DISC TWO

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DISC TWO CINEANGIOGRAM-BASED CASE STUDIES
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Table of Contents Disc Two
Please insert Disc One for Access to CATH Panel
Report 2003 Enoxaparin Dosing Guidelines for
ACS Clinical Trials Data and Summaries Clinica
l Presentations Animated Clinical
Pathways Clinical CME-Accredited Symposia
Videocast Clinical Cardiology CME-Accredited
Monographs Quick Consult Clinical Trials
Guide Clinical Pathways PDF Files
Cineangiogram-Based Clinical Case Studies

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ACS Problem Based Learning Case Studies

• Edward T. A. Fry, MD, FACC, FSCAI
• Director, Interventional Cardiology
• St.Vincent Hospital, Indianapolis, IN
• The Indiana Heart Center
• The Care Group, LLC
• Indiana Heart Institute

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ACS PBL Case 1
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ACS PBL Case 1
J.B. 65 y/o female, retired pathologist
Presents to ER at 9 PM with 2 hrs SSCP and
dyspnea, at rest. Better after TNG SL x 3 at
home. Some DOE x 2 wks. PMHx Stent in LAD
8/00, hyperlipidemia, smokes, HTN, bilateral
mastectomies for breast cancer, TAH (no HRT),
NKA Meds ASA, Lisinopril, Atorvastatin,
Metoprolol, Fluoxetine, Raloxifene
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Case 1 EKG 1
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ACS PBL Case 1
BP 160/90 HR 64 RR 16 135 lbs. Sat.93 on
2 lit. PE Chest clear, bilat.
mastectomies Cor RRR, S4, I/IV systolic
murmur at the apex, no S3 Abd Soft,
nontender, no HSM Ext No edema. Pulses
normal. Left carotid bruit
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ACS PBL Case 1
Labs (ER) WBC7.1 Hgb13.0 Plts315K K3.4
Lytes otherwise WNL Cr1.1 BUN22
Gluc101 CK77 MB2.8 TnIlt0.3 CXR
NAD Monitor NSR, BBB. No ectopy.
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ACS PBL Case 1
Issues upon presentation

• Initial diagnostic impression / differential
• Initial treatment(s)
• Additional labs, work-up
• Disposition
• Risk assessment

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ACS PBL Case 1
Admitted to Critical Care Unit NPO except
meds ASA 325 mg q AM O2 4 lit/min IV-NTG at 20
ug/min Eptifibatide 180 ug/kg bolus, 2
ug/kg/min Enoxaparin 30 mg IV x 1 in ER and 60
mg sc q 12 hr (1st dose at 10 PM) Home meds
continued
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ACS PBL Case 1
320 AM More CP (5/10), treated with SL NTG
x 2, MSO4 4 mg IV, Pain is improving. ECG
T-wave inversion, ST dep. V5-6 4 hr TnI lt0.3
500 AM Recurrent CP (8/10). ECG No
change. Rxd with TNG SL, MSO4

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Case 1 EKG 2
v
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ACS PBL Case 1
600 AM Emergent Cath (8 hrs after last
enoxaparin given)
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Press Space Bar or Enter to Advance Cines to next
image
Left Coronary angiogram significant ruptured
plaque visible
Right coronary angiogram moderate disease
visible
Case 1
Stent successfully placed
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ACS PBL Case 1
Emergent PCI Eptifibatide continued at 2
ug/kg/min for 12 hrs post PCI. Heparin? Enoxapar
in 0.3 mg/kg IV at PCI 3.5 x 18 mm stent
deployed, post- dilated to 4.0 mm. Sheath
removal?
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PEPCI Enoxaparin SC and IV Pharmacokinetics
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Dosing of Enoxaparin in PCI
Enox. dose At PCI (iv)
Last dose of Enoxaparin Pre-PCI
Abcix.
Trial
(none)
0.3 mg/kg
PEPCI
0.3 mg/kg
NICE-3
(none)
(none)
Collet
(none)
NICE-3
1.0 mg/kg
(none)
(none)
NICE-1
(none)
0.75 mg/kg
NICE-4
PCI
-12 hr
12 hr
-8 hr
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ACS PBL Case 1

