Interventional

Management of
Acute Coronary
Syndromes
Applying the Lessons of ST-elevation Services to
Non-ST-Elevation Myocardial Infarction
Dr Mark A de Belder, Cardiothoracic Division, The James Cook University Hospital, Marton Road,
Middlesbrough TS4 3BW, UK

PUBLISHED ONLINE JULY 11, 2012

 Introduction

•There are many treatments

•ST-elevation myocardial available for STEMI and non-
infarction (STEMI) is a STEMI ACS.
global concerns. •The best outcomes depend on
service re-configurations to ensure •The care for STEMI patients
•Primary angioplasty (PCI) could now be applied to the
is the most preferred rapid, effective and comprehensive
treatment. non-STEMI ACS to deliver a
method. better outcomes.

This journal highlights

additional changes to
healthcare services that
should be considered
 Requirements For A Successful Primary
Angioplasty (PPCI) Service

International guidelines reflect the consensus that :

▪ PPCI should be used as the preferred mode of reperfusion therapy for patients
suffering STEMI.
▪ Skilled teams, 24/7, and in a timely fashion.
Patient who present very early, efficient and timely angioplasty services will deliver
better clinical outcomes.
▪ European Society of Cardiology ‘Stent 4 Life’
▪ American College of Cardiology ‘Door-to-Balloon’ Alliance.
▪ UK government supported the National Infarct Angioplasty Project.
Reperfusion therapy for patients with STEMI are now more likely to survive in the
medium to long term than patients with NSTEMI.
 Systems Of Care Needed To Deliver An Effective
Primary Angioplasty Service

1. Rapid diagnosis wherever and whenever the patient presents.

2. Rapid communication from central triage with primary angioplasty team.
3. Rapid transfer to the catheter laboratory for treatment.
4. Focused assessment to start treatment as soon as possible.
5. Currently, a strategy to treat culprit vessel only and a plan to assess the
significance of other lesions for later treatment.
6. Appropriate utilisation of techniques to yield better outcomes.

- Time is Muscle -
 Systems Of Care Needed To Deliver An Effective
Primary Angioplasty Service

7. Immediate access to cardiothoracic anaesthetic, intensive care and

surgical colleagues.
8. Planned ‘step-down’ from the initial acute care, enabling secondary
preventive therapies, and start a rehabilitation program.
9. Appropriate follow-up
▪ Optimise compliance with treatment.
▪ Manage risk factors.
▪ Treat heart failure.
▪ Identify patients who will benefit from further revascularisation.
▪ Implantable cardioverter-defibrillator.
▪ Cardiac resynchronisation therapy.
 An Interventional Approach Is Better Than
One Based Only On Pharmacotherapy
▪ Agreed on STEMI, can’t be applied to the whole NSTEMI population.
▪ Revascularisation therapy benefits is better than its risk.
▪ No evidence of benefits in early invasive treatment at low-risk NSTEMI ACS, but
higher-risk patients have most benefits.
▪ All current guidelines, therefore, emphasise the need for early risk stratification.
▪ The clinical evaluation, ECG, and biomarkers allow us to categorise patients into
different risk groups within hours of admission.

Consideration for angiography.

 Medical and cardiology services able coordinate

and manage patients appropriately.
 Rapid Intervention Is Associated With Better
Outcomes
The Timing of Intervention in Acute Coronary Syndromes (TIMACS)
▪ Intervention within the first 24h does not benefit all patients, but it is
beneficial to the highest-risk patients.
▪ Global Registry of Acute Coronary Events (GRACE) score >140
Consider change to systems of care for earlier treatment of higher-risk patients.
ABOARD study patients with TIMI score of ≥3 were randomised There was no
difference in biomarker infarct size in the early intervention group, but their
length of stay in hospital was shorter.
 Early Diagnosis Enables Early Clinical Triage

▪ At the very least, patients should be assessed and

risk stratified on admission to hospital, and the
highest-risk patients should be referred for early
angiography within the first 24h .
▪ PCI every day (‘7/7’) and not just weekdays.
▪ All patients considered for an invasive approach
should undergo angiography within 72 h of
admission to hospital.
▪ Early diagnosis is critical, ambulance paramedic
should be trained for early diagnosis.
▪ Physician lead ambulance.
 Early Diagnosis Enables Early Clinical Triage

▪ Triage crew should be given training, knowledge, and early diagnostic tool.
▪ Early Triage and diagnosis should be extended to NSTEMI patient.
▪ Challenging NSTEMI ACS, Emergency, not Urgent.
▪ Redesigned the services further to meet the requirements of patients,
rather than to suit pre-set working patterns of the clinical staff.
▪ 7/7 services are set up to deal with the highest-risk patients, and given no
downside for patients at lower GRACE scores, it is likely that all appropriate
patients will eventually be offered angiography earlier than at present..
 TIMI SCORE

