PTC angiogram Coronary Artery Bypass Graft.pptx

PTCA

1. Myocardial Infarction Dr.B.Prabakar , Professor , Dept of General Medicine, KIMS

2. Myocardial Infarction Plaque erosion/rupture with occlusive thrombus Plaque erosion/rupture with non-occlusive thrombus

3. ECG

4. S ilent myocardial ischaemia. ST depression

5. Thrombolytic therapy ( Used only for STEMI) If Cathlab and Angioplasty unab le to be provided in < 2 hrs - Start thrombolysis Indications for Thrombolysis: Ischemic symptoms < 12 h (Class I , Level A) Evidence of ongoing ischemia 12 to 24 h after symptom onset and a large area of myocardium at risk or hemodynamic instability (Class II a, Level C) Largest benefit when given within 2 hrs of symptom onset ( A meta-analysis showed that thrombolysis within 6 hours of STEMI or LBBB MI prevented 30 deaths in every 1000 patients treated. Between 7 and 12 hours, 20 in every 1000 deaths were prevented . After 12 hours the benefits are limited, and there is evidence to suggest less benefit for older patients, possibly because of the increased risk of strokes) Fibrin-specific agent + Aspirin + Clopidogrel - recommended

6. Contraindication for Fibrinolytic therapy Absolute contraindications Any prior ICH Known structural cerebral vascular lesion (e.g., AV malformation) Known malignant intracranial neoplasm Ischemic stroke within 3 months Suspected aortic dissection Active bleeding or bleeding diathesis Significant Closed-head or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months For streptokinase, prior treatment within the previous 6 months Relative contraindications (SBP > 180 mm Hg or > DBP 110 mm Hg) History of prior ischemic stroke > 3 mo Traumatic or prolonged (> 10 min) CPR Major surgery (< 3 wk ) Recent (within 2 to 4 wk) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Oral anticoagulant therapy

7. Primary percutaneous coronary intervention (PCI) The preferred reperfusion therapy for STEMI is primary PCI with a target of 60 minutes for wire crossing of the culprit vessel. R adial access is the preferred route. Primary PCI performed with drug eluting stents is preferred to bare metal stents. Dual antiplatelet therapy is with aspirin & an ADP-receptor blocker (prasugrel or ticagrelor). Anticoagulant options include unfractionated heparin, enoxaparin or bivalirudin.

8. Primary PCI Indications ( Should be undergone within 24 hrs of STEMI) STEMI and cardiogenic shock - Only the occluded artery responsible for the STEMI should be treated because clinical trial evidence demonstrates no advantages and potential harms from treating multiple coronary arteries

9. Coronary angiography and intervention Very high-risk patients require urgent coronary angiography(<2 h) This includes those individuals with persistent or recurrent chest pain not responding to medical therapy, C linical signs of heart failure or haemodynamic instability or cardiogenic shock, L ife-threatening arrhythmias (ventricular fibrillation, ventricular tachycardia). High-risk patients with rising or falling cardiac troponin levels, dynamic ST-or T-wave changes, or elevated GRACE scores (>140) require coronary angiography within 24 h . Intermediate-risk patients with diabetes mellitus, renal impairment ( estimated GFR <60), LVEF below 40% or congestive cardiac failure, early post infarction angina, previous PCI or CABG, or a GRACE score of over 109 but less than 140 require coronary angiography within 72 h

10. Angiogram (Calculate Syntax Score)

11. Coronary artery bypass surgery Cardiac surgery is usually reserved for the complications of MI, such as ventricular septal defect or mitral regurgitation. Operative mortality is highest in the first 72 hours after STEMI

12. CABG CABG is preferred to PCI in patients with: T hree-vessel disease and diabetes or elevated SYNTAX score (>22) Patients with LMS and SYNTAX score of more than 22

13. C ardiac rehabilitation programme Post-ACS lifestyle modification After recovery from an ACS, patients should be encouraged to participate in a cardiac rehabilitation programme that provides education and information appropriate to their requirements. An exercise programme forms part of the rehabilitation. Dietary recommendations include calorie control of obesity, increased fruit and vegetables, reduced trans and saturated fats, and reduced salt intake in patients with hypertension. Restrict Alcohol consumption within safe limits ( ≤ 14 units per week for both men and women), avoiding binge drinking. Emotional problems, such as denial, anxiety and depression, are common and must be addressed.

14. C ardiac rehabilitation programme Patients should be physically active (30 min of moderate aerobic exercise 5 times per week). Patients should stop smoking (nicotine patches and buprenorphine are safe). A healthy weight (BMI <25 kg/m2) should be maintained. Blood pressure should be reduced to a systolic measurement <140 mmHg. Patients with diabetes should be treated to maintain HbA1c <7% (53 mmol/mol).

15. Post-ACS drug therapy and assessment A fter MI, most patients should be taking most of the following medications: A spirin 75 mg daily ADP-receptor blocker/ oral beta-blocker to maintain HR <60Bpm PPI for patients at high risk of bleeding while on dual antiplatelet therapy ACE inhibitor or angiotensin receptor blocker, particularly if LVEF is <40%

16. Post-ACS drug therapy and assessment H igh-intensity statin with target LDL cholesterol <1.8 mmol/L A ldosterone antagonist, if there is clinical evidence of heart failure and LVEF is <40% the serum creatinine is <221 μ mol /L (men) or <177 μ mol /L (women); and the serum potassium is <5.0 mEq /L. Patients with permanent atrial fibrillation receiving medical therapy or CABG should be treated with dual therapy: aspirin or clopidogrel with anticoagulation warfarin or a DOAC.

17. HAS-BLED score

18. Patients with permanent atrial fibrillation receiving stenting A ssessment for their bleeding risk using the HAS-BLED score If this is 0–2, they can receive triple therapy for 6 months (aspirin and clopidogrel and warfarin) and then dual therapy (aspirin or clopidogrel with anticoagulation warfarin or a DOAC). If it is over 2, they can receive triple therapy for 4 weeks (aspirin and clopidogrel and warfarin) and then dual therapy (aspirin or clopidogrel with anticoagulation warfarin or a DOAC) for a further 11 months.

19. Thank you.