Acute Coronary Syndrome by Lokeswara Rao Sajja - STAR Hospitals

Current management of
Acute Coronary Syndrome
Lokeswara Rao Sajja,
MCh, MD, FACS
Star Hospitals
Sajja Heart Foundation
Hyderabad, India
63rd Annual Conference of IACTS, 2017, 23-26 Feb 2017, Bengaluru

 A spectrum of conditions compatible with acute
myocardial ischemia and/or infarction that are
usually due to an abrupt reduction in coronary
blood flow
Acute coronary syndrome
Current management of Acute Coronary Syndrome
 The spectrum of acute ischemia related syndromes
ranging from
[----UA-------NSTEMI--------STEMI----]
that are secondary to acute plaque rupture or plaque erosion

Unstable Angina NSTEMI STEMI
Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes
Non-occlusive
thrombus
ST depression +/-
T wave inversion on
ECG
Elevated cardiac
enzymes
Complete thrombus
Occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
Enzymes
More severe
symptoms
Acute Coronary Syndrome (ACS)

Decreased O2 Supply
•Flow- limiting stenosis
•Anemia
•Plaque rupture/clot
Increased O2 Demand
O2 supply/demand mismatch→Ischemia
Myocardial ischemia→necrosis
Pathophysiology ACS
Asymptomatic/
stableangina
UnstableAngina
MyocardialInfarction
Pathophysiology of Stable Angina and ACS
Stable
angina

 Over seven million people every year die from CAD, 12.8% of
all deaths (WHO 2011)
 1.5 million hospital admissions in the U.S. annually:
Approximately 70% - NSTE-ACS
(Heart Disease and Stroke Statistics-2014 Update from AHA)
 In the Europe (incidence per 100,000/year) :
 77 STEMI
 132 non-STEMI (ESC guideline 2012)
 India has the highest burden of ACS in the world
 (Treatment and outcomes of ACS in India (CREATE S)- a
prospective analysis of registry data
Epidemiology

Comparison of ACS in developed and developing countries
Xavier D. Create Registry .Lancet 2008 : 371 ;1435-42
Syndrome
Mean
Age
(Yrs)
Time (min) Practice
30 day
mortality
STEMI NSTEMI
Onset of
symptoms to
admission
hospital
Admission
to
thromboly
sis
Primary
PCI
(STEMI vs
NSTEMI)
Thrombolytic
treatment
( Proportion
streptokinase)
STEMI NSTEMI
CREATE
Indian
Registry
61% 39% 57 300 50
8% vs
7%
59% 9% 4%
Global
registry of
ACS
31-
40%
60-70% 64-69 140 -
40% vs
28%
47% 8% 3%
European
heart
Survey
42% 51% 63 170 40
40% vs
25%
37% 7% 1%
US
National
registry of
MI
- - 68 128 32-38 36% 21% 8% -

 Young age at presentation
 ST segment elevation myocardial infarction (STEMI)
is more common in India compared to Western
Countries
 Majority of patients receive thrombolysis
 30-day mortality is higher in India compared to
Western Countries
The unique features of ACS in Indians
Mansoor AH, Kaul U. Prehospital Thrombolysis. Indian Heart J. 2009; 61:433-436

 The ‘gold-standard’ treatment for most patients
presenting with ACS is primary percutaneous coronary
intervention (PCI) of the culprit coronary vessel
 Currently, the optimal treatment of STEMI is the primary
PCI or systemic thrombolysis
 The initial approach to the patient with non-ST segment
elevation ACS is pharmacological stabilization followed by
risk stratification
Treatment

 The technical advances in PCI in the setting of ACS have
relegated coronary artery bypass graft (CABG) largely to a
secondary position in most cases
 Conventional surgical revascularizatio achieves a combined
prospect of an excellent long term outcomes and an average
risk of < 3% which can be further reduced using off-pump
CABG , particularly in high risk patients

Recent trials for ACS
Comparing an invasive and a conservative strategy
FRISC II TACTICS-TIMI 18
RITA 3
 PCI was recommended for one
vessel or two vessel disease and
CABG for three vessel disease or left
main stenosis
 higher repeat revascularisation rate
for PCI (14.8%) than CABG (6.9%)

