SURVIVE STEMI

1
Heart Attacks Killers in Disguise!
W. Frank Peacock, MD, FACEPVice Chief, Emergency
DepartmentThe Cleveland Clinic
2
Agenda

• What is an Acute Coronary Syndrome?
• (a heart attack)
• Why do you care?
• CAD is the number one killer in Scotland
• Who gets ACS?
• What are the symptoms?

3
Agenda

• When should you go to the hospital?
• why you should go to the hospital?
• How do we diagnosis it?
• What happens if your diagnosed with it?
• What can be done to prevent getting this?

4
How does the heart work?

• Its just a pump, right?

5
Its also a gland
Myocardial injury
Fall in LV performance
ANP BNP
Activation of RAAS, SNS, ET, and others
Peripheral vasoconstriction Hemodynamic
alterations
Myocardial toxicity
Remodeling and progressive worsening of LV
function
Heart failure symptoms
Morbidity and mortality
6
Epidemiology of CHD in the US

• Single most frequent cause of death
• 656,000 deaths in 2002
• 1 of every 5 deaths
• Incidence
• Each year, 1.2 million Americans will have a new
  or recurrent coronary event, and gt40 will die as
  a result
• 700,000 events will be first attacks 500,000
  will be recurrences
• Prevalence
• 13 million Americans have a history of CHD
  (acute MI, other acute ischemic (coronary) heart
  disease, angina pectoris, atherosclerotic
  cardiovascular disease, and all other forms of
  heart disease)

CHD coronary heart disease MI myocardial
infarction.American Heart Association. Heart
Disease and Stroke Statistics2005 Update 2005.
7
Epidemiology of CHD Scotland

• Single most frequent cause of death
• Incidence
• Prevalence

CHD coronary heart disease MI myocardial
infarction.American Heart Association. Heart
Disease and Stroke Statistics2005 Update 2005.
8
Risk for CHD Increases With Additional Risk
Factors INTERHEART Study
512 256 128 64 32 16 8 4 2 1
Odds ratio (99 Cl)
PS psychosocial
Yusuf S, et al. Lancet. 2004364937-952.
9
INTERHEART Impact on CV Risk of Multiple Risk
Factors (Smoking, Lipids, Hypertension, Diabetes,
Abdominal Obesity, Diet, ?Physical Activity,
Alcohol, Psychosocial)
512
Large intl case-control study 15,152 cases
14,820 controls 52 countries Follow-up 4
years
256
128
64
32
Odds Ratio for 1st MI (99 CI)
16
Smk smoking DM diabetes HTN
hypertension Obes abdominal obesity Ps
psychosocial factors
8
4
2
1
Smk(1)
DM(2)
HTN(3)
ApoB-ApoA1(4)
123
All 4
All 4 Obes
All 4 Ps
All riskfactors
eg, stress, depression Note odds ratio plotted
on a doubling scale.
.
Yusuf S, et al. Lancet. 2004364937-952.
10
What does an ACS feel like?
11
Symptoms of CAD

• NONE..
• Sudden Cardiac Death
• Chest Pain
• Usually a pressure
• Not seconds
• Anginal equivalents
• Jaw or shoulder pain
• Nausea vomiting
• Shortness of breath
• Weak dizzy
• Diaphoresis

12
Symptoms of Heart Attack

• Anginal equivalents
• Jaw/shoulder pain
• Nausea vomiting
• Shortness of breath
• Weak dizzy
• Diaphoresis

• Classicpresentation
• Chest pressure
• Elephant
• Sweating
• Nausea/vomiting
• Radiation of pain
• Shortness of breath

13
Who gets Equivalents?

• Women
• Diabetics
• Elderly
• Heart Transplant patients
• Patients who cant perceive/communicate well?
• Drunk
• Mentally ill

14
Options for Transport of Patients With STEMI and
Initial Reperfusion Treatment
Hospital fibrinolysis door-to-needle within
30 min
Not PCI capable
Call 9-1-1 Call fast

• EMS on-scene
• Encourage 12-lead ECGs
• Consider prehospital fibrinolytic if capable and
  EMS-to-needle within 30 min

EMS triage plan
Inter-hospital transfer
Onset of symptoms of STEMI
9-1-1 EMS dispatch
PCI capable
GOALS
5 min
8 min
EMS Transport
Patient
EMS
Prehospital fibrinolysis EMS-to-needle within 30
min
EMS transport EMS-to-balloon within 90
min Patient self-transport Hospital
door-to-balloon within 90 min
Dispatch 1 min
Golden hr 1st 60 min
Total ischemic time within 120 min
Adapted with permission from Antman EM, et al.
Available at http//www.acc.org/clinical/guidelin
es/stemi/index.pdf. Accessed November 1, 2005.
15
What happens in the Ambulance?

