What is no reflow phenomenon?
Suboptimal myocardial perfusion despite restoration of lumen patency in the infarct-related artery. Angiographically, this is associated with a Thrombolysis in Myocardial Infarction flow of 2 or lower. This has been attributed to the combined effects of inflammation, endothelial injury, edema, and atheroembolization causing microvascular obstruction, vasospasm, and myocyte reperfusion injury.
No definitive treatment until now.
What is acetyl choline testing?
-Endothelial-dependent reactivity
-In patients with coronary microvascular disease, the vascular endothelium becomes dysfunctional, and the vasodilator response to pharmacological interventions is attenuated, results in attenuated coronary blood flow, and may even cause vasoconstriction
-Nitroglycerin, papaverine, adenosine, or dipyridamole may also be seen in patients with microvascular disease but are largely mediated by vascular smooth muscle.
What is the choice of anticoag options in NTE ACS?
Treatment options for anticoagulation include:
1) enoxaparin continued for the duration of hospitalization or until percutaneous coronary intervention (PCI) is performed;
2) bivalirudin, only in patients managed with an early invasive strategy, continued until diagnostic angiography or PCI;
3) fondaparinux continued for the duration of hospitalization or until PCI is performed (with unfractionated heparin [UFH] or bivalirudin administered during PCI because of the risk of catheter thrombosis); 4) UFH continued for 48 hours or until PCI is performed.
Thrombolysis in STEMI
**Fibrinolytic therapy should be administered to patients with STEMI at non-PCI-capable hospitals when the anticipated first medical contact-to-device time at a PCI-capable hospital exceeds 120 minutes.
**It should be administered within 30 minutes of arrival at the hospital.
**The goal is to inject the bolus of fibrinolytics within 10 minutes from STEMI diagnosis, and patients should be transferred to a PCI-capable facility as soon as possible after bolus lytics administration.
**Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days, or until revascularization if performed.
Recommended regimens include unfractionated heparin, enoxaparin, or fondaparinux.
Ticagrelor MOA
Direct acting, reversibly binding, noncompetitive P2Y12 receptor inhibitor and is associated with rapid onset and greater platelet inhibition compared to clopidogrel.
By coupling with a site distinct from the ADP-binding site, ticagrelor reversibly inhibits P2Y12 receptor conformational change and G-protein activation induced by ADP. Through this mechanism, platelet activation and aggregation induced by ADP is inhibited.
Noninvasive testing for ischemia after non−ST-segment elevation myocardial infarction (non-STEMI) and before discharge
Class I:
**Noninvasive stress testing is recommended in low- and intermediate-risk patients who have been free of ischemia at rest or with low-level activity for a minimum of 12-24 hours. (Level of Evidence B)
**Treadmill exercise testing is useful in patients able to exercise in whom the ECG is free of resting ST changes that may interfere with interpretation. (Level of Evidence C)
**Stress testing with an imaging modality should be used in patients who are able to exercise but have ST changes on resting ECG that may interfere with interpretation. In patients undergoing a low-level exercise test, an imaging modality can add prognostic information. (Level of Evidence B)
**Pharmacologic stress testing with imaging is recommended when physical limitations preclude adequate exercise stress. (Level of Evidence C)
**A noninvasive imaging test is recommended to evaluate left ventricular function in patients with definite acute coronary syndrome. (Level of Evidence C)
4 types of Takosubo
- Apical type
- Midventricular type
- Basal Type and
- Focal type
Accelerated idioventricular rhythm (AIVR)
Occurs within the first 24 hours after a myocardial infarction and usually indicates reperfusion. AIVR is transient, benign, and generally does not require treatment.
Posteriolateral mitral valve leaflet rupture
Most commonly seen with inferior infarcts
Can rupture within 1-7 days after Inferior wall MI
Antiplatelets when aspirin is contraindicated
The CAPRIE (Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events) trial compared clopidogrel 75 mg daily with aspirin 325 mg daily in patients with atherosclerotic vascular disease (ischemic stroke, recent MI, or symptomatic peripheral artery disease) and found that clopidogrel provided superior secondary prevention of atherosclerotic vascular events by a small margin.
In the PARIS (Persantine-Aspirin Reinfarction Study. Part II. Secondary coronary prevention with Persantine and aspirin), the combination of aspirin plus dipyridamole was not superior to aspirin alone for secondary prevention of MI.
Prasugrel and ticagrelor are P2Y12 inhibitors that have been studied in acute coronary syndromes but not in patients with SIHD.
HTN and stable ischemic heart disease
First line: BB, ACEI or ARB
Still elevated:
-If angina- add calcium channel blockers and nitrates
-No angina- Add HCTZ, MRA or CCB
Duke treadmill score calculation and prognosis
Duration of exercise- 5x ST deviation- 4xangina index
DTS >5 indicates 5 year survival of >97%
DTS -10 to 4 indicates 5 year survival of 90%
DTS <-11 indicates 5 year survival of 65%
Diagnostic criteria for stress induced cardiomyopathy
The Mayo Clinic diagnostic criteria for stress cardiomyopathy include all four of the following for diagnosis:
1. Transient LV systolic dysfunction (hypokinesis, akinesis, or dyskinesis). The wall motion abnormalities are typically regional and extend beyond a single epicardial coronary distribution; rare exceptions are focal (within one coronary distribution) and the global type.
- The absence of obstructive coronary disease or angiographic evidence of acute plaque rupture. If coronary disease is found, the diagnosis of stress cardiomyopathy can still be made if the wall motion abnormalities are not in the distribution of the coronary disease.
- New electrocardiographic abnormalities (either ST-segment elevation and/or T wave inversion) or modest elevation in cardiac troponin.
- The absence of pheochromocytoma or myocarditis.
TIMI predictors of 30d mortality
Age ≥75 years: 3 points
Age 65-74 years: 2 points
History of diabetes mellitus, hypertension, or angina: 1 point
Systolic blood pressure <100 mm Hg: 3 points
Heart rate >100 bpm: 2 points
Killip class II-IV: 2 points
Weight <67 kg: 1 point
Anterior ST elevation or left bundle branch block: 1 point
Time to reperfusion therapy >4 hours: 1 point
Pseudoaneurysms vs LV aneurysm
PSA occur mostly in the posterior wall vs LVA occur in the anterior walls or apex
PSA has a higher risk of rupture vs LVA
Pseudoaneurysms are distinctively different from left ventricular aneurysms (LVAs) and notably have a narrow neck that communicates freely with the left ventricle (LV). An LVA, in contrast, is a thin, scarred segment of the LV and is the result of a transmural myocardial infarction (MI).
Nitrates with slidenafil and tadalafil
CI within 24 hours of Sildenafil or vardenafil
48 hours of Tadalafil
