NICE guideline : Acute Coronary Syndrome Mx SHAHRIAR.pptx

Brief presentation

1. Management of Acute Coronary Syndromes NICE guideline Published: 18 November 2020 Dr. S.M. Shahriar Islam MBBS Intern Doctor, MU-2, FMCH

2. Contents: STEMI: early management NSTEMI and unstable angina: early management Hyperglycemia in acute coronary syndromes Drug therapy for secondary prevention Coronary revascularization after an MI Selected patient subgroups Communication of diagnosis and advice Cardiac rehabilitation after an MI Lifestyle changes after an MI

3. ACS : ST-segment elevation myocardial infarction (STEMI) Non-ST-segment elevation myocardial infarction (NSTEMI) Unstable angina

4. STEMI – early management

5. Assessment Eligibility (irrespective of age, ethnicity or sex) for coronary reperfusion therapy (PCI or fibrinolysis) Deliver coronary reperfusion therapy as quickly as possible

6. Initial drug therapy ASPIRIN: 300 mg as soon as possible unless clear evidence of allergy to it Do not offer routine GP IIb/ IIIa inhibitors or fibrinolytic drugs before arrival at catheter laboratory to people with acute STEMI for whom primary PCI is planned

7. CAG with follow-on primary PCI Coronary reperfusion strategy is preferred Radial artery is preferred to femoral artery

8. CAG with follow-on primary PCI… Indications : Presentation is within 12 hours of onset of symptoms Primary PCI can be delivered within 120 minutes of time when fibrinolysis could have been given Acute STEMI presenting >12 hours after onset of symptoms if there is evidence of continuing myocardial ischemia Acute STEMI & cardiogenic shock who present within 12 hours of onset of symptoms of STEMI Acute STEMI who present >12 hours after onset of symptoms and who have cardiogenic shock or go on to develop it

9. Dual antiplatelet therapy for people with acute STEMI having primary PCI Prasugrel with aspirin : if they are not already taking an oral anticoagulant If risk of bleeding with prasugrel outweighs its effectiveness: ticagrelor or clopidogrel as alternatives) Clopidogrel with aspirin : if they are already taking an oral anticoagulant

10. Thrombus extraction during primary PCI Consider thrombus aspiration during primary PCI for people with acute STEMI Do not routinely use mechanical thrombus extraction during primary PCI for people with acute STEMI

11. Drug-eluting stents in primary PCI If stenting is indicated, offer a drug-eluting stent to people with acute STEMI undergoing revascularisation by primary PCI [2020]

12. Fibrinolysis Offer fibrinolysis to people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 min

13. Fibrinolysis… Offer an ECG 60 to 90 minutes after fibrinolysis For those who have residual ST-segment elevation suggesting failed coronary reperfusion: 1. Offer immediate CAG, with follow-on PCI 2. Do not repeat fibrinolytic therapy A person with recurrent myocardial ischaemia after fibrinolysis: seek immediate specialist cardiological advice & offer CAG, with follow-on PCI Consider CAG during same admission after successful fibrinolysis

14. Management for people with STEMI not treated with PCI Ticagrelor with aspirin, unless high bleeding risk Clopidogrel with aspirin, or aspirin alone if high bleeding risk Medical management if ineligible for any reperfusion therapy Before discharge, assess left ventricular function in all people

15. NSTEMI and Unstable Angina Early Management

16. Initial drug therapy Aspirin as soon as possible & continue indefinitely unless bleeding risk or hypersensitivity ASPIRIN: 300 mg as soon as possible FONDAPARINUX: who do not have a high bleeding risk, unless they are undergoing immediate coronary angiography

17. Initial Drug Therapy... UNFRACTIONATED HEPARIN : alternative to fondaparinux in significant renal impairment (creatinine >265µmol/L) Carefully consider the choice and dose of antithrombin in: • advanced age • known bleeding complications • renal impairment • low body weight Avoid dual antiplatelet therapy without confirmation of UA or NSTEMI

18. Risk assessment Assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality ( e.g , GRACE scoring) Include in the formal risk assessment: • History: age, previous MI & previous PCI or CABG • Examination: pulse, BP • A 12-lead ECG: look for dynamic or unstable patterns indicating ischemia • Blood tests: troponin I or T, creatinine, glucose & Hb

19. Risk assessment….

20. CAG with follow-on PCI Immediate CAG: if condition is unstable CAG (with follow-on PCI) within 72 hours: if intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality >3.0%) CAG with follow-on PCI: initial low risk of adverse cardiovascular events & ischemia is subsequently experienced or demonstrated by ischemia testing Some younger people with low risk scores for mortality at 6 months may benefit from early angiography

21. Benefits and risks of early invasive treatment compared with conservative management for people with unstable angina or NSTEMI

22. Continued…

23. Management when PCI is not indicated Consider conservative management without early coronary angiography for people with low risk of adverse cardiovascular events Ticagrelor or Clopidogrel to people with unstable angina or NSTEMI when PCI is not indicated, unless they have a high bleeding risk

24. Tests before discharge Consider ischemia testing before discharge for people whose condition has been managed conservatively and who have not had CAG Assess LV function in all people with NSTEMI & UA

25. Hyperglycaemia in Acute Coronary Syndromes

26. Managing hyperglycemia in inpatients within 48 hours of acute coronary syndrome Keep blood glucose <11.0 mmol /L Avoid hypoglycemia Consider a dose-adjusted insulin infusion with glucose monitoring Do not routinely offer intensive insulin therapy unless indicated

