ACS Updates

1
ACS Updates

• Joe Lex, MD, FAAEM
• Temple University
• Philadelphia, PA USA

Heavily Borrowed from Amal Mattu
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Disclosure
Nothing to declare
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• New Risk Factors

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Stopping NSAIDs

• Compare 8688 first MI with 33,923 matched
  controls
• First MI no difference between nonusers and
  current users
• Stopping NSAIDs significantly increased odds for
  MI within 29 days after cessation

Fischer et al. Arch Intern Med 2004 1642472
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Stopping NSAIDs

• Worse if
• gt40 NSAID prescriptions
• RA or SLE
• Consistent among most common nonaspirin NSAIDs
  ibuprofen, indomethacin, ketoprofen, naproxen

Fischer et al. Arch Intern Med 2004 1642472
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Hostility

• Recognized risk for 1st event
• What about reoccurrence?
• 3227 outpatients in Nova Scotia followed for 4
  years
• Composite end points death and hospitalization

Haas DC et al Heart 2005911609-1610
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Hostility

• Hostility predicted bad end points in men
• Hostility protective in women

Haas DC et al Heart 2005911609-1610
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SLE and ACS

• Patients with SLE have MIs 20 years earlier than
  those without
• Young patients with SLE have 9-fold risk of
  significant CAD
• Women age 35 44 with SLE have 50-fold risk of
  significant CAD

Mattu A, et al Am J Emerg Med 200523696
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Triggers of MI

• That couldnt be MI because
• it started during an argument, so it must be
  stress or anxiety.
• it started while eating spicy food, so it must
  be indigestion.
• it woke him up from sleep, so it cant possibly
  be a heart attack.

Culic V et al Int J Cardiol 2005991-8
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Triggers of MI
Culic V et al Int J Cardiol 2005991-8
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• Chlamydia Hypothesis

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Chlamydia Hypothesis 1

• PROVE IT TIMI 22
• 4162 patients
• gt60 PCI for chlamydia
• Gatifloxacin x 2 weeks, then 10 days / month
• Two year follow-up

Cannon et al. N Engl J Med 20053521646
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Chlamydia Hypothesis 1

• No difference in death, MI, hospitalization for
  unstable angina, revascularization, stroke
• Subgroup analysis still no difference, even with
  highest chlamydia titers

Cannon et al. N Engl J Med 20053521646
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Chlamydia Hypothesis 2

• 4012 patients with stable angina
• Azithromycin 600 mg weekly for one year
• Four year follow-up
• No difference in any primary or secondary endpoint

Grayston et al N Engl J Med 2005 3521637
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• History

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Chest Pain History

• Stabbing, pleuritic, positional, or reproducible
  by palpation lessens possibility of ACS
• but no descriptor or combination good enough to
  rule out ACS
• All we can do is risk stratify
• Best predictor pain to right arm

Swap CJ et al. JAMA 20052942623-2629
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GERD vs. MI

• 20 of patients with AMI describe pain as
  indigestion
• Give him a GI cocktail
• 15 AMI patients get some relief from antacids
• 7 AMI patients get complete relief from antacids

Dobrzycki et al. Int J Cardiol 20059967-72
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GERD vs. MI

• 20.6 of acute cardiac ischemia is associated
  with acute GERD
• GERD patients have longer periods of ischemia,
  more frequent ST depression
• GERD may provoke / worsen ACS

Dobrzycki et al. Int J Cardiol 20059967-72
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• Sidetrack

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Pericarditis

• 120 patients with first pericarditis
• Group I aspirin only
• Group II aspirin colchicine
• Steroids rescue medicine only

Imazio M et al. Circulation 20051122012
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Pericarditis

• Steroids independent risk factor for recurrence

Imazio M et al. Circulation 20051122012
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• Therapy ACS

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COMMIT

• Clopidogrel and Metoprolol in Myocardial
  Infarction Trial
• Chinese study 45,852 patients with acute MI
• 87 STEMI
• 7 ST depression
• 6 LBBB

Chen et al. Lancet. 2005366(9497)1607-21
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COMMIT

