SCA NON ST

Claudiu STOICESCU, MD. PhD.

University of Medicine Carol Davila

University Hospital of Bucharest
Department of Interventional Cardiology
Erele terapeutice in managementul SCA

Era Observatiei clinice

- prima jumatate secol XX

Era Unitatii Coronariene (U.C.)

- analiza detaliata si tratamentul riguros aritmii

Era High-Technology
- monitorizare hemodinamica invaziva; tratament sustinut

Era Intervention
 Reperfuzia toate SCA?
Ocluzie trombotica

Durere
STEMI ST
TnT

Durere
NSTEMI Fara ST
TnT

Durere
UA Fara ST
Fara TnT
Agregare plachetara
STEMI = sau NSTEMI?

Acute Card Care. 2007;9(2):87-92.

STEMI = sau NSTEMI?

Acute Card Care. 2007;9(2):87-92.

Fundamental
MANAGEMENTUL SCA non-ST
STEP 1
Evaluare initiala

STEP 2
Validarea disgnosticului si evaluarea riscului

STEP 3
Strategia invaziva

STEP 4
Modalitatea de revascularizare

STEP 5
Externare si recomandari
 Ischaemic chest pain

Stable Unstable NSTEMI STEMI

Angina Angina

PREDICTABLE UNPREDICTABLE
CE FAC IN FATA UNEI AP?

European Heart Journal (2011) 32:2999-3054

 LOCALIZAREA ANGINEI PECTORALE

In partea sup a Radiere substernala

Radiere substernala
sternului catre partea latero
catre gat si mandibula
interna a bratului stang

Durere epigastrica Durere la

radiata catre gat, nivelulu gatului si
Epigastric mandibula si brate mandibulei

Durere la nivelul umarului

stang si pe fetele interioare Interscapular
ale bratelor

Adaptat dupa Harrison, vol 7

Recomandari pentru diagnostic
si stratificare risc (I)

PU
U /C
U P
IN

European Heart Journal (2011) 32:2999-3054

SCORUL DE RISC GRACE

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 TIMI Risk Score for UA/NSTEMI

Age >65 years

C Statistic=0.65
>3CAD Risk Factors
2 trend P<.001

Prior Stenosis >50 %

50

D/MI/Urg Revasc (%)

40.9
ST deviation 40
>2 Anginal 30 26.2
events <24 hours 19.9
20 13.2
ASA in last 7 days 8.3
10 4.7
Elev Cardiac
Markers (CK-MB or 0
troponin) 0/1 2 3 4 5 6/7
Number of Risk Factors
Population (%): 4.3 17.3 32.0 29.3 13.0 3.4

Antman EM, et al. JAMA. 2000;284:835-442.

 SCORUL DE SANGERARE
INTRASPITALICEASCA CRUSADE

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DECIZIE RAPIDA IN CAZ DE hsTn

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Tn ... si din alte cauze

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Cine? / Unde? / Cum?

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Algoritm de management al SCA

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 Recomandari pentru
evaluarea invaziva si revascularizare

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 Criterii de risc inalt cu
indicatie de management invaziv

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 Revascularizare

PLACA ATEROM

TROMBUS
 NSTEMI ANTERIOR INTINS CU FEVS 30%

Placa rupta LAD2, revascularizata prin PCI cu stent

 NSTEMI ANTERIOR INTINS CU FEVS 30%

EKG-ul cazului prezentat anterior Colaterale catre LAD-ul precedent

vizualizat dintr-o RCA neregulata
 Tratamentul recomandat cand
diagnosticul de SCA este foarte probabil

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Tratamentul recomandat inainte de PCI

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INHIBITORII P2Y12

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Recomandari pentru antiplachetare orale (1)

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Recomandari pentru antiplachetare orale (2)

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 GP IIb/IIIa Receptor Inhibitors

Prevents cross linking of

plts
May help with early
opening of arteries
Contraindications:
active bleeding
thrombocytopenia
history of stroke
Adverse effects:
bleeding
immune mediated
thrombocytopenia

Kastrati et al. JAMA 2004;291:947-954

Recomandation for GP IIb/IIIa Receptor Inhibitors

European Heart Journal (2011) 32:2999-3054

 Tratamentul recomandat cand
diagnosticul de SCA este foarte probabil

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Tratamentul recomandat inainte de PCI

