Interactive ACS Case Presentation Rodney Zimmermann, MD, FRCPC, - PowerPoint PPT Presentation

Interactive ACS Case Presentation Rodney Zimmermann, MD, FRCPC, FACC March 12, 2012 ACC Rockies

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ACC Rockies Case Study: Mr GP  75 yo male admitted with progressive typical exertional angina – Troponin I = 0.17  Awaiting back surgery on elective basis – anticipated wait of 10-12 months.  PMHx and risk status: – Ex-smoker of 5 years – Chronic Atrial Fibrillation – rate controlled – Hypercholesterolemia – Hypertension – Sensory neuropathy with previous treatment of IVIG – ?Rheumatoid arthritis – on prednisone started earlier in year (+RF) – ASA allergy with difficulty breathing and rash – 10 or more years ago

 Medications: – Warfarin, metoprolol, atorvastatin, on weaning doses of prednisone, perindopril  Physical Examination non-contributory regarding cardiac findings, except for atrial fibrillation

 ECG:

 What are Investigation Options? – AUDIENCE RESPONSE QUESTION: 1. EST 2. Functional Assessment (echo stress or perfusion study) 3. Cardiac Catheterization 4. CT Angiogram

 Management /Investigation Options?  Risk Stratification: – TIMI risk score : 3 (risk over next year of 13%) » Points for age, risk factors, angina (not: known CAD, ASA use, markers, ST segment deviation)  Cardiac Perfusion Study: – Large area of ischemia in inferior and lateral walls

 LV:

 RCA:

 LAD:

 LCx:

 Management Plan? – AUDIENCE RESPONSE QUESTION: 1. CABG 2. Multivessel PCI with BMS 3. Multivessel PCI with DES 4. Single Vessel PCI (RCA) – incomplete revascularization 5. Medical Management and optimization

 Management Issues: – PCI (multivessel) vs CABG? – ASA allergy? – Antiplatelet agent choice? – Planned elective back surgery? – Prednisone use?

 Management Issues: – Anticoagulation with warfarin » CHADS2 score – 2, Hypertension, age (not CHF, DM, Stroke)  Risk of stroke 4.0% per year » HAS-BLED – 2 (for hypertension, age)  Risk of major bleed 1.88% per year

Number and Crude Incidence Rate of Bleeding Events Associated With Single, Dual, and Triple Antithrombotic Treatment After Atrial Fibrillation Hospitalization **Incidence Rate, Unadjusted, % per Patient-year Variable Events, Warfarin Aspirin Clopidogrel Aspirin + Warfarin + Warfarin + Warfarin + No. Monotherapy Monotherapy Monotherapy Clopidogrel Aspirin Clopidogrel Aspirin + Clopidogrel Nonfatal bleeding 12 192 3.6 3.3 4.8 7.0 6.4 13.3 15.4 Fatal bleeding 1381 0.2 0.4 0.8 0.6 0.4 0.6 0.2 Fatal and nonfatal 13 573 3.9 3.7 5.6 7.4 6.8 13.9 15.7 bleeding Intracranial 2154 0.6 0.5 1.0 0.2 0.8 0.8 1.0 bleeding Airway bleeding 3185 1.3 0.7 1.0 2.2 2.3 7.1 7.1 Gastrointestinal 4637 0.9 1.5 1.9 3.1 2.1 3.8 5.1 bleeding Urinary tract 3051 1.0 0.9 1.3 1.7 1.6 2.0 2.4 bleeding Hansen, Sørensen et al, Arch Intern Med. 2010;170(16):1433-1441

 Management Plan? – AUDIENCE RESPONSE QUESTION: 1. CABG 2. Multivessel PCI with BMS 3. Multivessel PCI with DES 4. Single Vessel PCI (RCA) – incomplete revascularization 5. Medical Management and Optimization

Antiplatelet therapy in patients requiring warfarin Current CCS guidelines on antiplatelet therapy:

 ASA desensitization and plan to proceed to Multivessel PCI – Desensitization completed without difficulty next day – BMS stenting performed

 PCI to RCA with 3 DRIVER (BMS) stents:

 PCI to Cx with DRIVER stent (BMS):

 No issues post procedure – Discharged 2 days later on warfarin, ECASA, and clopidogrel – Other therapy: atorvastatin, perindopril, metoprolol