• Paramedics take your history and perform a
  brief exam
• IV
• Oxygen
• Put on the monitor
• May receive nitroglycerin under the tongue.
  (tingle, get a H/A)
• Maybe ECG, thrombolytic (clot dissolver)

16
What happens when you get to the hospital?
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ED Visits - US
130,000,000 annually
10.4 M chest pain (8.0)
6.24 M suspected or actual cardiac
4.1 M sent home non-cardiac
50,000 MIs
3.1 M non-cardiac (50)
1.2 M AMI (20)
1.5 M UA (24)
374,400 sudden death (6)
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Spectrum of Acute Coronary Syndromes
Ischemic Discomfort at Rest
Presentation
ST-segment Elevation
No ST-segment Elevation
Emergency Department

Cardiac Markers




In-hospital 6-24 hours
Unstable Angina (UA)
Non-Q-wave MI (NSTEMI)
Q-wave MI (STEMI)
Adapted from Braunwald E, et al. Available at
http//www.acc.org/clinical/guidelines/unstable/un
stable.pdf
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STEMI Brief Physical Exam in the Emergency
Department

• Airway, Breathing, Circulation (ABC)
• Vital signs, general observation
• Presence or absence of jugular venous distension
• Pulmonary auscultation for rales
• Cardiac auscultation for murmurs or gallops
• Presence or absence of stroke
• Presence or absence of pulses
• Presence or absence of systemic hypoperfusion
  (cool, clammy, pale/ashen)

Antman EM, et al. Available at
http//www.acc.org/clinical/guidelines/stemi/index
.pdf. Accessed November 1, 2005.
20
STEMI Acute Medical Therapy

• Analgesics
• Nitrates
• Oxygen
• ß-blockers (decrease heart rate)
• Primary PCI or coronary thrombolysis(primary PCI
  preferred after 3 hours)
• Aspirin (162-325 mg, acute dose)
• Heparin
• If PCI
• Clopidogrel
• GP IIb/IIIa inhibitors

• General treatment
• measures

Infarct size limitation
Reperfusion
Antithrombotic and antiplatelet therapy
Antman EM, et al. Available at
http//www.acc.org/clinical/guidelines/stemi/index
.pdf. Accessed November 1, 2005.
21
Chest Pain on a Saturday morning

• While the physician was examining the ECG, the
  patient became unconscious and the rhythm on the
  monitor changed

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Chest Pain on a Saturday morning

• 1201 100J DC cardioversion, patient
  immediately in NSR
• 1203 Clot box brought to room and
  catheterization lab team notified
• 1204 IV line started, 325 mg aspirin chewed
  and metoprolol given
• 1210 Open cath table and staff available,
  heparin iv and clopidogrel po given
• 1219 Patients stretcher rolls

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Goals of Reperfusion Therapy
Patient
Transport
In-hospital
Reperfusion
D-N 30 min
5 min
lt 30 min
D-B 90 min
Methods of Speeding Time to Reperfusion

• Media campaign
• Patient education
• Greater use of 9-1-1

• MI protocol
• Critical pathway
• Quality improvement program

• Bolus lytics
• Dedicated PCI team

• Prehospital ECG and Prehospital Rx, if possible

Adapted with permission from Antman EM, et al.
Available at http//www.acc.org/clinical/guidelin
es/stemi/index.pdf. Accessed November 1, 2005.
24
Time from Symptom Onset to Treatment Predicts 1
Year MortalityPrimary PCI
The relative risk of 1 year mortality increases
by 7.5 for each 30 minute delay.
Roughly 1 every 3 minutes
Y2.86 ( 1.45) 0.0045X1 0.000043X2Plt.001
De Luca G, et al. Circulation. 20041091223-1225.
25
Meta-analysis of 50,246 Patients in Lytic
Trials (Juice to squeeze)
Boersma E, et al. Lancet.1996348771
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Primary PCI vs Thrombolysis in STEMI
Meta-analysis (23 RCTs, N7739)
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Short-term Outcomes (4-6 weeks)
Plt.0001
Bonferroni correction 6 variables p lt0.0083
20
Plt.0001
15
P.0002
Plt.0001
PCI
Frequency ()
P.032
10
Thrombolytictherapy
5
Plt.0001
0
Death
Nonfatal MI
Recurrent Ischemia
Hemor- rhagic Stroke
Major Bleed
Death, Nonfatal Reinfarction, or Stroke
Adapted with permission from Keeley EC, et al.
Lancet. 200336113-20.
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What if the ECG is not diagnostic?

• (As it is in gt95)

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Blood Markers

• Necrosis
• Something has to die
• Strain
• Natriuretic peptides
• Other
• Inflammation
• Plaque rupture
• Ischemia changes the blood

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ACS Sequence and Timing
All Necrosis
All Ischemia
Some Ischemia, Some Necrosis
Amount of Tissue
Time
BNP
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Appearance of necrosis markers
Hospital arrival
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Disease vs Events?
32
What is in the future?

