Acute coronary syndromes. Šimek S

Transkript

1 Acute coronary syndromes Šimek S

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3 PŘÍMÁ PTCA UZÁVĚRU RIA ANTERO- EXTENZIVNÍ AIM

4 PŘÍMÁ PTCA UZÁVĚRU RIA ANTERO- EXTENZIVNÍ AIM

5 PŘÍMÁ PTCA UZÁVĚRU RIA ANTERO- EXTENZIVNÍ AIM

6 PŘÍMÁ PTCA UZÁVĚRU RIA ANTERO- EXTENZIVNÍ AIM

7 PŘÍMÁ PTCA UZÁVĚRU RIA ANTERO- EXTENZIVNÍ AIM

8 CHD = insufficient blood supply to myocardium LCA LAD CXA Stenosis Occlusion RCA

9 The Evolution of Atherosclerosis Foam Cells Fatty Streak Intermediate Lesion Atheroma Fibrous Plaque Complicated Lesion/Rupture Endothelial Dysfunction From 1st Decade From 3rd Decade From 4th Decade Growth Mainly by Lipid Accumulation Adapted From Stary HC et al. Circulation. 1995;92: Smooth Muscle & Collagen Thrombosis, Hematoma

10 Risk factors SMOKING HLP HT DIABETES MELLITUS POSITIVE FH OBESITY, PHYSICAL INAKTIVITY

11 CHD - SYMPTOMS AP CHEST PAIN HEART FAILURE - DYSPNEA ARRHYTMIAS

12 CHD ACUTE FORMS (CHANGING 1 m, DANGEROUS) CHRONIC FORMS (LONG LASTING UNCHANGED, RISK SMALLER)

13 Acute coronary syndromes Cause: coronary vessel thrombosis due to rupture of unstable plague

14 STABLE VERSUS UNSTABLE PLAQUE Falk E, et al. Circulation. 1995;92:

15 PLAQUE RUPTURE

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17 RIZIKOVÉ FAKTORY RUPTURY PLÁTU Lokální Faktory fatique of the cap smoking Cholesterol Systémové Faktory content of the plaque inflamation thickness of the cap Diabetes Mellitus Homocystein Fibrinogen impaired Fibrinolysis Ruptura plátu Fuster V, et al. N Engl J Med. 1992;326: Falk E, et al. Circulation. 1995:92:

18 Acute coronary syndromes SymptomS Chest pain change in frequence, intensity or duration Atypical symptoms up to 50% (pain in neck, back, ear, abdomen, dyspnoea, dizziness)

19 Acute coronary syndromes final classification UNSTABLE ANGINA PECTORIS (flow limiting stenosis), <20 min ACUTE MYOCARDIAL INFARCTION (occlusion), >20 min SUDDEN DEATH

20 Acute coronary syndromes Newer Final CLASSIFICATION UNSTABLE ANGINA PECTORIS (UAP) Minimal myocardial lesion=microinfarct ( Troponin T+I, 1g of myocardium) MI without ST elevations (NSTEMI) MI with ST elevations(stemi) Sudden death

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22 Eur Heart J 2000;21: NEW CLASSIFICATION OF ACS Acute coronary syndromes orking diagnosis according to EKG ACS without STE (NSTE-ACS) cardiomarkers negative ACS with STE (STEMI) cardiomarkers pozitive NSTEMI DEFINITIVE DIAGNOSIS UAP non QIM QIM

23 TREATMENT NSTE - AKS AIMS: TO PREVENT DEVELOPEMENT OF OCCLUSIVE TROMBUS TO PREVENT MYOCARDIAL NECROSIS

24 TREATMENT OF NSTE ACS FARMACOTHERAPY Antiischemic REST IN BED, oxygenotherapy Nitrates, betablockers, Calcium channel blockers ACE inhibitors (HT,SS,DM), sartans Opiates Antithrombotic ASA, Clopidogrel, Ticlopidin Heparin, LMWH Inhibitors of GP IIb/IIIa Stabilisation of plaque statins

25 NSTE ACS Interventional treatment

26 InvazivE vs Conservative strategy VANQWISH ICTUS léčby NAP/NSTEMI MATE TIMI IIIB ISAR- COOL RITA-3 VINO TRUCS TACTICS- TIMI 18 FRISC II conservative Invasive

27 Unstable plague trombus

28 PTCA + stent

29 concentric stenosis

30 PTCA + stent

31 STEMI In 90% thrombus on ruptured plaque occlusion of entire vessel Aims: to open the artery as soon as possible De Wood M.,NEJM 1980;303:

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34 MAin tasks Treatment of STEMI 1. To open IRA as soon as possible aspirin heparin (10 000j. I.V., Clexane 1ml i.v. nebo s.c.) Fibrinolytics or primary PCI 2. prevent death due to mallignant arrhytmias = ECG monitor 3. lover oxygen demands (decrease pain,activity,hr) 4. increase oxygen supply (O2) 5. improve collateral supply

35 FIBRINOLYSIS - EASY FAST CHEAP - SUCCES recanalisation of IRA 50-70% normal flow 30-55% 10-20% reoklusion risk of serious bleeding 1,8%

36 Metaanalysis od 23 randomized studies PCI versus fibrinolýsis (n=7739) 8 7 p=0,003 p=0, ,8 % ,5 p=0, p=0,001 0,05 1,1 PTCA FIBRINOLÝZA ÚMRTÍ re IM CMP hemorh CMP

37 Transfer to PCI vs fibrinolýza úmrtí ReMi CMP Úmrtí/MI/CMP

38 FIBRINOLYSIS Streptokináza j i.v min + Hydrocortizon 200mg i.v. Altepláza, Actilyse, tpa 60mg i.v. 30 min mg i.v. 60 min

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56 Distální protekce FilterWire (BS)

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61 FREQUENT MISTAKES TIME LOOSING IV. PORT ABSENT KPR NOT SUFFICIENT CONCLUSIONS MADE FROM FIRST ENYZMES Aspirin NOT GIVEN MI OF POSTERIOR WALL NOT RECOGNIZED

62 WHY THE POSTERIOR MI NOT RECOGNIZED? ST elevations present mostly in posterior ECG leads V7-V9 (v 68%) Kulkarni AU, Brown R, Ayoubi M. Clinical use of posterior electrocardiographic leads: a prospective electrocardiographic analysis during coronary occlusion. Am Heart J Apr;131(4): In some patients only in V7,V8,V9)

63 55 letá exkuřačka, leta HT, leta ICHS přijata pro 2 hod trvající bolest na hrudi EKG hodnoceno jako koronární insuficience, kardioenzymy negativní, léčena konzerativně po 6 hodinách pro neúspěch konzervativní léčby přeložena k SKG jako NSTE AKS

64 Nováková

65 55 letá exkuřačka, leta HT, leta ICHS přijata pro 2 hod trvající bolest na hrudi EKG hodnoceno jako koronární insuficience, kardioenzymy negativní, léčena konzerativně po 6 hodinách pro neúspěch konzervativní léčby přeložena k SKG jako NSTE AKS

66 ACS - DISCHARGE MEDICATION Anopyrin 100 mg FOR EVER Clopidogrel (6-12M) Betablocker (FOR EVER) Antisclerotic diet + statin ACEI if EF<0.40, HF, HT, DM

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