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9/17/2016
1
STEMI Presentation and Case Discussion
Scott M Lilly MD PhD, Interventional CardiologyThe Ohio State University Contemporary
Multidisciplinary Cardiovascular ConferenceOrlando, Florida
September 17th, 2016
Case #1• 37 year old male
• Hypertension, tobacco use
• Works as a roofer
• Typical work day, returned home, experienced sudden onset chest pain
• Presented to local hospital
• Symptom onset to presentation: 30 minutes
• ECG obtained
• Aspirin, ticagrelor, heparin bolus
• Transferred
• Estimated Transfer Time: 45 minutes
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Case #1
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Pathophysiology and Therapy
Lilly et al. 2012Lilly and Wilensky, Curr Pharm Ther 2011
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ACS Management: Drug Therapy
• Anti‐platelet
– Aspirin
– ADP‐Receptor Inhibitor
• Clopidogrel
• Prasugrel
• Ticagrelor
• Anti‐coagulation
Address Pathophysiology
• Beta‐receptor antagonists
• ACE‐inhibitors
• Statins
Minimize Consequences
Aspirin in ACS
O’Gara et al. 2013 ACC/AHA STEMI Guideline.O’Gara et al., STEMI Guidelines; The RISC Group. Lancet. 1990
Multiple trials
30‐50% RR in
death, myocardial
infarction
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Months of Follow-up
Yusuf S et al. N Engl J Med. 2001;345:494.
CURE: Clopidogrel for UA/NSTEMI
Clopidogrel + Aspirin(n=6259)
Placebo + Aspirin(n=6303)
P<0.001n=12,562
3 6 90 12
20%Relative RiskReduction
0.12
0.14
0.10
0.06
0.08
0.00
0.04
0.02
Cu
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ADP‐Receptor Inhibitors
CLOPIDOGREL PRASUGREL TICAGRELOR CANGRELOR
Plt inhibition 40‐60% 70% 80‐90% 95‐100%
PharmacologyIrreversible, pro‐
drugIrreversible, pro‐
drugReversible, active drug
Reversible, active drug
Onset 2‐4h h 30 min 30 min 2 min
Duration 3‐10 d 5‐10 d 3‐4 d 60‐90 min
Trials CURE TRTON TIMI‐38 PLATOCHAMPIONPHOENIX
Outcomes Standard CV Mort, MI,
CVA CV Mort, MI,
CVA**MI, ST
Dose/Cost QD/+ QD/++ BID/+++ IV/++++
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Balancing Risks
PRASUGREL TICAGRELOR CANGRELOR
Ischemia/MACE Reduced Reduced Reduced
Bleeding Increased No increase Increased
Mortality No change Reduced No change
ExclusionsCVA/TIA, < 60 kg,
> 75 yoICH ICH
Platelet Inhibition
Ischemic risk Bleeding risk
Case Conclusion and Take Home Points
• First medical contact to balloon: 82 minutes
• Drug eluting stent to left anterior descending artery
• Pre‐discharge ejection fraction 25‐30%
• Discharge medications included aspirin 81 mg daily, ticagrelor 90 mg twice daily, metoprolol XL 50 daily, and lisinopril 10 mg daily
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Case #2• 73 year old male
• No past medical history
• Awoke with chest pain and diaphoresis
• Progressed, included nausea and emesis
• Presented to local hospital
• Symptom onset to presentation: ~ 25 minutes
• ECG obtained
• Aspirin, clopidogrel, heparin bolus
• Transferred
• Estimated Transfer Time: 45 minutes
Case #2
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Clinical Course
• Drug eluting stent to the right coronary artery
• First contact to balloon 90 minutes
• Post‐PCI ejection fraction 60‐65% with mild inferior wall hypokinesis.
• Experienced dyspnea on ticagrelor transitioned to clopidogrel
ADP‐Receptor antagonists have different
pharmacodynamics. These differences are
incredibly relevant when transitioning
between agents in the vulnerable peri‐
myocardial infarction period.
Transition between ADP Receptor Antagonists
ACC.16; Min et al., submitted
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Transition between ADP Receptor Antagonists
Maintained Clopidogrel
n = 2857 (94%)
Ticagrelor to Clopidogrel
n = 182 (6%)
P‐Value
Composite Endpoint 66 (2.31) 4 (2.20) 0.999
Myocardial infarction 27 (0.95) 2 (1.10) 0.6915
In‐hospital mortality 0 (0.00) 0 (0.00) 0.999
Cerebrovascular events 3 (0.11) 0 (0.00) 0.999
Bleeding event within 72 hrs 36 (1.26) 2 (1.10) 0.999
ACC.16; Min et al., submitted
Case Conclusion and Take Home Points
• Drug eluting stent to the right coronary artery
• Transitioned from ticagrelor to clopidogrel due to dyspnea
• Pre‐discharge ejection fraction 60‐65% with mild inferior wall hypokinesis.
• Large observational series or randomized trials are needed to establish an optimal algorithm for transition between ADP‐receptor antagonists.
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Case #3
25
• 60 year old male, hypertension, hyperlipidemia
• Acute substernal chest pain, nausea and emesis
• Called EMS, and to arrived at non‐PCI hospital within an hour of symptom onset
• Inclement weather with anticipated transfer delay of 2.5 hours
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• 60 year old male with inferior STEMI
• Tenecteplase administered, along with aspirin, clopidogrel and heparin
• Transferred to Ross Heart Hospital
• Hemodynamically stable, but with ongoing chest pain
Case #3
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Case #3
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Boersma et al. 1996 Lancet 348: 771‐75
• 22 randomized trials 1983 – 1993, n = 50,246
• Thrombolysis v placebo in STEMI
• Mortality benefit if < 2 hours from symptoms
• Stroke rate 1-2%
Thrombolysis: Clinical Efficacy
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Horowitz et al. Lancet 2013; 128:803‐810Pinto, ACC.13 “Pharmacotherapy if delay to reperfusion”
New PCI Centers, 1997 - 2008
PCI in 1997
PCI in 2008
No PCI in 1997
Thrombolysis: Why Now?
400 new PCI centers 2001-2006pPCI access increased from 79% to 79.9%
Case Conclusion and Take Home Points
• Rescue PCI, drug‐eluting stent to the distal right coronary artery
• Pre‐discharge ejection fraction 55% with mild inferior wall hypokinesis.
• In STEMI, thrombolysis is indicated if first medical contact to primary PCI time is judged to be > 2 hrs
• Transfer to PCI capable hospital, evaluate for angiography on arrival