Cardiovascular Updates-1

Cardiovascular Updates-1 - ACS Updates ACS ACS Updates Joe...

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Unformatted text preview: ACS Updates ACS ACS Updates Joe Lex, MD, FAAEM Temple University Philadelphia, PA USA Heavily Borrowed from Amal Mattu Heavily Borrowed from Amal Mattu Disclosure Disclosure Disclosure New Risk Factors New Stopping NSAIDs Stopping Stopping NSAIDs • Compare 8688 first MI with Compare 33,923 matched controls 33,923 • First MI: no difference between First nonusers and current users nonusers • Stopping NSAIDs: significantly Stopping increased odds for MI within 29 days after cessation days Fischer et al. Arch Intern Med 2004; 164:2472 Stopping NSAIDs Stopping Stopping NSAIDs • Worse if… …>40 NSAID prescriptions …RA or SLE • Consistent among most Consistent common nonaspirin NSAIDs: ibuprofen, indomethacin, ketoprofen, naproxen ketoprofen, Fischer et al. Arch Intern Med 2004; 164:2472 Hostility Hostility Hostility • • • Recognized risk for 1st event What about reoccurrence? 3227 outpatients in Nova Scotia 3227 followed for 4 years followed • Composite end points: death Composite and hospitalization and Haas DC et al: Heart 2005;91:1609-1610 Hostility Hostility High Hostility Low Hostility Men 54% 33% Women 44% 52% • Hostility predicted bad end Hostility points in men points • Hostility protective in women Hostility protective Haas DC et al: Heart 2005;91:1609-1610 SLE and ACS SLE SLE and ACS • Patients with SLE have MIs 20 Patients years earlier than those without years • Young patients with SLE have 9fold risk of significant CAD • Women age 35 – 44 with SLE Women have 50-fold risk of significant CAD CAD Mattu A, et al: Am J Emerg Med 2005;23:696 Triggers of MI Triggers Triggers of MI “That couldn’t be MI because… …iit started during an argument, t so it must be stress or anxiety.” so …iit started while eating spicy t food, so it must be indigestion.” food, …iit woke him up from sleep, so it t can’t possibly be a heart attack.” can’t Culic V et al: Int J Cardiol 2005:99:1-8 Triggers of MI Triggers Triggers of MI Heavy physical exertion 6.1% Mild to moderate activity 28.6% Sexual activity 1.1% Emotional stress 6.8% 6.8% Eating 8.2% Sleeping 20.7% Culic V et al: Int J Cardiol 2005:99:1-8 Chlamydia Chlamydia Hypothesis Hypothesis Chlamydia Hypothesis #1 Chlamydia Chlamydia Hypothesis #1 • • • • PROVE IT TIMI 22 4162 patients >60% PCI+ for chlamydia Gatifloxacin x 2 weeks, then 10 Gatifloxacin days / month days • Two year follow-up Cannon et al. N Engl J Med 2005;352:1646 Chlamydia Hypothesis #1 Chlamydia Chlamydia Hypothesis #1 • No difference in death, MI, No hospitalization for unstable angina, revascularization, stroke angina, • Subgroup analysis: still no Subgroup difference, even with highest chlamydia titers chlamydia Cannon et al. N Engl J Med 2005;352:1646 Chlamydia Hypothesis #2 Chlamydia Chlamydia Hypothesis #2 • • 4012 patients with stable angina Azithromycin 600 mg weekly for Azithromycin one year one • Four year follow-up • No difference in any primary or No secondary endpoint secondary Grayston et al N Engl J Med 2005; 352:1637 History History Chest Pain History Chest Chest Pain History • Stabbing, pleuritic, positional, or Stabbing, reproducible by palpation lessens possibility of ACS… lessens …but no descriptor or but combination good enough to “rule out” ACS “rule • All we can do is “risk stratify” • Best CJ et al. JAMA 2005;294:2623-2629 predictor: pain to right arm Swap GERD vs. MI GERD GERD vs. MI • 20% of patients with AMI 20% describe pain as “indigestion” describe “Give him a GI cocktail” • 15% AMI patients get some 15% relief from antacids relief • 7% AMI patients get complete 7% relief from antacids relief Dobrzycki et al.: Int J Cardiol 2005:99:67-72 GERD vs. MI GERD GERD vs. MI • 20.6% of acute cardiac ischemia 20.6% is associated with acute GERD is • GERD patients have longer GERD periods of ischemia, more frequent ST depression frequent • GERD may provoke / worsen GERD ACS ACS Dobrzycki et al.: Int J Cardiol 2005:99:67-72 Sidetrack Sidetrack Pericarditis Pericarditis Pericarditis • • • • 120 patients with first pericarditis Group I: aspirin only Group II: aspirin + colchicine Steroids: rescue medicine only Imazio M et al. Circulation 2005;112:2012 Pericarditis Pericarditis Pericarditis ASA ASA + ASA Colchicine Colchicine 32% 11% Recurrence at 6m 32% 12% Symptoms at 72h • Steroids: independent risk factor Steroids: for recurrence for Imazio M et al. Circulation 2005;112:2012 Therapy: ACS Therapy: COMMIT COMMIT COMMIT • Cllopidogrel and Metoprolol in opidogrel etoprolol Myocardial Infarction Trial yocardial nfarction • Chinese study: 45,852 patients Chinese with acute MI with 87% 87% 7% 7% 6% 6% STEMI STEMI ST depression ST LBBB LBBB Chen et al. Lancet. 2005;366(9497):1607-21 COMMIT COMMIT COMMIT • Composite endpoint: death or Composite reinfarction or stroke reinfarction • Death from any cause Treatment (all got aspirin 162mg): • Clopidogrel 75 mg/d 22,961 22,961 • Placebo 22,891 Placebo 22,891 Chen et al. Lancet. 2005;366(9497):1607-21 Clopidogrel Arm Clopidogrel Clopidogrel Arm • 9% relative in all endpoints 9% relative – 9.2% vs. 10.1%; p=0.002 – Absolute reduction: 0.9% – 9 fewer events per 1000 patients fewer NNT 110 • 7% reduction in death – 7.5% vs. 8.1%; p=0.03 Chen et al. Lancet. 2005;366(9497):1607-21 Clopidogrel Arm Clopidogrel Clopidogrel Arm • Fibrinolytic used: urokinase – Not fibrin-specific • Relatively low rate (54%) of PCI • For elderly patients who got For fibrinolytic therapy, no safety data in those who also got clopidogrel clopidogrel Chen et al. Lancet. 2005;366(9497):1607-21 Metoprolol Arm Metoprolol Metoprolol Arm • 5mg IV x 3, then 50 mg po x 28d Death or MI or CVA Death Arrhythmic death Cardiogenic shock Shock death Shock Treated Control Control 9.4% 9.9% 1.7% 2.2% 5.0% 3.9% 3.3% 2.7% Chen et al. Lancet. 2005;366(9497):1607-21 Metoprolol Arm Metoprolol Metoprolol Arm At two weeks: 11 / 1000 cardiogenic shock 11 – Most apparent days 0 – 1 5 / 1000 reinfarction or v-fib 1000 – Most apparent day 2 onward Conclusion: delay beta-blocker Conclusion: delay until hemodynamically stable until Chen et al. Lancet. 2005;366(9497):1607-21 What If We Change Controls ?? What What If We Change Controls ?? • Clopidogrel: death/MI/CVA Clopidogrel: placebo 10.1% vs. treated: 9.2% placebo NNT = 110 • Metoprolol: death/MI/CVA Metoprolol: placebo 9.9% vs. treated: 9.4% placebo NNT = 200 Chen et al. Lancet. 2005;366(9497):1607-21 What If We Change Controls ?? What What If We Change Controls ?? If we switched placebo groups… • Clopidogrel now changes Clopidogrel outcome from 9.9% to 9.2% outcome • Metoprolol now changes Metoprolol outcomes from 10.1% to 9.4% outcomes Clopidogrel: new NNT = 143 Clopidogrel: 143 Metoprolol: new NNT = 143 Metoprolol: 143 Chen et al. Lancet. 2005;366(9497):1607-21 Early Statins During MI #1 Early Early Statins During MI #1 • National Registry of Myocardial National Infarction (NRMI) Database Infarction • Statins… …already being taken by 9.8% …given within 24 hours to 22.4% …stopped in some …not used in remainder Fonarow et al. Am J Cardiol. 