• CP resolved. ECG NSR, LBBB, no change
• Sheath removed 4 hrs after start of PCI (1000
  AM)
• Subsequent enzymes were negative for MI
• Transferred to telemetry floor
• Clopidogrel 300 mg x 1, then 75 mg daily.
• Continued on ACE-I, Beta-Blocker, Statin, ASA
• Released home next AM

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ACS PBL Case 2
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PBL Case 2 Acute MI

• S.S. 47 y/o male, Indianapolis Airport Security
  Guard, new onset severe CP at 400 AM
• Presents to ER at 500 AM. BP150/85, HR84
  (NSR), 220 lbs, diaphoretic, Sat94 RA,
  Chest-clear, S4, RRR, No murmur, No edema
• No hx of PUD, CVA, TIA, HTN, DM, MI
• Strong family hx. Smokes 1 ½ packs/day

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Case 2 EKG 1
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PBL Case 2 AMI Rx Options

• Thrombolysis
• Agent TNK vs r-PA vs t-PA
• Combination therapy?
• Heparin UFH vs enoxaparin
• Transfer for Primary PCI (30 miles)?
• Facilitated PCI

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PBL Case 2 AMI

• ASA 81 mg chewable x4, IV TNG
• Enoxaparin 30 mg IV bolus x 1 followed
  immediately by 100 mg SC and then q 12 hrs.
• TNK 50 mg IV bolus x 1 at 530 AM
• Metoprolol 25 mg PO BID
• 700 AM CP better, ST elevation nearly gone
• Arrangements for transfer to St. Vincent made at
  730 AM

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PBL Case 2 AMI

• Patient arrives at St. Vincent at 900 AM
  initially pain free.
• At 930 AM, he has recurrent CP and inferior ST
  elevation
• Emergency cath and possible PCI recommended

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image
Right coronary angiogram significant occlusion
Left coronary angiogram No disease visible
Stent is placed. Balloon is inflated at thrombis
location
Catheterization successful
Case 2
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PBL Case2 AMI

• Rescue PCI
• Heparin / Enoxaparin dosing?
• GP IIb/IIIa inhibitor therapy?
• Sheath management?
• Reheparinization / LMWH?

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PCI Following Enoxaparin
Time from last dose of Enoxaparin
Time after PCI
12 hr
8 hr
0
4-8 hr
Sheath Pull
0.3 mg/kg IV
None
And gt12 hr after TNK given,
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Case 2 EKG 2
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PCI Following Enoxaparin
Time from last dose of Enoxaparin
Time after PCI
12 hr
8 hr
0
4-8 hr
Sheath Pull
0.3 mg/kg IV
None
ENOX lt 260 ENOX gt 260 ENOX lt
200-250
And gt12 hr if TNK given,
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LMWH in the Invasive Treatment of ACS and MI
Take Home Message

• Enoxaparin is superior to UFH in ACSs and in
  thrombolysis with TNK
• Enoxaparin has favorable interactions with
  platelets that enhance use of GP IIb/IIIa
  inhibitors.
• Enoxaparin can be used safely and effectively in
  PCI with or without a GP IIb/IIIa
  inhibitor.

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LMWH in the Invasive Treatment of ACS and MI
Take Home Message

• Patients can be easily transitioned from medical
  stabilization with enoxaparin to an early
  invasive strategy of care including PCI in ACSs
  and AMI.
• Use of enoxaparin should not be an obstacle to
  cath or PCI. An early invasive strategy of care
  should not be an obstacle to use of enoxaparin.

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LMWH in the Invasive Treatment of ACS and MI
Take Home Message

• Use of UFH in PCI is historical and emperic,
  founded on broad experience, but little data.
• Growing body of data supports the use of LMWH in
  PCI in multiple clinical settings.
• LMWH may be superior to UFH in PCI.