Recent trials for ACS
Comparing PCI and CABG for the treatment of
ischemic heart disease
ARTS
SoSERACI II

 In a propensity- matched comparison
from the ACUITY trial, moderate- and
high-risk patients with ACS and
multivessel disease treated with PCI
rather than CABG had lower rates of
peri-procedural stroke, MI, major
bleeding, and renal injury, with
comparable 1-month and 1-year rates
of mortality
 but more frequently developed recurrent ischemia requiring repeat
revascularization procedures during follow-up

ACC/AATS/AHA/ASE/ASNC/SCAI/ SCCT/STS 2016
Appropriate Use Criteria for Coronary Revascularization in
Patients With Acute Coronary Syndromes

Class I Recommendations (Level of Evidence: B)
1. acute MI in whom
 primary PCI has failed or cannot be performed
 coronary anatomy is suitable for CABG, and
 persistent ischemia of a significant area of myocardium at
rest and/or hemodynamic instability refractory to
nonsurgical therapy is present
2. Patients undergoing surgical repair of a post infarction
mechanical complicationof MI
 ventricular septal rupture
 mitral valve insufficiency because of papillary muscle
infarction and/or rupture
 free wall rupture
Hillis et al 2011 ACCF/AHA CABG Guideline
Indications for CABG (ACCF/AHA CABG Guideline)

Class I Recommendations (Level of Evidence: B)
3. Patients with cardiogenic shock and who are suitable for
CABG irrespective of the time interval from MI to onset of
shock and time from MI to CABG
Class I Recommendations (Level of Evidence: C)
4. Patients with life-threatening ventricular arrhythmias(believed
to be ischemic in origin) in the presence of left main stenosis
greater than or equal to 50% and/or 3-vessel CAD

Class IIa Recommendations (Level of Evidence: B)
1. Patients with multivessel CAD with recurrent angina or MI
within the first 48 hours of STEMI presentation as an
alternative to a more delayed strategy
Class III Recommendations (Level of Evidence: C)
1. Emergency CABG should not be performed in patients with
persistent angina and a small area of viable myocardium who are
stable hemodynamically
2. Emergency CABG should not be performed in patients with no
reflow (successful epicardial reperfusion with unsuccessful
microvascular reperfusion)

Failed PCI
 Abrupt vessel closure
 Extensive coronary artery dissection
 Incomplete revascularization
 Coronary perforation
 Unsuccessful dilation
 Other situations resulting in hemodynamic instability
and requiring surgical intervention
Emergency CABG After Failed PCI
Yang et al. 2005 JACC Vol. 46, No. 11

Recommendations Class I level of evidence B
1. Emergency CABG is recommended after failed PCI in the
presence of ongoing ischemia or threatened occlusion with
substantial myocardium at risk
2. Emergency CABG is recommended after failed PCI for
hemodynamic compromise in patients without impairment of
the coagulation system and with out a previous sternotomy
Recommendations Class IIa level of evidence C
1. Emergency CABG is reasonable after failed PCI for retrieval
of a foreign body (most likely a fractured guide wire or stent)
in a crucial anatomic location
2. Emergency CABG can be beneficial after failed PCI for
hemodynamic compromise in patients with impairment of the
coagulation system and without previous sternotomy
Emergency CABG After Failed PCICurrent management of Acute Coronary Syndrome

Recommendation Class IIbLevel of Evidence: C
1. Emergency CABG might be considered after failed PCI for
hemodynamic compromise in patients with previous sternotomy
Recommendation Class III Level of Evidence: C
1. Emergency CABG should not be performed after failed PCI in
the absence of ischemia or threatened occlusion
2. Emergency CABG should not be performed after failed PCI if
revascularization is impossible because of target anatomy or a no-
reflow state
Emergency CABG After Failed PCI

 NSTE-ACS
In a large database analysis of unselected patients admitted for
ACS, performance of early CABG(< 48 hrs), even in higher-risk
patients, was associated with low in-hospital mortality.
(MonteiroP. Circulation2006;114), (Parikh SV. JACC CardiovascInterv2010;3(4)
 STEMI
When possible, in the absence of persistent pain or haemodynamic
deterioration, a waiting period of 3–7 days appears the best
compromise
(Weiss ES,J ThoracCardiovascSurg2008;135(3)
 In patients referred for urgent CABG, clopidogrel and ticagrelor
should be discontinued for at least 24 hours to reduce major
bleeding complications
Class I recommendation (Hillis et al 2011 ACCF/AHA CABG Guideline)
Timing of CABG