2005 ;96(5):611 Early Statins During MI #1 Early Early Statins During MI #1 In-Hospital Mortality Statin Use n= Started 21,978 4.2% Continued 17,118 5.3% Not Used 126,128 15.4% Stopped 9,411 16.5% • Database info: not randomized, Database controlled, or double-blinded controlled, Fonarow et al. Am J Cardiol. 2005 ;96(5):611 Early Statins During MI #1 Early Early Statins During MI #1 • Associated with lower… …cardiogenic shock …arrhythmias …cardiac arrest …myocardial rupture • But no change in recurrent MI Fonarow et al. Am J Cardiol. 2005 ;96(5):611 Early Statins During MI #2 Early Early Statins During MI #2 • • PROVE IT-TIMI 22 Pravastatin or Atorvastatin Pravastatin Evaluation and Infection Therapy – Thrombolysis in Myocardial Infarction 22 Myocardial • 4162 patients hospitalized with 4162 ACS, followed for 24 months ACS, Ray KK, et al. J Am Coll Card 2005;46(8):1405 Early Statins During MI #2 Early Early Statins During MI #2 Statin Control Control Death or MI or USA or 30-d revascularization or stroke at 4 months or 8.2% 10.2% Same at 24 months 15.1% 17.7% Death or MI or USA at Death 3.0% 4.2% 30 days 30 Same at 24 months 9.6% 13.1% Ray KK, et al. J Am Coll Card 2005;46(8):1405 LMWH vs. UFH in ACS LMWH LMWH vs. UFH in ACS n = 9978 6 month death / MI 12 month death / MI 6 month readmit UFH LMWH 884 380 911 872 359 858 • Low-molecular weight heparin Low-molecular no advantage Mahaffey et al. JAMA. 2005 ;294(20):2594 Heparin: Hurt or Harm? Heparin: Heparin: Hurt or Harm? • • Bleeding occurs in 3 – 9% Need to be weight based and Need dependent on renal function dependent • When overdosed, cause major When bleeding: ICH, transfusion, hematocrit fall 12% or greater hematocrit Alexander KP et al: JAMA 2005;294:3108 30% 25% Significant Bleeding Unfractionated heparin Low molecular weight heparin 20% 15% GP2B3A inhibitor 10% 5% 0 Un ss ss ed ce ce nd e ex ex m r ht m jo a lig co S M Re se do er d Alexander KP et al: JAMA 2005;294:3108 Heparin: Hurt or Harm? Heparin: Heparin: Hurt or Harm? • Dosing errors common: must be Dosing weight based weight • More side effects in elderly • More common if renal impaired Alexander KP et al: JAMA 2005;294:3108 GP IIbIIIa Inhibitors GP GP IIbIIIa Inhibitors • • • Helps in NSTEACS / USA if PCI 27,115 patients with AMI Abciximab reduced 30-day Abciximab mortality (3.4% 2.4%) and 612 month mortality (6.2% 12 4.4%) in STEMI patients undergoing PCI undergoing De Luca et al. JAMA 2005;293:1759-1765 GP IIbIIIa Inhibitors GP GP IIbIIIa Inhibitors • Slight increased bleeding risk Slight when combined with lytic (5.2% vs. 3.1%) but not with PCI alone vs. • Eptifibatide: no benefit • Tirofiban: no benefit De Luca et al. JAMA 2005;293:1759-1765 Door-to-Balloon Times Door-to-Balloon Door-to-Balloon Times • Current ACC / AHA guidelines: Current STEMI patients get balloon inflation within 90 minutes inflation • If longer, use fibrinolytic agent • National Registry of Myocardial National Infarction: 4278 patients from 419 hospitals 419 Nallamothu et al. Circulation 2005;111:761 Door-to-Balloon Times Door-to-Balloon Door-to-Balloon Times • Median door-to-balloon: 180 Median minutes minutes • Treated within 90 minutes: 4.2% Treated 4.2% • If PCI available at hospital If where patient presents: door-towhere balloon time 120 minutes Nallamothu et al. Circulation 2005;111:761 Door-to-Balloon Times Door-to-Balloon Door-to-Balloon Times Editorial with last article • Even when presenting hospital Even has PCI, <30% have door-tohas balloon <90 minutes • “Too early to recommend routine Too transfer for primary PCI for all patients with STEMI.” patients Hermann HC. Circulation 2005;111:718-720 Therapy: CHF Therapy: Morphine for Heart Failure Morphine Morphine for Heart Failure • • • ADHERE registry of CHF 20,782 patients got morphine 126,580 patients did not Peacock WF et al. AEM 2005;12(5;Suppl. 