27. Identifying people with hyperglycemia after ACS with high risk of developing DM Investigations: • HbA1c before discharge • FBS no earlier than 4 days after onset of ACS Do not routinely offer OGTT, if HbA1c & FBS levels are normal

28. Advice and monitoring for people with hyperglycemia after ACS and without known DM Offer lifestyle advice on the following: • healthy eating • physical exercise • weight management • smoking cessation • alcohol consumption

29. Should consult their GP if they experience the following symptoms: - frequent urination - excessive thirst - weight loss - fatigue Should be offered tests for diabetes at least annually

30. Drug therapy for secondary prevention

31. For secondary prevention, offer people who have had MI treatment with the following drugs: • ACEi • Dual antiplatelet therapy (aspirin plus a second antiplatelet) • Beta-blocker • Statin

32. ACE inhibitors In acute MI : ACEi as soon as possible in hemodynamically stable pt. Continue ACEi indefinitely. Titrate ACEi dose at short intervals ( e.g , 12-24h) up to max. tolerated or target dose Do not offer combination of an ACEi & an ARB

33. ACE inhibitors… ARB: if intolerant to ACEi Renal function, electrolytes & BP should be measured before starting an ACEi or ARB and again within 1 or 2 weeks of starting Rx

34. Antiplatelet therapy Offer ASPIRIN to all people after an MI or who have had an MI >12 months ago, continue it indefinitely, unless they are aspirin intolerant or have an indication for anticoagulation. Continue dual antiplatelet therapy for up to 12 months after an MI unless contraindicated In Aspirin hypersensitivity : Clopidogrel monotherapy , as an alternative Offer Clopidogrel instead of aspirin to people with clinical vascular disease & who have : - had an MI and stopped dual antiplatelet therapy - had an MI >12 months ago

35. Antiplatelet therapy for people with an ongoing separate indication for anticoagulation Consider the following when thinking about the duration and type (dual or single) of antiplatelet therapy in the 12 months after an ACS : bleeding risk thromboembolic risk cardiovascular risk person's wishes. For people already on anticoagulation who have had PCI, continue anticoagulation and clopidogrel for up to 12 months. If taking a direct oral anticoagulant, adjust the dose assuming the risks For people who haven’t had PCI, continue anticoagulation. Consider Aspirin/ clopidogrel up to 12 months unless there’s a high bleeding risk

36. Beta-blockers Beta-blocker in hemodynamically stable pt as soon as possible & continue indefinitely in patients with reduced LV ejection fraction Consider continuing a beta-blocker for 12 months after an MI for people without reduced left ventricular ejection fraction

37. Calcium channel blockers (CCB) Do not routinely offer CCB to reduce cardiovascular risk Diltiazem or verapamil may be considered for secondary prevention, when beta-blockers are contraindicated (e.g. In people who doesn’t have pulmonary congestion or reduced left ventricular ejection fraction) For people whose condition is stable after an MI, calcium channel blockers may be used to treat hypertension and/or angina For people with heart failure with reduced ejection fraction, use amlodipine, and avoid verapamil, diltiazem and short-acting dihydropyridine agents

38. Potassium channel activators Do not offer nicorandil to reduce cardiovascular risk after an MI

39. Statins and other lipid-lowering agents Statin therapy is recommended for adults with clinical evidence of cardiovascular disease

40. Coronary Revascularization after an MI

41. Offer a cardiological assessment to everyone who has had a previous MI, but not had coronary revascularization to consider whether coronary revascularization is appropriate. This should take into account comorbidity.

42. Selected patient subgroups

43. People who have reduced left ventricular ejection fraction should be considered for an implantable cardioverter defibrillator

44. Communication of diagnosis and advice

45. After an acute MI, ensure that the following are part of every discharge summary: • confirmation of the diagnosis of acute MI • results of investigations • incomplete drug titrations • future management plans • advice on secondary prevention

46. Cardiac rehabilitation after an MI

47. All people (regardless of their age) should be given advice about and offered a cardiac rehabilitation program with an exercise component Programs should provide a range of options, and people should be encouraged to attend all those appropriate to their clinical needs If a person has cardiac or other clinical conditions that may worsen during exercise, these should be treated if possible before they are offered the exercise component of cardiac rehabilitation

48. Lifestyle changes after an MI

49. Changing diet Eat a Mediterranean-style diet more bread, fruits, vegetables and fish less meat replace butter and cheese with products based on plant oils Do not routinely recommend eating oily fish for preventing another MI. If people choose to consume oily fish, there is no evidence of harm Do not advise omega-3 fatty acid capsules or omega-3 fatty acid supplemented foods to prevent another MI. If people choose to take those, there is no evidence of harm

50. Changing diet… Advise people not to take supplements containing beta-carotene. Do not recommend antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk Offer people an individual consultation to discuss diet, including their current eating habits, and advice on improving their diet Give people consistent dietary advice tailored to their needs Give people healthy eating advice that can be extended to the whole family

51. Regular physical activity Regular physical activity increases exercise capacity Be active for 20 to 30 minutes a day to point of slight breathlessness Increase activity in a gradual, step-by-step way, to increase exercise capacity Benefit of exercise may be enhanced by tailored advice from a suitably qualified professional

52. Smoking cessation Advise all people who smoke to stop Offer assistance from a smoking cessation service Pharmacotherapy NICE guideline on stop smoking interventions and services

53. Weight management According to NICE guidelines on obesity

54. Cordial Invitation to the Wonders of Beauty

55. Thanchi …

56. Cox’’’’’’’’’’’’’’’’’’’’’”””’’’’’’’’’'s Bazar

57. Thank You