• Composite endpoint death or reinfarction or
  stroke
• Death from any cause
• Treatment (all got aspirin 162mg)
• Clopidogrel 75 mg/d 22,961
• Placebo 22,891

Chen et al. Lancet. 2005366(9497)1607-21
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Clopidogrel Arm

• 9 relative ? in all endpoints
• 9.2 vs. 10.1 p0.002
• Absolute reduction 0.9
• 9 fewer events per 1000 patients ? NNT 110
• 7 reduction in death
• 7.5 vs. 8.1 p0.03

Chen et al. Lancet. 2005366(9497)1607-21
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Clopidogrel Arm

• Fibrinolytic used urokinase
• Not fibrin-specific
• Relatively low rate (54) of PCI
• For elderly patients who got fibrinolytic
  therapy, no safety data in those who also got
  clopidogrel

Chen et al. Lancet. 2005366(9497)1607-21
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Metoprolol Arm

• 5mg IV x 3, then 50 mg po x 28d

Chen et al. Lancet. 2005366(9497)1607-21
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Metoprolol Arm

• At two weeks
• ? 11 / 1000 cardiogenic shock
• Most apparent days 0 1
• ? 5 / 1000 reinfarction or v-fib
• Most apparent day 2 onward
• Conclusion delay beta-blocker until
  hemodynamically stable

Chen et al. Lancet. 2005366(9497)1607-21
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What If We Change Controls ??

• Clopidogrel death/MI/CVA placebo 10.1 vs.
  treated 9.2
• NNT 110
• Metoprolol death/MI/CVA placebo 9.9 vs.
  treated 9.4
• NNT 200

Chen et al. Lancet. 2005366(9497)1607-21
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What If We Change Controls ??

• If we switched placebo groups
• Clopidogrel now changes outcome from 9.9 to 9.2
• Metoprolol now changes outcomes from 10.1 to
  9.4
• Clopidogrel new NNT 143
• Metoprolol new NNT 143

Chen et al. Lancet. 2005366(9497)1607-21
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Early Statins During MI 1

• National Registry of Myocardial Infarction (NRMI)
  Database
• Statins
• already being taken by 9.8
• given within 24 hours to 22.4
• stopped in some
• not used in remainder

Fonarow et al. Am J Cardiol. 2005 96(5)611
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Early Statins During MI 1

• Database info not randomized, controlled, or
  double-blinded

Fonarow et al. Am J Cardiol. 2005 96(5)611
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Early Statins During MI 1

• Associated with lower
• cardiogenic shock
• arrhythmias
• cardiac arrest
• myocardial rupture
• But no change in recurrent MI

Fonarow et al. Am J Cardiol. 2005 96(5)611
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Early Statins During MI 2

• PROVE IT-TIMI 22
• Pravastatin or Atorvastatin Evaluation and
  Infection Therapy Thrombolysis in Myocardial
  Infarction 22
• 4162 patients hospitalized with ACS, followed for
  24 months

Ray KK, et al. J Am Coll Card 200546(8)1405
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Early Statins During MI 2
Ray KK, et al. J Am Coll Card 200546(8)1405
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LMWH vs. UFH in ACS

• Low-molecular weight heparin ? no advantage

Mahaffey et al. JAMA. 2005 294(20)2594
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Heparin Hurt or Harm?

• Bleeding occurs in 3 9
• Need to be weight based and dependent on renal
  function
• When overdosed, cause major bleeding ICH,
  transfusion, hematocrit fall 12 or greater

Alexander KP et al JAMA 20052943108
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Unfractionated heparin
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Significant Bleeding
Low molecular weight heparin
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GP2B3A inhibitor
15
10
5
0
Underdose
Slight excess
Major excess
Recommended
Alexander KP et al JAMA 20052943108
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Heparin Hurt or Harm?