Each of the following criteria constitutes one point

for TIMI scoring
▪ Age ≥65 years
• Three or more risk factors for coronary artery
disease (CAD) (family history of CAD,
hypertension, hypercholesterolemia, diabetes
mellitus, tobacco use)
• Known CAD (stenosis >50%)
• Aspirin use in the past 7 days
• Severe angina (≥2 episodes in 24 hours)
• ST deviation ≥0.5 mm
• Elevated cardiac marker level
GRACE SCORE

AGE = 45
Have HF History
Have AMI History
HR = 100
SBP = 150 mmHG
No depressed ST segment
Creatinine = 1.2
Elevated Enzyme Marker
No Percutaneous revascularization
Father have CAD, Patient have hypertensions, Patient
have DM, and an active smoker. Have history of CAD
more than 50%, on Aspirin Medication, have severe
angina, and elevated cardiac marker.
 TIMI SCORE

Each of the following criteria constitutes one point

for TIMI scoring
▪ Age ≥65 years
• Three or more risk factors for coronary artery
disease (CAD) (family history of CAD,
hypertension, hypercholesterolemia, diabetes
mellitus, tobacco use)
• Known CAD (stenosis >50%)
• Aspirin use in the past 7 days
• Severe angina (≥2 episodes in 24 hours)
• ST deviation ≥0.5 mm
• Elevated cardiac marker level
 GRACE SCORE

AGE = 45
Have HF History
Have AMI History
HR = 100
SBP = 150 mmHG
No depressed ST segment
Creatinine = 1.2
Elevated Enzyme Marker
No Percutaneous revascularization
TIMI SCORE >3
114
0.05 HIGH RISK STEMI  Consider Invasive Therapy
 PCI Is The Preferred Method Of Revascularisation

▪ STEMI patients, PPCI is the dominant form of reperfusion

therapy.
▪ NSTEMI ACS patients, however, CABG is the preferred means
of revascularisation.
▪ Clopidogrel, Wait 5 days minimal, still wait for 1 - 4 weeks for
surgery.
▪ Ticagrelor, effect wears off rapidly reduce the need for delay
to CABG to 3 days.
▪ Redesign in the surgical as well as the cardiology components
of care is needed.
 A ‘Complete System’ Approach Delivers Better Outcomes Than Just
Concentrating On One Aspect Of Care

Prided themselves on their DTB (Door To Balloon) times.

NO use of short DTB time if the patient was initially taken to the wrong
hospital.
Only angioplasty service no appropriate secondary preventive care and
rehabilitation.
Similar in NSTEMI ACS
No use training paramedics to triage patients if they are still forced by local
protocols to take the highest-risk NSTEMI ACS patients to a hospital that does
not have 7/7 capability of caring for them;
Hospital should care for such patients without a change to the local
ambulance protocols enabling primary transfer of the highest-risk patients.
Rapid And Effective Systems Of Care Require Changes To The Clinical
Infrastructure, But Outcomes Are Better, And The Strategy Is Cost Effective

Changes in the national reperfusion service for PPCI more easily in some parts of
the country.
▪ Pre-hospital thrombolysis as a service.
▪ Geographical considerations.
▪ Staffing levels .
▪ Involvement a PCI centre.
UK, staffing challenges, communication between ambulance and the PPCI and
non-PPCI hospitals has been solved.
Extension of this philosophy to an NSTEMI ACS, Non cost effective.
Clinical networks should have designated centres providing 7/7 service.
Ambulance
▪ High-risk patients  7/7 centre.
▪ Non-PCI  non-7/7 centres.
Revascularisation Services Must Be Aligned To
Systems That Provide Optimal Secondary Preventive
Care And Rehabilitation

▪ Small hospital with catheterisation service or not, provide cardiology

services, performing early risk assessment.
▪ Identify, who can either be treated locally or via a rapid transfer to an
adjacent 7/7 centre.
▪ Clinical outcomes in ACS depend as much on secondary preventive
therapies and cardiac rehabilitation as on acute revascularisation.
▪ Clinical networks should ensure that there is ‘joined-up-thinking’ on the care
that is offered after the acute phase.
▪ Agreed protocols between primary, secondary and tertiary care services will
ensure that patients receive the best advice and treatment.
 CONCLUSIONS

▪ The management of patients with STEMI and NSTEMI ACS clearly different in many ways.
▪ Time is the main difference, but many parallels.
▪ Much is currently being done to change the systems of care for patients with STEMI, it will
also benefits all ACS patients.
▪ Rapid risk assessment and triage is needed, patients should be delivered to the right place at
the right time, treated by the right teams.
▪ Individual components of the pathway of care should not work alone, and each should accept
designated roles, which may vary depending on day of the week and time of day.
▪ Clinical networks should develop agreed protocols that optimise the care of all patients.
▪ Many progress has been made over the last few years, there are still too many patients
waiting too long for procedures to be done.
▪ Further changes to healthcare services are inevitable.