Note to myself: I have downloaded the 2023 ESC Guidelines for the management of acute coronary syndromes on the desktop of my laptop. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Bryne. Eur Heart J. 2023 Oct 12;44(38):3720-3826. doi: 10.1093/eurheartj/ehad191
And be sure to review The Curbsiders‘ #450 Acute Coronary Syndrome with Dr. Sanjeev Francis – Part 1.*
*Amin, M, Trubitt, M, Coleman C, Francis S, Williams PN, Watto MF. “#450 Acute Coronary Syndrome with Dr. Sanjeev Francis”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast August 26, 2024.
Today, I review, link to, and excerpt from The Curbsiders’ #451 Acute Coronary Syndrome with Dr. Sanjeev Francis – Part 2.*
*Amin, M, Trubitt, M, Coleman C, Francis S, Williams PN, Watto MF. “#451 Acute Coronary Syndrome with Dr. Sanjeev Francis-Part 2”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Sept 2, 2024.
All that follows is from the above resource.
Transcript available via YouTube
Quit playing games with my heart
Yet another beat no to skip here with part 2 of our conversation with cardiologist Dr. Sanjeev Francis (@, Maine Medical Center)for acute coronary syndrome. Learn about the warranty on stress tests, initial management of ACS and how to deal with those pesky elevated troponins from patients with sepsis.
Claim CME for this episode at curbsiders.vcuhealth.org!
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Show Segments
- Start Part 1
- Intro
- Rapid fire questions/Picks of the Week
- Case 1
- History and Physical
- ECGs
- Definitions
- Risk Stratification Tools
- Non-invasive Testing Options
- End Part 1
- Start Part 2
- Case 2
- Warranty on Non-invasive Testing
- Invasive Management of non ST elevation ACS
- Medical Management of non ST elevation ACS
- Case 3
- Myocardial Injury Definitions
- Diagnostics to Consider for Myocardial Injury
- Transitions of Care
- Outro
- End Part 2
Show notes from Part 2.
“Warranty” on Tests
Dr. Francis says the “warranty” for a high-quality negative coronary CT is about two years, meaning you can treat a negative test obtained any time in the last 2 years as current. For all other testing modalities, the “warranty” is shorter, on the order of one year. However, recognize that plaque rupture is unpredictable, so patients presenting with concerning symptoms during the “warranty” period may still need further work-up (Gulati, 2021).
Cardiac Catheterization
Patients with STEMI need prompt cardiac catheterization and revascularization. If revascularization is not available at your institution, then administration of thrombolytics and initiating transfer to a facility that can perform catheterization are indicated (Byrne, 2023).
Patients with NSTEMI need further evaluation to determine timing of cardiac catheterization. High-risk features that should prompt catheterization within 24 hours include “confirmed diagnosis of NSTEMI based on high-sensitivity troponin algorithms, dynamic ST segment or T wave changes, transient ST segment elevation, or a GRACE risk score > 140.” Very high-risk features that should prompt emergent catheterization include diagnosis of NSTEMI and “hemodynamic instability or cardiogenic shock, recurrent or ongoing chest pain refractory to medical treatment, acute heart failure presumed secondary to myocardial ischemia, mechanical complications, and recurrent dynamic ECG changes suggestive of ischemia” (Byrne, 2023).
If cardiac catheterization is not available in your facility, plan for early initiation of transfer of high-risk patients with NSTEMI to a capable facility, and use serial ECG and biomarker determinations to monitor evolution of ACS.
Medical Management
Aspirin
All patients with suspected acute coronary syndrome should receive a one-time loading dose of aspirin 325 mg, followed by a maintenance dose of 81 mg daily (Byrne, 2023). Dr. Francis reminds us that if you are unsure whether a patient received a loading dose, give it again.
Statins
A lipid panel can be falsely low during the acute coronary event, so it may not provide meaningful data. As lipid lowering slows long-term plaque progression, most patients should start lipid-lowering agents during the index hospitalization if not already on them (Byrne, 2023). The high-intensity options are atorvastatin 40 mg or 80 mg daily and rosuvastatin 20 mg or 40 mg daily (Dr. Francis recommends the higher doses since doses can be reduced as an outpatient if the patient achieves marked LDL lowering). Second agents are reserved for patients with suspicion of familial hypercholesterolemia or those already on high-intensity statins prior to hospitalization.
