CORONARY ARTERY

DISEASE

Mirco Baccino
Cardiologia
Ospedale Santa Corona – Pietra L.

Maggio 2009
MAKE A DECISION
 GOOD THERAPY BAD THERAPY

Arrhythmic damage
Reduct damage Left ventricle remodelling
Clinic improvement Heart faliure/shock
ECG signal reduction mortality increase
Fast markers evolution
ABORTED AMI

TROMBOLITHIC TERAPY

PTCA PRIMARY/RESCUE
 Pathogenetic components of
acute coronary syndromes

White/red Hemodynamic
thrombus stress

Inflammation

Vascular damage
 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 ↓
8%
ST ↑
Mortality

6%

4% T wave
inversion

2%

0%
0 30 60 90 120 150 180
Days
AMI Markers

time
AMI Markers
 TnT and in-hospital
outcome in UA (n=84)
35
30
In-hospital D/MI (%)

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

Death
16
AMI
Urgent MR
12

0
CRP < 3mg/l (n=11) CRP > 3mg/l (n=20)
(Liuzzo et al, NEJM 1994)
TnT, CRP and Prognosis in UA
(n=102)
60
MI/death at 3 months (%)

50

40

30

20

10

0
Tn- and CRP- Tn+ or CRP+ Tn+ and CRP+
(n=46) (n=45) (n=11)
(Rebuzzi et al, AJC 1998)
 KILLIP CLASS
clinical evidence % AMI mortality

K1 no heart failure 40-50% 6%

K2 heart failure 30-40% 17%
K3 acute pulmonary edema 10-15% 38%
K4 shock 5-10% 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
MSCT
and
Stents
64 row CT 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%
4 3.5%
3.3%
%

2.5% 2.5%
2.2%*
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 33
33 min.
min.
REPAIR
REPAIR 47
47 min.
min.
EMIP
EMIP 55
55 min.
min. Median 63 min.
GREAT
GREAT 130
130 min.
min.
Nijmegen
Nijmegen 63
63 min
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