• Dosing errors common must be weight based
• More side effects in elderly
• More common if renal impaired

Alexander KP et al JAMA 20052943108
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GP IIbIIIa Inhibitors

• Helps in NSTEACS / USA if PCI
• 27,115 patients with AMI
• Abciximab reduced 30-day mortality (3.4 ? 2.4)
  and 6-12 month mortality (6.2 ? 4.4) in STEMI
  patients undergoing PCI

De Luca et al. JAMA 20052931759-1765
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GP IIbIIIa Inhibitors

• Slight increased bleeding risk when combined with
  lytic (5.2 vs. 3.1) but not with PCI alone
• Eptifibatide no benefit
• Tirofiban no benefit

De Luca et al. JAMA 20052931759-1765
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Door-to-Balloon Times

• Current ACC / AHA guidelines STEMI patients get
  balloon inflation within 90 minutes
• If longer, use fibrinolytic agent
• National Registry of Myocardial Infarction 4278
  patients from 419 hospitals

Nallamothu et al. Circulation 2005111761
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Door-to-Balloon Times

• Median door-to-balloon 180 minutes
• Treated within 90 minutes 4.2
• If PCI available at hospital where patient
  presents door-to-balloon time 120 minutes

Nallamothu et al. Circulation 2005111761
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Door-to-Balloon Times

• Editorial with last article
• Even when presenting hospital has PCI, lt30 have
  door-to-balloon lt90 minutes
• Too early to recommend routine transfer for
  primary PCI for all patients with STEMI.

Hermann HC. Circulation 2005111718-720
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• Therapy CHF

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Morphine for Heart Failure

• ADHERE registry of CHF
• 20,782 patients got morphine
• 126,580 patients did not

Peacock WF et al. AEM 200512(5Suppl. 1)97
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Morphine for Heart Failure

• Morphine for CHF substandard

Peacock WF et al. AEM 200512(5Suppl. 1)97
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Nesiritide 1

• CHF declining renal function poor prognostic
  sign
• 5 randomized trials, 1269 pts
• Nesiritide significant increase risk of
  worsening renal function
• Trend toward higher mortality

Sackner-Bernstein et al. Circulation
20051111487
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Nesiritide 2

• Three randomized double-blind studies
• 30 day mortality higher in nesiritide (7.2) than
  controls (4.0)

Sackner-Bernstein et al. JAMA 20052931900
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• Brugada

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Brugada Syndrome

• EKG Findings
• Complete or incomplete Right Bundle Branch Block
  in V1 V2
• 2 mm ST elevation in V1 or V2
• Placing leads V1 / V2 up one rib space increases
  accuracy

Francis J et al. Int J Cardiol 2005101173
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Brugada Syndrome
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Brugada Syndrome

• Responsible for
• 4 of sudden death
• 20 if no structural disease
• ? ? SIDS
• No treatment mortality 10/yr
• With AICD 100 survival

Francis J et al. Int J Cardiol 2005101173
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• ACLS Updates

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1. Chest Compressions

• Encourage rescuers to push hard and fast at a
  rate of about 100 compressions per minute, with
  about equal time for compression and relaxation
  and as few interruptions in compressions as
  possible.

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2. New Ratio

• New compression-to-ventilation ratio for lone
  rescuers of 302 for all victims from infants
  (excluding newborns) through adults. New
  approach longer series of uninterrupted chest
  compressions

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3. Rescue Breathing

• Rescue breaths last 1 second and cause the chest
  to rise. Previously, the duration standard was
  not precise and mentioned durations of 1 to 2
  seconds, now deemed too long.

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4. Defibrillation

• One shock followed by immediate chest
  compressions. Previously, the rule was 3 shocks
  without CPR between them. The new system
  increases the chances that the heart can create
  blood flow after the shock.

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5. Basic Life Support

• BLS now emphasized over pulse checks and drug
  administration. Rescuers should not sacrifice
  chest compressions right after a shock to do
  pulse checks or administer drugs, although
  neither of these practices was eliminated from
  the guidelines.

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6. AEDs in Kids

• Automated external defibrillators for all
  children age 1 year or older.

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7. Cooling the Survivors

• Unconscious adults with return of spontaneous
  circulation (ROSC) after out-of-hospital cardiac
  arrest be cooled to 32 to 34 Celsius for 12 to
  24 hours when the initial rhythm was ventricular
  fibrillation.

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Thank you for your attention

• For copy of slideset joe_at_joelex.net