P2Y12 Inhibitors
There are three options for P2Y12 inhibitors: clopidogrel, ticagrelor, and prasugrel. All three utilize a loading dose followed by a maintenance dose. A common practice of loading all patients with ACS with a P2Y12 inhibitor came from studies in an era when catheterization may not occur for several days. Given improvements in the timeliness of catheterization and the downside of delaying surgical revascularization if indicated, guidelines no longer recommend P2Y12 inhibitor loading prior to catheterization. However, if for any reason an extended delay in catheterization is anticipated, loading with a P2Y12 inhibitor should be considered (Byrne, 2023).
Anticoagulation
All patients with ACS should initiate parenteral anticoagulation. Unfractionated heparin (UFH) is favored in those undergoing cardiac catheterization with possibility of angioplasty/stenting. Low molecular weight heparin (LMWH) and bivalirudin are alternatives for patients with STEMI. Fondaparinux is recommended as an alternative to UFH for patients with NSTEMI who are not expected to undergo early angiography (Byrne, 2023). Patients on oral anticoagulants for other diagnosis should have their oral anticoagulants held and should be transitioned to UFH during ACS (Byrne, 2023).
Nitrates
Sublingual nitroglycerin is the first-line therapy for pain management in suspected ACS. If pain is relieved by nitroglycerin, guidelines recommend repeated ECGs to assess for improvement of any ST changes, which should increase your suspicion for ACS. If pain returns, longer-acting formulations delivered as a paste or intravenous infusion can be used. Contraindications to nitrates include: “hypotension, marked bradycardia or tachycardia, right ventricular infarction, known severe aortic stenosis, or phosphodiesterase 5 inhibitor use within 24-48 hours” (Byrne, 2023).
Beta Blockers
Beta blockers, which slow the heart rate and decrease myocardial work, are effective anti-anginal drugs. Dr. Francis recommends using metoprolol tartrate which is easily titratable every 6-8 hours to lower heart rates. It can be especially beneficial in patients with LVEF <40% (Byrne, 2023), but in the acute setting should be used with caution if there is concern for low cardiac output.
Morphine
Morphine may be used as a supplemental analgesic for pain that persists despite nitrates and beta blockers; however, be vigilant for ongoing ischemic symptoms that may warrant expedited catheterization. Additionally, opioids can slow gut motility, which may delay antiplatelet therapy absorption (Byrne, 2023).
Myocardial Injury
This is a relatively new concept in the era of high-sensitivity troponins. For example, patients with noncardiac conditions like infections or renal failure commonly have elevated high-sensitivity troponins in the absence of ACS. Any elevated troponin, whether acute (i.e. sepsis, atrial fibrillation) or chronic (ESRD, hypertensive heart disease, cardiomyopathy) portends a poor prognosis compared with patients without elevated troponins (Gulati, 2021).
Dr. Francis recommends an echocardiogram during the inpatient stay for most patients with myocardial injury. If a chest CT was performed for any reason, you can review this for evidence of coronary calcifications. Clear abnormalities on either of these tests should prompt further work-up during hospitalization. If these studies are equivocal or normal, Dr. Francis recommends outpatient evaluation after the acute illness has resolved (expert opinion).
Transitions of Care
Patients with ACS should follow up with an outpatient cardiologist and their primary care provider until the outpatient management plan is determined and can be maintained by the PCP. Patients with myocardial injury (but not ACS) may follow up with their primary care provider until further testing has been completed that can help determine the need for cardiology follow-up.
Cardiac rehab is a cornerstone of post-acute cardiac care we should recommend to all patients with ACS. While insurance and distance remains a barrier, its mortality benefit is large (Byrne, 2023).
Physical activity after ACS can be challenging, but patients should slowly increase physical exercise based on their tolerance with the goal of increasing exercise capacity. Guidelines note that self-guided physical activity does not replace the benefit of cardiac rehab (Byrne, 2023).