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 Anticoagulantele

Heparins
unfractionated heparin (UFH)
low molecular weight heparin (LMWH)
enoxaparin, dalteparin
Factor X-A Inhibitor
fondaparinux
Direct Thrombin Inhibitors
bivalirudin: reversible binding
lepirudin: irreversible binding
argatroban: reversible binding
 Unfractionated Heparin (UFH)

Binds antithrombin & inhibits clotting factors

Xa & IIa (thrombin)
IV bolus followed by infusion, adjust
according to aPTT or antifactor Xa levels
Can be used in patients with renal
dysfunction
Continue 48 hrs in patients who will be on
warfarin, otherwise discontinue immediately
after PCI
 ENOXAPARIN

NSTEMI ACS
option for patients undergoing planned early
angiography and revascularization (Class 2a)
UFH recommended over enoxaparin or fondaparinux
(Class 1b)
may be used in patients in whom an initial
conservative strategy is planned (Class 1)
fondaparinux recommended over enoxaparin (Class 1a)
enoxaparin recommended over UFH (Class 1b)

Schnemann HJ, Hirsh J, Guyatt G, et al. Executive Summary: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). Chest. 2008;133;71-109.
 ENOXAPARIN

Shorter chain length compared to UFH

more predictable effects
Contraindications:
active bleeding, severe bleeding risk
history of HIT
recent stroke
CrCl < 15 ml/min
avoid in CABG patients
Dose: 1 mg/kg every 12 hrs (renal adjustment required)
Adverse effects: bleeding & HIT (lesser extent than UFH)
 Fondaparinux

Inhibits factor Xa
less likely to cause HIT than UFH, LMWH
NSTE ACS
option for patients in whom an initial
conservative strategy is planned
preferred agent for patients with high risk for
bleeding (Class 1)

Schnemann HJ, Hirsh J, Guyatt G, et al. Executive Summary: American College of Chest Physicians Evidence-Based
Clinical Practice Guidelines (8th Edition). Chest. 2008;133;71-109.
Tratamentul anticoagulant

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Tratamentul recomandat inainte de PCI

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 Direct Thrombin Inhibitors

NSTE ACS
bivalirudin: option in patients undergoing
planned early angiography & revascularization
(Class 1)
Inhibit clot-bound & circulating thrombin
Does not bind plasma proteins
More predictable response than UFH
Antiplatelet activity
 Sumarul terapiei anticoagulante
Unfractionated heparin
- difficult to use, small evidence base
LMWH
- abundant evidence of additional benefit over aspirin alone
- good data to support benefit over UFH

Fondaparinux is better and has lower bleeding risk

Bivalirudin marginally better over LMWN if PCI is undertaken

Choice depends on strategy

- Conservative
- Fondaparinox with addition of UFH at time of PCI
- Enoxaparin only if bleeding risk is low

- Planned urgent PCI

- Best evidence supports UFH or Bivalarudin
Special populations and situtions

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Antithrombotic drugs in CKD

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 Glycemic Control

Hyperglycemia associated with increased morbidity

& mortality in hospitalized patients
NICE-SUGAR (Normoglycemia in Intensive Care
Evaluation-Survival Using Glucose Algorithm
Regulation)
n=6104
blood glucose target < 180 mg/dL for critically ill
patients resulted in lower mortality than intensive
glucose control (target 81 to 108 mg/dL)

NEJM. 2009;360:1283-1297
Tratamentul recomandat post PCI / externare

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 Oral anticoagulation (AVK)

Consider anticoagulation in select patients following

ACS
LV thrombus
history of thromboembolic events
chronic atrial fibrillation
Routine AVK treatment should not be used in HF
patients in normal sinus rhythm without another
indication
Reduces risk of death, MI, stroke
Doubles major bleeding risk
 Sumarul revascularizarii coronariene

Early strategy has slighty more early mortality

disadvantage

Early PCI has late benefit in terms of combined

CV endpoints

Benefit effect not seen in negative Tn patients /

very low risk patients
 Ischaemic chest pain

Unstable
Stable NSTEMI STEMI
Angina
Angina
CHALLENGE IS HOW TO
PREDICT THE
UNPREDICTABLE

PREDICTABLE UNPREDICTABLE