ACS (Brenner 12/18/2019)

Thank you to Dr. Dan Brenner for his great talk this week on Acute Coronary Syndrome (ACS).

A dear mentor and teacher of mine who knows more than almost anyone I know said in the hallway after GR, “You know, you think you know everything there is to know about a topic, and then you go to Grand Rounds. . .and I learn something new every time!”

It’s true.

Here’s what I learned this week:

·         Family docs are the masters of prevention. (I already knew that!)

o   Diet and exercise modifications can reduce CAD risk up to 50%. Wow!

o   Use the ASVD calculator to guide primary prevention recommendations (not applicable to those with known CAD)

§  Patients with ASCVD 10 year risk >7.5% OR with Diabetes should be on a statin AND aspirin

§  Coronary calcium score may also help guide decisions about ASA for primary prevention

·         Stable Coronary Artery Disease should be managed medically

o   Ischemia Trial  of >5000 patients with stable CAD (excluded left main disease) raises questions about medical management vs. invasive treatment (PCI) in Stable CAD

§  Their bottom line: medical management trumps PCI, BUT I will note that Dr. Brenner took issue with some of their conclusions

·         Optimal medical therapy is CRITICAL in the treatment of stable disease, AND  revascularization may still be indicated in patients to prevent long-term risk of MI and improve symptoms (i.e. angina)

§  Shared decision-making should be employed (my favorite topic!!)

·         To review definitions in ACS

o   Unstable angina: chest pain, no EKG changes, no cardiac enzyme elevation

o   NSTE-ACS: chest pain, +/- EKG changes (e.g. non-specific, ST depressions, T wave inversions, etc), +cardiac enzyme elevation

o   STEMI: chest pain, ST elevation EKG changes, +/- cardiac enzyme elevation

·         The best thing a patient can do if they are having an MI is call 911. The ambulance can expedite an EKG and mobilize cardiology teams at the hospital because “time is myocardium”

o   Goal EMS to drug (heparin) <30 minutes

o   Goal EMS to balloon <90 minutes

o   Symptom onset to reperfusion <120 minutes

·         Pharmacotherapy: beta blocker (slow heart rate), nitrates, ACE-I, statin, dual antiplatelet (ASA+ ticagrelor, ASA+clopidogrel),

o   Goal: optimize balance of myocardial supply/demand

·         Percutaneous intervention (PCI)

o   Goal: open the artery, optimize balance of myocardial supply/demand

o   Radial approach is better than femoral (decreased risk bleeding complications)

o   After a drug eluting stent (DES) is placed, dual antiplatelet therapy (DAPT) should be continued for at least a year (call the cardiologist if you have questions).

o   Complications of PCI occur of 1-2% of patients: bleeding, contrast-induced neophropathy, Acute CVA/embolism, dissection/perforation, MI, emergent CT surgery, death

·         ACS secondary prevention (that is us again!)

o   Smoking cessation

o   Cardiac rehab (supervised exercise program)

o   Diet

o   Medical therapy: ASA +/- p2y12 inhibitor (ticagrelor, clopidogrel), statin, ACE-I (improved survival), aldosterone antagonist (reduced HF and sudden cardiac death), beta blockers (reduced HF, infarct size, arrhythmia, sudden cardiac death)