Acute Coronary Syndrome

Cindy Baker, MD FACCDirector Peripheral Vascular InterventionsDivision of Cardiovascular Medicine

Topics

Timing is everything

So many drugs to choose from

What’s a MINOCA?

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Acute Coronary Syndrome

Clinical syndrome with acute myocardial ischemia and/or infarction due to an abrupt reduction in coronary blood flow.

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UA

NSTEMISTEMI

Libby P. Inflammation in Atherosclerosis. Nature 420;868-74.

Myocardial Infarction

NSTE-ACS

Final Dx

Cardiac Biomarker

ECG

Working Dx

Presentation Ischemic Discomfort

ACS

No ST Elevation

NQMI

STEMINSTEMIUA

Unstable AnginaQwMI

ST Elevation

Noncardiac Etiologies

* *

Acute Coronary Syndromes

Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

2013 ACC/AHA Guideline for the Management of STEMI

Primary PCI in STEMI

IIb

2013 ACC/AHA Guideline for the Management of STEMI

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NSTEMI/UA

Early Invasive Strategy

Ischemia Driven

Strategy

TIMI Risk Score* for NSTE-ACSTIMI Risk

ScoreAll-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent

Revascularization Through 14 d After Randomization, %

0–1 4.72 8.33 13.24 19.95 26.2

6–7 40.9

*The TIMI risk score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables: ≥65 y of age; ≥3 risk factors for CAD; prior coronary stenosis ≥50%; ST deviation on ECG; ≥2 anginal events in prior 24 h; use of aspirin in prior 7 d; and elevated cardiac biomarkers.

GRACE Risk Model Nomogram

To convert serum creatinine level to micromoles per liter, multiply by 88.4.

Factors Associated With Appropriate Selection of Early Invasive

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Immediate Invasive (within 2 hrs)•Signs or symptoms of HF or worsening MR•Hemodynamic instability•Recurrent angina or ischemia at rest or with low –level activites despite intensive medical therapy•Sustained VT or VF

Early Invasive (within 24 hrs)•None of the above but GRACE score > 140•Temporal change in Tn•New or presumably new ST depression

Delayed invasive (within 24-72hrs)•None of the above but diabetes mellitus•Renal insufficiency (GFR < 60 mL/min.1.73m2)•Reduced LV systolic function (EF <0.40)•Early post-infarct angina•PCI within 6 months•Prior CABG•GRACE risk score 109-140; TIMI score >/=2

Factors Associated With Appropriate Selection of Ischemia-Guided Strategy

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Ischemia-guided stategy• Low-risk score (TIMI 0 or 1), GRACE <109• Low-risk Tn negative female patient• Patient or clinician preference in the absence of

high-risk features

Antiplatelet Therapy in Acute Coronary Syndrome

Deepak L. Bhatt et al. Circ Res. 2014;114:1929-1943

Copyright © American Heart Association, Inc. All rights reserved.

Adjunctive Antiplatelet Therapy to Support Reperfusion With Primary PCI

*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

2013 ACC/AHA Guideline for the Management of STEMI

Steg PG, et al. Circulation. 2010;122:2131-2141

Plato Trial

NSTEMI/UATreated With an Initial Invasive or Ischemia-Guided Strategy

Recommendations COR LOEA P2Y12 inhibitor (either clopidogrel or ticagrelor) in addition to aspirin should be administered for up to 12 months to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy. Options include:• Clopidogrel: 300-mg or 600-mg loading dose, then 75 mg

daily • Ticagrelor║: 180-mg loading dose, then 90 mg twice daily

IB

B

‖The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

Treated With an Initial Invasive or Ischemia-Guided Strategy

Recommendations COR LOEIt is reasonable to use ticagrelor in preference to clopidogrelfor P2Y12 treatment in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strategy.

IIa B

In patients with NSTE-ACS treated with an early invasive strategy and dual antiplatelet therapy (DAPT) with intermediate/high-risk features (e.g., positive troponin), a GP IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. Preferred options are eptifibatide or tirofiban.

IIb B

Cangrelor

Intravenous P2Y12 inhibitorADP analogue

Plasma half-life: 3-6 minutesFull recovery of platelet function within 60 minutes

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Champion Phoenix Trial

Bhatt DL et al. N Engl J Med 2013;368:1303-1313

21Yeh RW, Secemsky EA, Kereiakes DJ, et al, DAPT Study Investigators. JAMA. 2016;315:1735-1749.

Eur Heart J 2016

• A positive cardiac biomarker

• Clinical evidence of ischemia (symptoms, ST-T wave changes, development of pathologic Q waves, imaging evidence of new loss of viable myocardium or new wall motion abnormality

• Non-obstructive coronary arteries on angiography (less than 50%)

MINOCA -Definition

MINOCA -Incidence

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• Estimated 54,000-187,000 cases/year in US

• Up to 5% one-year death rate

AHA statistics 2016; Pasupathyet al Circulation. 2015; 131: 861-870

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Non-Obstructive CAD- Common in All Forms of ACS

MINOCA is Caused By a Variety of Underlying Etiologies

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MINOCA is Caused By a Variety of Underlying Etiologies

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Plaque Rupture

27Images taken from Light Lab Imaging/SJM

Cardiac MRI Can Be Helpful to Identify Cause of MI

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Women’s Heart Attack Program (HARP)

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• Clinical Imaging Study: OCT and MRI in women with MINOCA

• Population Stress Study: Randomized trial of stress management intervention in women with MI

• Basic Platelet Study: Comprehensive assessment of thrombotic and platelet-mediated pathways in women with MINOCA

funded by the AHA Go Red for Women Network

THANK YOU!

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