Timing of urgent CABG in patients with STEMI in
relation to use of antiplatelet agents
Aspirin should not be withheld before urgent CABG
Short-acting intravenous GP IIb/IIIa receptor
antagonists (eptifibatide, tirofiban) should be
discontinued at least 2 to 4 hours before urgent CABG
Clopidogrel or ticagrelor should be discontinued at least
24 hours before urgent on-pump CABG, if possible
I IIaIIb III
I IIaIIb III
I IIa IIb III

Timing of urgent CABG in patients with STEMI in
relation to use of antiplatelet agents
Abciximab should be discontinued at least 12 hours
before urgent CABG
Urgent off-pump CABG within 24 hours of
clopidogrel or ticagrelor administration might be
considered, especially if the benefits of prompt
revascularization outweigh the risks of bleeding
Urgent CABG within 5 days of clopidogrel or
ticagrelor administration or within 7 days of prasugrel
administration might be considered, especially if the
benefits of prompt revascularization outweigh the
risks of bleeding
I IIaIIb III
I IIaIIb III
I IIaIIb III

Myocardial
oxygen demand
CPB related
inflammatory
injury
Global
ischemia
Conventional
CABG
On Pump
Beating Heart -
OPCAB - - -
Surgical technique
38% of patients need Intra aortic balloon pump

 Where emergency CABG is required, OPCAB is
theoretically ideal as it preserves coronary flow, avoids
global myocardial ischaemia and reduces ischaemia-
reperfusion injury
 OPCAB may have offer some benefits by avoiding full
heparinization and avoiding the inflammatory response
associated with cardiopulmonary bypass

Stable hemodynamic
 CA is superior in
 Shorter CPB time
 More distal anastomoses
 LCx territory grafting
 BH is superior in
 Time to culprit lesion revascularization
Rastanet al .Beating Heart CABG in Emergency ACS, Circulation 2006
 638 (3.3%) (stable 531, CS 107)
 240 Beating heart operation 124 OPCAB
 116 on pump beating heart 398 conventional CPB/CA
BH is superior in
•less Inotrope
•less bleeding
•less hospital stay

Off-pump coronary artery bypass can be performed safely
and effectively and should be considered in selected patients
with acceptable hemodynamics undergoing emergency
coronary revascularization

 The total arterial revascularization may further improve
long-term outcome and patients with bilateral internal
thoracic artery grafts had significantly better freedom
from readmission for ACS

 The use of composite arterial grafts based upon the internal
mammary arteries eliminates the need for anastomosing
grafts to the aorta, permitting a true “no touch” aortic
technique, further reducing the risk of stroke

 ACS is a potentially life-threatening condition that affects
millions of individuals each year
 The initial approach to the patient with non-ST segment
elevation ACS is pharmacological stabilization followed by
risk stratification
 The consensus is rapidly evolving for the treatment of
NSTEMI and unstable angina based on a system of risk
stratification includes multiple clinical, demographic and
ECG variables in addition to the use of serum biomarkers
Conclusions

Initial ACS management should include
risk stratification
appropriate pharmacologic management
including
 DAPT
 Anticoagulation and
 Appropriate adjuvant therapies
decision to pursue an early invasive or
conventional treatment strategy
Conclusions

 The number of emergency CABGs is on decline
 The mortality rate associated with emergency CABG
remains high
 Off-pump coronary artery bypass graft may improve
the outcome but may not suitable for the unstable
patients and LM disease
 Initial stabilization followed by CABG is the
preferred mode of treatment for patients with ACS
and multivessel CAD
Conclusions

 Long-term management following an ACS event should
 follow evidence-based recommendations
 be individualized to each patient.
 Secondary prevention with antiplatelet therapy, beta blockade,
lipid lowering therapy, and ACE inhibitors or ARBs is critical
to the long term success of revascularization
Conclusions
Decision of treatment by the Heart Team
is the trend in the
Current Management of ACS

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