Coronary Artery Disease

CORONARY ARTERY DISEASE

Mirco Baccino Cardiologia Ospedale Santa Corona – Pietra L.

Maggio 2009

MAKE A DECISION

GOOD THERAPY Reduct damage Clinic improvement ECG signal reduction Fast markers evolution ABORTED AMI TROMBOLITHIC TERAPY PTCA PRIMARY/RESCUE

BAD THERAPY Arrhythmic damage Left ventricle remodelling Heart faliure/shock mortality increase

Pathogenetic components of acute coronary syndromes White/red thrombus

Inflammation

Vascular damage

Hemodynamic stress

RISK FACTORS Diabetes Gender (male) Age Smoke Hypertension Dislipidemia Obesity Sedentary life

Coronary artery disease clinical pattern

Two ways:

CHRONIC ACUTE

CAD Damage’s consequences Systolic dysfunction EF reduction Heart failure Shock Arrhythmia

CAD

CHRONIC CORONARY SYNDROME STABLE ANGINA: most frequent, tipical angina pectoris. SILENT ISCHEMIA

CAD ACUTE CORONARY SYNDROME UNSTABLE ANGINA : CHEST PAIN AT REST SILENT ISCHEMIA PRINZMETAL’S ANGINA ACUTE MYOCARDIAL INFARCTION: necrosi del miocardio secondaria ad un’interruzione del flusso coronarico non transitoria, bensì permanente; generalmente dovuta alla mancata dissoluzione spontanea del trombo. SUDDEN DEATH: decesso inaspettato per cause cardiache, che si verifichi entro un’ora dalla comparsa dei sintomi o, anche, in assenza di questi.

STABLE ANGINA

UNSTABLE ANGINA

GRAVITY ACUTE MYOCARDIAL INFARCTION

CAD SYMPTOMS ECG MARKERS CLINICAL ESTIMATE IMAGING: Coronary Angiography – Computed Tomography – Cardiovascular Magnetic Resonance – Nuclear Cardiology - Echocardiography

TIME in diagnosis and terapia

SYMPTOMS Pain (85%) more then 20 minuts. Pallor / sweat Dyspnea without pain (10%) No symptoms (5%), [diabetes] Acute pulmonary edema / shock

Transwall ischemia

Subendocardial ischemia

Ischemia - ST

depression

Myocardial infarction

• ST elevation

Subendocardial ischemia

Anteriore AMI

Inferiore AMI

Basal ECG and prognosis Six months mortality 10%

ST

↓

ST

↑

Mortality

8% 6%

T wave inversion

4% 2% 0% 0

30

60

Days

90

120

150

180

AMI Markers

time

AMI Markers

TnT and in-hospital outcome in UA (n=84) 35 In-hospital D/MI (%)

30 25 20 15 10 5 0

TnT<0.2mcg/l (n=51)

TnT>0.2mcg/l (n=34) (Hamm et al, NEJM 1992)

CRP on admission and ( in-hospital outcome in UA 20 16 12

Death AMI Urgent MR

8 4 0

CRP < 3mg/l (n=11)

CRP > 3mg/l (n=20) (Liuzzo et al, NEJM 1994)

TnT, CRP and Prognosis in UA (n=102) MI/death at 3 months (%)

60 50 40 30 20 10 0

Tn- and CRP(n=46)

Tn+ or CRP+ (n=45)

Tn+ and CRP+ (n=11) (Rebuzzi et al, AJC 1998)

KILLIP CLASS clinical evidence K1 K2 K3 K4

no heart failure heart failure acute pulmonary edema shock

% AMI 40-50% 30-40% 10-15% 5-10%

mortality 6% 17% 38% 81%

TIMI RISK SCORE – UA/NSTEMI – – – – – –

Age > 65 anni Risk factors (three or more) Well-know coronary disease ST depression/elevation in ECG AMI markers Angor since 48 hours -- ASA since seven days

TIMI RISK SCORE – UA/NSTEMI 0/1...................4.7% 2 ......................8.3% 3 ......................13.2% 4 ......................19.9% 5 ......................26.2% 6/7 ...................40.9% (events a 14 days)

