Title: Coronary heart disease
1???????????????????????????????????????????(Coro
nary heart disease)
- ??? ??.??. ????????? ??????????
- ???????????????????????? ??????????????????
- ??????????????????? ????????????????????
- ????????????? ??????????????????
2Pathophysiology
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
3Pre hospital management
- Health education program
- Risk control
- Symptoms
- Call EMS earlier
- How to contact?
- When to contact?
- Early EKG on site
- ASA on site.
4ED 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
5Investigations
- Electrocardiography
- Cadiac enzyme
- Chest film
- Echocardiography
- Coronary angiography, CAG
- Other risk factors FPG, lipid profiles
6Chest film
- Cardiac abnormality
- Determine CHF
- DDx
- Aortic dissection
- Pericardial effusion
7Echocardiography in ACS
8Coronary angiogram
9TIMI 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
10TIMI 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.
11Principle 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
12Medication 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
13Efficacy of fibrinolytic agents to mortality
Percentage mortality
0-1h 2-4 h 4-6 h
7-12 h 13-24 h
Lancet 1994343311
14Fibrinolytic 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
15Fibrinolytic 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
???????????? ?
17Antiplatelets 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.
18Antiplatelets 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.
19CLARITY-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.
20COMMIT 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)
21Antiplatelets GPIIb/IIIa
- All patients receiving intravenous GP IIb/IIIa
inhibitors must also receive concomitant UFH or
another antithrombotic agent.
22Heparin
- 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
23Am Heart J 2002 143 966-70
24ExTRACT-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.
25OASIS 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.
26Anticoagulants 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.
27Oxygen 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)
28NTG
- 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
29Analgesia
- 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
30Why 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
31Beta-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
32Calcium 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.
33ACEI
- 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
34How 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
35How 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.
36Percutaneous coronary angioplasty
37Primary PCI and Lytic Therapy
Death Reinfarction
Death Reinfarction 30
days
6 months
Grines CL. Circulation 1999
38Indication 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
39Coronary Arterial Bypass Graft
40Indication 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
41Indications 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.
42RV 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)
43Right Ventricular Infarction
44Principle 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
45Complicated AMI
- Congestive heart failure
- Cardiogenic shock
- Acute mitral regurgitation
- Acute VSD
- LV perforation
- VF, Heart block
46Congestive 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
47Shock
- 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
48Acute 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
49VSD 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
50VF, 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
51Primary Prevention
52Identification 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
53Secondary Prevention and Long-Term Management
54Risk 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
55Secondary 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
56Secondary 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
57Medications 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
58Secondary 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
59Secondary 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
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62??????????????????? 2
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??????????????????????????????? - ????????????
- ??????????????????
- ??????????????????????????????????????????????????
- Stroke
- PAD
- CAD
63??????????????????? 3
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????? - ?????????????????????????
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??????????????????? - ??????????????????????? 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(No Transcript)
67(No Transcript)
68(No Transcript)
69(No Transcript)
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(No Transcript)
72?????????????
- ??????????????????????????????????????????????????
??? ???????????? Guideline ???????????
?????????????????????????? ????????????? Fax EKG
??????????? 13 ???? ??? Code ????????????????????.
????????????????? - ??????????????????????????????????????????????????
??????????????????????? - ????????????????????? monitor, ventilator,
medications - ???????????????????????????????????????
- ?????????????????????????????????????????????
- ????????.??????? Refer ?????????.???????? Refer
?????????????.??????????????????
73???????????????????????? ?????????????????????????
??????????????????????????????????????????????????
???????? (Pilot Project of Comprehensive
Cardiac Referral System in Khon Kaen
Province) ???? ...................................
...................... ??????? ...................
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..............................???????????? 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 ???? ....................
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75??????????????????
- ?????????????? ???????? ????????? ??????????????
- ????????????????????????????????? ??????????????
?????????????? ???????? ?????????????????? - ??????????????????????????????????????????????????
- ????????????????? ????????????????????????????????
?????????????????????????????? ???????????????????
???????????????? Echo ?????????????????
76??????????????????
- ???????????? ?????????
- ???????????????????????????????????????????
- ??????????????????????????????????
????????????????? Echo EST CAG ?????????????? - ???????????????????????????????????????????????
LDL lt 70 mg/dl, BS lt 140, HbA1c lt 7 - ??????????????????????????????????????????????
77(No Transcript)