1):97 Morphine for Heart Failure Morphine Morphine for Heart Failure Morphine Control Mortality 13.0% 2.4% Ventilator 15.0% 3.0% 5.6 4.2 38.7% 14.4% Hospital days ICU Admission • Morphine for CHF: “substandard” Peacock WF et al. AEM 2005;12(5;Suppl. 1):97 Nesiritide #1 Nesiritide Nesiritide #1 • CHF: declining renal function CHF: poor prognostic sign • 5 randomized trials, 1269 pts • Nesiritide “significant increase… Nesiritide risk of worsening renal function” risk • Trend toward higher mortality Sackner-Bernstein et al. Circulation 2005;111:1487 Nesiritide #2 Nesiritide Nesiritide #2 • Three randomized double-blind Three studies studies • 30 day mortality higher in 30 nesiritide (7.2%) than controls (4.0%) (4.0%) Sackner-Bernstein et al. JAMA 2005;293:1900 Brugada Brugada Brugada Syndrome Brugada Brugada Syndrome EKG Findings • Complete or incomplete Right Complete Bundle Branch Block in V1 & V2 Bundle • ≥2 mm ST elevation in V1 or V2 • Placing leads V1 / V2 up one rib Placing space increases accuracy space Francis J et al. Int J Cardiol 2005;101:173 Brugada Syndrome Brugada Brugada Syndrome Brugada Syndrome Brugada Brugada Syndrome • Responsible for… …~4% of sudden death …20% if no structural disease …? ? SIDS • No treatment: mortality 10%/yr • With AICD: 100% survival Francis J et al. Int J Cardiol 2005;101:173 ACLS Updates ACLS 1. Chest Compressions 1 1.. Chest Compressions Encourage rescuers to “push hard Encourage and fast” at a rate of about 100 compressions per minute, with about equal time for compression and relaxation and as few interruptions in compressions as possible. possible. 2. New Ratio 2 2.. New Ratio New compression-to-ventilation New ratio for lone rescuers of 30:2 for all victims from infants (excluding newborns) through adults. New approach: longer series of uninterrupted chest compressions uninterrupted 3. Rescue Breathing 3 3.. Rescue Breathing Rescue breaths last 1 second and Rescue cause the chest to rise. Previously, the duration standard was not precise and mentioned durations of 1 to 2 seconds, now deemed too long. deemed 4. Defibrillation 4 4.. Defibrillation One shock followed by immediate One chest compressions. Previously, the rule was 3 shocks without CPR between them. The new system increases the chances that the heart can create blood flow after the shock. flow 5. Basic Life Support 5 5.. Basic Life Support BLS now emphasized over pulse BLS checks and drug administration. Rescuers should not sacrifice chest compressions right after a shock to do pulse checks or administer drugs, although neither of these practices was eliminated from the guidelines. eliminated 6. AEDs in Kids 6 6.. AEDs in Kids Automated external defibrillators Automated for all children age 1 year or older. older. 7. Cooling the Survivors 7 7.. Cooling the Survivors Unconscious adults with return of Unconscious spontaneous circulation (ROSC) after out-of-hospital cardiac arrest be cooled to 32° to 34° Celsius for 12 to 24 hours when the initial rhythm was ventricular fibrillation. rhythm Thank you for your attention Thank Thank you for your attention For copy of slideset: For [email protected] [email protected] ...
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This note was uploaded on 01/11/2012 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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