TIMI RISCK SCORE – STEMI Ag > 75 . . . . . . . . . . . . . . . . . . 3 Age 65-75 . . . . . . . . . . . . . . . . 2 DM, HTA . . . . . . . . . . . . . . . . . 1 SBP <100mmHg . . . . . . . . . . . 3 HR >100 bpm . . . . . . . . . . . . . 2 Killip II-IV . . . . . . . . . . . . . . . . . 2 Weight <67 Kg . . . . . . . . . . . . 1 AMI Ant, LBBB . . . . . . . . . . . . 1 Time >4 h . . . . . . . . . . . . . . . . 1

TIMI RISCK SCORE – STEMI 0 . . . . . 0.8% 1 . . . . . 1.6% 2 . . . . . 2.2% 3 . . . . . 4.4% 4 . . . . . 7.3% 5 . . . . . 12% 6 . . . . . 16% 7 . . . . . 23% 8 . . . . . 27% >8 . . . . . 36% (mortality 30 days)

MITRAL TETHERING

ASSOCIAZIONE ATEROMASIA AORTICA con MALATTIA CORONARICA

STUDIO dei TRATTI PROSSIMALI delle CORONARIE

TC STENOSIS

Coronary artery

Management of Acute Coronary Syndromes Multislice Computed Tomography As A Substitute for Coronary Angiography Udo Sechtem Robert-Bosch-Krankenhaus - Stuttgart, Germany

Keelan, P. C. et al. Circulation 2001;104:412-417 (cardiac death, non-fatal MI)

The Ideal Patient Stable heart rhythm < 65/min Able to hold breath for 20 sec (8 sec) No allergy or contraindication to contrast agents No severe coronary calcification No intracoronary stents (?) Lesions (if present) only in segments ≥ 2mm (>0.5 mm)

16 Row CT Coronary Angiography Mollet NR et al. - J Am Coll Cardiol 43:2265-70, 2004

16 row CT

64 row CT

MSCT and Stents Courtesy of Stephan Achenbach

MSCT In The Emergency Room? Dirksen MS et al. Am J Cardiol 95:457-61, 2005

20% of patients no CAD 19% of segments uninterpretable (4 slice MSCT) 94% negative predictive value

MSCT cannot be recommended at this moment as a substitute for conventional coronary angiography in properly risk stratified patients with UAP

RCA

LCX

CORONARY ANGIOGRAPHY

Coronary abgiography + PCA

AMI therapy FIBRINOLYSIS (prehospital/hospital) PRIMARY PCA RESCUE PCA

Fibrinolysis vs. primary PCI

Non-STE ACS Invasive vs Conservative Strategies: Mortality at 6 to 12 months Non-invasive

6

Invasive 4.6% 3.9%

3.9% 3.5%

3.3%

%

4

2.2%*

2.5% 2.5%

2

0

RITA-3

TACTICS

FRISC II

ICTUS

N = 1810

N = 2220

N = 2457

N = 1200

*P < 0.05.

Aborted Myocardial Infarction Definition of aborted infarction

Time gained by Prehospital Thrombolysis

MITI MITI REPAIR REPAIR EMIP EMIP GREAT GREAT Nijmegen Nijmegen

33 33 min. min. 47 47 min. min. 55 55 min. min. 130 130 min. min. 63 63 min min..

Median 63 min.

Percentage of patients treated from time of onset of chest pain 100%

home in hospital

50%

0:00 0:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 hrs

USIC. Circulation 2004;110:1909-1915

Conclusions Diagnosis Risk score Therapy (choise, timing) Evolution (EF!) Prognosis Follow up

OPTIMAL REPERFUSION THERAPY 2009

Conclusions

fibrinolysis

prehospital bolus lytic +

PCI as late as clinically acceptable

primary PCI

prehospital triage +

direct referral to PCI center +

aspirin/heparin + ? other facilitation

AMI therapy

LIGURIA

ITALIA

Savona