• New better markers

33
What is IMA?
Bar Or et al, European Journal of Biochemistry,
2001
34
Chest Pain at Presentation
EP Protocol with good NPV ischemia marker
35
What if the markers are all negative?

• (And they are in gt90)

36
If It Moves, Even Below Your Hospitals Cutpoint,
It Is Bad
N2,188
Logistic regression models showing the odds
ratios for predicting ACS
MACE MI, revascularization (PCI or CABG), or
positive testing (gt70 stenosis at
catheterization, MPI or non-invasive stress
testing) within 30 days of index visit.
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All this testing Whats the end result?

• Most (88) of the time, its negative
• You go home
• 18 of the time, something is positive
• ECG ? IMMEDIATE Cath lab
• Marker ? URGENT Cath lab
• Stress test ? Semi-elective Cath lab

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What happens in the Cath Lab?

• Define the anatomy
• Acutely closed vessel ? fix it
• Chronically closed vessel ? nothing
• Stenotic vessel have options
• 50 either medicine or angioplasty works
• gt70 most get angioplasty

39
Scotland Epidemiology
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Prevalence of coronary heart disease in Scotland
Scottish Heart Health Study.

• 10,359 men and women aged 40-59 years from 22
  districts in the Scottish Heart Health Study
• Described the prevalence rates of coronary heart
  disease in Scotland in 1984-1986 and their
  relation to the geographical variation in
  mortality in these districts.
• Coronary heart disease in Scotland was the
  highest reported to the WHO from 1984-86
• Angina was more common in men (5.5) than in
  women (3.9)
• A history of MI was 3 times more common in men
  than women
• Angina correlated well with mortality from
  coronary heart disease

Br Heart J. 1990 Nov64(5)295-8
41
2001 The good news

• The Cardiovascular Epidemiology Unit at the
  University of Dundee celebrated its 20th
  anniversary with a 40 decline in coronary
  mortality rate
• The steep decline in coronary mortality in
  Scotland mirrors the pattern in the rest of
  Britain.
• Improvement is a combination of
• Heightened awareness of health issues
• Improved diet and more exercise
• Improvement in treatments.
• Scotland's record on heart disease is much
  improved
• Russia now has the highest coronary mortality
  rate.

42
2003 British Women's Heart and Health Study

• 4286 Women
• 20 MI, angina, HF, CVA, PVD.
• 50 HTN, 12 smoked, 25 obese
• 50 w/ total cholesterol gt 6.5 mmol/l, only 3
  had low HDL
• Age adjusted CVD prevalence
• highest in Scotland 25.0 (21.5 to 28.8)
• lowest in S. England 15.4 (13.5 to 17.6).
• Woman in Scotland are 1.53 times more likely to
  have CVD
• Of women with CVD
• 12 are smokers, 1/3 had uncontrolled HTN, 1/3
  were obese
• 90 had a cholesterol gt 5 mmol/l.
• Only 41 were taking antiplatelet drugs and 22
  were taking a statin.

Journal of Epidemiology and Community Health
200357134-140
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In Scotland

• Coronary Heart Disease
• one of the leading causes of death
• 10,331 deaths in 2005
• Scotland has one of the highest death rates from
  CHD in the western world
• Due to
• high rates of smoking
• poor diet
• deprivation

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In the year ending March 31 2006

• Scottish hospitals
• 48,962 hospital discharges for CHD
• 16,320 were for AMI(heart attack)
• CHD discharges represented around 4 of all
  acute hospital discharges.
• NHSScotland carried out
• 2,319 Coronary Artery Bypass Grafts 5,803
  angioplasties
• 17,065 angiographies

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http//www.isdscotland

• CHD mortality is strongly related to age.
• 0-44 year olds is 4.1 per 100,000
• 75, the rate is 1682.1 per 100,000
• The incidence of CHD is higher in men, elderly
  and deprived areas of Scotland
• Smoking
• being overweight
• raised blood pressure
• raised level of cholesterol

46
Cost of Cardiovascular Disease in the UK

• CVD cost the UK 29.1 billion in 2004
• (exceeds the GDP of Kuwait)
• 29 (8.5 billion) was due to Coronary Heart
  Disease
• 27 (8.0 billion) Cerebrovascular Disease
• CVD Cost break down
• 60 health care
• 23 productivity losses
• 17 informal care-related costs
• Conclusions
• CVD is a leading public health problem in the UK
  measured by the economic burden of disease.

Heart 2006921384-1389
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Small changes in UK cardiovascular risk factors
could halve CHD mortality

• The UK called for a 40 reduction in CVD
  mortality by 2010.
• Potential reductions from the year 2000, were
  calculated for
• Continuation of recent risk factor trends
• 10,685 fewer CAD deaths in 2010 than in 2000
• Modest additional reductions in cholesterol and
  smoking
• 51,270 fewer deaths
• Optimistic changes in obesity, DM, and physical
  activity, would have relatively small effects.

Journal of Clinical Epidemiology 58 (2005) 733740