stent then low
  dose aspirin indefinitely CLASSICS

58
Secondary Prevention

• BP goal
• General goal below 140/90 mmHg
• DM and CKD below 130/80 mmHg
• Statin goal
• LDL-C lt 100 mg/dL I (A)
• consider LDL-C lt 70 mg/dL IIa (A)
• DM goal HbA1c lt 7

59
Secondary Prevention

• Ask, advise, assess, and assist patients to stop
  smoking
• Daily physical activity 30 min 7 d/wk, minimum 5
  d/wk
• Hormone replacement therapy (HRT) should not be
  started in patients with ACS. Patients on HRT at
  the time of ACS should be advised to discontinue
  it.
• Annual influenza immunization

60
??????????????????????????????????? ACS
61
??????????????????? 1

• ??????????????????????????????? ??????????
• ??????????
• ?????????????????
• ???????????????????????????????????
• ??????????????????????????????????????? 35
  ????????????????? 3 ??????? ??????????????????????
  ?????????????? ???????????? ???????????????
  ???????????????????

62
??????????????????? 2

• ??????????????????????????????????????????????????
  ???????????????????????????????
• ????????????
• ??????????????????
• ??????????????????????????????????????????????????
  
• Stroke
• PAD
• CAD

63
??????????????????? 3

• ??????????????????????????????????????????????????
  ?????
• ?????????????????????????
• ??????????????????? ????????????????
• ???????????????????????????????????
• ?????????????????????????
• ??????????, ???????????, ?????????????????????????
  ???????????????????
• ??????????????????????? NSAIDS
• ????????????????????????????????????
• ????????????????????????????????????????????????
  (Primary prevetnion)
• ASA, Statin, ACEI or ARB.

64
????????????????????

• ????????????????????????????????????? ????????
  angina, syncope, CHF
• ??????????????????? Nitrate ???????????? angina
• ???????????????????????????????.???? 1669
  ?????????????????
• ??????????????????????????????????????????????????
  ??????????? ??????
• ????????????????????? angina ??? Guideline
  ??????????????????????????
• ????????????????????????????
• ?????? ASA V ?????????????????????????? ??????
  Nitrate ?????? Oxygen therapy
• ????????????????????????????? Thrombolytic

65
???????????

• ??????????????????????????????????? ????????
  angina ??? Guideline ??????????????????????????
• ????????????????????????????????? 10 ????
  ???????????????
• ?????? ASA V ??????????? ???????????????
• ???????????????????
• ?????? Oxygen therapy
• ????????????? ????????????????????????????????????
  ????? ???? CBC, BS, BUN, Cr, Elyte, Cardiac
  enzyme, Lipid profile
• ?????? Nitrate ???????????????
• ?????? Morphine ???????????????
• ????????????????????????????? Thrombolytic
  ????????????????????? Guideline

66
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67
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70
?????????

• ??????????????????????????????????????????????????
  ????
• ??????????????????? chest pain score
• ???????????????????? ????????? cardiopulmonary
  examination.
• ???????????????????????? (monitor EKG, serial EKG
  q 6 hr.) ???????????????? Throbolytic
  ??????????????????????????????????????????? 90
  ???????????????????????????????????? ??? ST
  segment ??????????? 50 ????????????????
• ???????????????????????????????? (Cardiac enzyme
  q 6 hr.)
• ????????????????????????????????????? 24 hr.
  ??????????????????????????

71
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72
?????????????

• ??????????????????????????????????????????????????
  ??? ???????????? Guideline ???????????
  ?????????????????????????? ????????????? Fax EKG
  ??????????? 13 ???? ??? Code ????????????????????.
  ?????????????????
• ??????????????????????????????????????????????????
  ???????????????????????
• ????????????????????? monitor, ventilator,
  medications
• ???????????????????????????????????????
• ?????????????????????????????????????????????
• ????????.??????? Refer ?????????.???????? Refer
  ?????????????.??????????????????

73
???????????????????????? ?????????????????????????
??????????????????????????????????????????????????
???????? (Pilot Project of Comprehensive
Cardiac Referral System in Khon Kaen
Province) ???? ...................................
...................... ??????? ...................
.................................................
???? ................????? O ??? O
???? ?????????????????? .....................
............................. ??????
..............................???????????? O
??????? O ??????? O ????? O ????????? O
??????????????????????????????????? O
UA O NSTEMI O STEMI??????????????
?????? O ????????????????????? O
???????????????????? O ???????????????????? 1.
??????????????? ???? ............................
...... ?. 2. ?????????????? ????
.................................. ?. 3.
???????????????????? ????? .......................
..... ?????/???? ??????? .....................
... ??. ???? 4. ???????????????? O
?? O ????? 5. ???????????????
O STEMI O NSTEMI ???? UA
???? ...................... ?.
6. ???????????? O ?? O ?????
74
???????????????????????? (???) 7.
???????????????? O ASA O ??? O ??????
O Clopidogrel O ??? O ?????? 8.
??????????????? (NTG) O ??? O ??????
???? .......................................
.............. 9. ????????? O ??? O
?????? ???? ............................
???? .................. ?. 10.
???????????????????????????? (LMWH) O ??? O
?????? ???? ..............................
...................... ???? .....................
....... ???? .................. ?. 11.
???????????????? (Thrombolytic) O ??? O
?????? ???? ..............................
...................... ???? .....................
....... ???? .................. ?. 12.
????????????????????? O Dopamine ????
............................ O Adrenaline
???? ............................ 13. ??? ET
tube O ??? O ?????? 14. ????????? CPR O
??? O ?????? 15. ???????????????????????????
? O ???? O ??????? 16. ??????????????????????
?? ????? .................................
?????/???? 17. ???????????????????
..................................................
............................... 18.
?????????????????? Refer ???? ....................
.................................................
???????????? ...................................
................................
75
??????????????????

• ?????????????? ???????? ????????? ??????????????
• ????????????????????????????????? ??????????????
  ?????????????? ???????? ??????????????????
• ??????????????????????????????????????????????????
  
• ????????????????? ????????????????????????????????
  ?????????????????????????????? ???????????????????
  ???????????????? Echo ?????????????????

76
??????????????????

• ???????????? ?????????
• ???????????????????????????????????????????
• ??????????????????????????????????
  ????????????????? Echo EST CAG ??????????????
• ???????????????????????????????????????????????
  LDL lt 70 mg/dl, BS lt 140, HbA1c lt 7
• ??????????????????????????????????????????????

77
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