Evidence Based Strategies for Acute Myocardial Infarction Care: Unstable Angina/Non-STEMI

1. Evidence Based Strategies for Acute Myocardial Infarction Care:Unstable Angina/Non-STEMI Scott A. Sample DO, FACC Cardiovascular Interventionist April 2010

2. Why a Systems Approach to Acute Coronary Syndrome Care? • Therapy for ACS has been well studied and validated. Standardized protocols for treatment are evidence based and readily available. • A systems approach results in improved adherence to evidence based treatment strategies. These strategies improve patient outcomes and survival. • A systems approach provides a scaffold for program development and real time feedback measurements that can be used to improve care. • A systems approach encourages providers across the entire continuum of care to place focus on the patient.

3. Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Unstable Angina/Non-STEMI Risk Scoring/Management/ Transfer Considerations American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines

4. Pre-Hospital Care Patients with chest pain suspicious for acute coronary syndromes should undergo the following: Activation of EMS LOE* B Aspirin 162-325mg chewed and swallowed (Unless already self administered by patient) LOE A 12 Lead EKG, if available in the field LOE B Rapid stabilization and transfer to Emergency Department (Unless care pathways for Acute MI PCI direct to the catheterization laboratory are in place) LOE A * LOE = Level of Evidence

5. ACS Recognition Upon arrival to the Emergency Department, 12 lead EKG (10 minutes) LOE B Initiate continuous EKG monitoring, oximetry, and frequent vital sign monitoring LOE B Establish IV access with two large bore peripheral IVs Once ACS is suspected/established, initiate aspirin, oxygen, nitrates and morphine

6. ACS Risk Stratification Obtain baseline laboratory markers including a CBC, Metabolic Panel and Cardiac Markers If the initial EKG is nondiagnostic, repeat every 15-30 minutes Assess cardiac risk factors

7. Assessment of Risk Identify chest pain into 4 groups Non-cardiac Pain Stable Angina Possible Acute Coronary Syndrome Definite Acute Coronary Syndrome

8. Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Unstable Angina/Non-STEMI Risk Scoring/Management/ Transfer Considerations American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines

9. Approach For Acute Coronary Syndrome for Critical Access Hospitals: STEMI

10. NONSTEMI Care for Critical Access Hospitals

11. Risk Stratification • Assessment of risk with readily available clinical and demographic features of patients has been validated. • One such tool is the Thrombolysis in Myocardial Infarction (TIMI) risk score. • The score is based on 7 features of patients with suspected ACS. • Positive answers to the risk elements result in 1 point per element. The maximum score is 7. • The higher the score, the greater the risk of mortality for the patient. • Use of this score may aid in determining therapy for the patient as well as determining which patients may benefit from elevation of care and early transfer.

12. TIMI Risk Score for UA/NSTEMI TIMI Score Risk of mortality/ recurrent ischemic event 0-1 4.7% 2 8.3% 3 13.2% 4 19.9% 5 26.2% 6-7 40.9% Historical Points Age > 65 yrs 1 > 3 CAD Risk Factors 1 Known CAD ( > 50% Stenosis) 1 ASA use in past 7 days 1 Presentation Recent ( < 24H) severe angina 1 Elevated Cardiac Markers 1 ST deviation > 0.5mm 1 Risk Score = total points (0-7) low (0-2; 5-8% risk) intermediate (3-4; 13-20% risk) high (5-7; 26-41% risk) Antman et al JAMA 2000 www.timi.org

13. Further Assessment Admit for observation Check serial enzymes Continuous EKG monitoring For high risk patients with multiple cardiac risk factors, consider early transfer to PCI capable hospitals

14. Optimal Medical Management Vasodilators Anti-Platelet therapy Anti-Thrombotic therapy Anti-Ischemic agents Lipid Lowering therapy General Medical therapy

15. Vasodilators Nitroglycerin Sublingual Initially Intravenous Transdermal

16. Anti-Platelet Agents Aspirin 162-325mg daily Clopidogrel 75mg daily (loading dose of 150-300mg) Ticlopidine 250mg twice daily (loading dose of 500mg) IIb/IIIa glycoprotein inhibitors bolus and continuous infusion per protocol driven dosing schedules

17. IIb/IIIa Glycoprotein Inhibitors Abciximab (Reopro) indicated in patients anticipated to go to the catheterization laboratory within 12 hours. Bolus and drip Integrilin indicated in patients anticipated to go to the catheterization laboratory or for patients treated with medical management for up to 72 hours. Bolus and drip

18. Anti-Thrombotic Therapy Unfractionated Heparin Low Molecular Weight Heparin Fondaparinux Lepirudin

19. NONSTEMI Beta Blocker Class I Oral beta blocker therapy is indicated in all patients recovering from NONSTEMI unless contraindicated by other medical condition indefinitely Recovering NONSTEMI patients with moderate to severely depressed left ventricular systolic function should be treated with beta blockers with a careful dose titration strategy.

20. Relative Contraindications to Beta Blockers Heart rate < 60 bpm SBP < 100mmHG Signs of peripheral hypoperfusion Severe LV failure PR interval > 0.24 seconds

21. Secondary or tertiary AV block Severe COPD Hx of asthma Severe peripheral vascular disease IDDM Relative Contraindications to Beta Blockers cont.

22. Lipid Lowering Therapy Early initiation of statin type lipid lowering agents has been shown to be beneficial in the treatment of acute coronary syndromes The most studied agents include pravastatin, simvastatin and atorvastatin

23. General Medical Management Oxygen therapy Analgesics Stool softeners Antacids Other medical therapies for co-morbid conditions

24. Risk StratificationRecommendations Noninvasive stress testing is recommended in low and intermediate-risk patients who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 h. Choice of stress test is based on the resting EKG, ability to perform exercise, local expertise, and technologies available. Treadmill exercise is useful in patients able to exercise in whom the EKG is free of baseline ST-segment abnormalities, bundle-branch block, left ventricular (LV) hypertrophy, intraventricular conduction defect, paced rhythm, preexcitation, and digoxin effect. An imaging modality should be added in patients with resting ST-segment depression (greater than or equal to 0.10 mV). LV hypertrophy, bundle-branch block, intraventricular conduction defect, preexcitation, or digoxin who are able to exercise. In patients undergoing a low-level exercise test, an imaging modality can add sensitivity. Pharmacological stress testing with imaging is recommended when physical limitations (e.g., arthritis, amputation, severe peripheral vascular disease, severe chronic obstructive pulmonary disease).

25. Transfer Considerations • Establish contact with accepting hospital • Accepting Physician • Administrative Acceptance • Establish safest method of transfer • Arrange for copies of transfer documents • Copies of all pertinent clinical material

26. Summary: Evidence Based Strategies for Acute Myocardial Infarction Care Pre-hospital Care/Diagnosing Acute Coronary Syndromes Unstable Angina/Non-STEMI Risk Scoring/Management/ Transfer Considerations American College of Cardiology Website ACC/AHA STEMI and non-STEMI guidelines