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Interactive ACS Case Presentation Rodney Zimmermann, MD, FRCPC, - - PowerPoint PPT Presentation
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 No conflicts to declare for this presentation ACC Rockies Case Study: Mr GP 75 yo male admitted with progressive typical exertional angina
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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
- f 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
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Medications:
– Warfarin, metoprolol, atorvastatin, on weaning doses of prednisone, perindopril
Physical Examination non-contributory
regarding cardiac findings, except for atrial fibrillation
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ECG:
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What are Investigation Options?
– AUDIENCE RESPONSE QUESTION:
- 1. EST
- 2. Functional Assessment (echo stress or perfusion
study)
- 3. Cardiac Catheterization
- 4. CT Angiogram
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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
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LV:
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RCA:
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LAD:
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LCx:
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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
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Management Issues:
– PCI (multivessel) vs CABG? – ASA allergy? – Antiplatelet agent choice? – Planned elective back surgery? – Prednisone use?
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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
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Number and Crude Incidence Rate of Bleeding Events Associated With Single, Dual, and Triple Antithrombotic Treatment After Atrial Fibrillation Hospitalization
Variable Events, No. Warfarin Monotherapy Aspirin Monotherapy Clopidogrel Monotherapy Aspirin + Clopidogrel Warfarin + Aspirin Warfarin + Clopidogrel Warfarin + 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 bleeding 13 573 3.9 3.7 5.6 7.4 6.8 13.9 15.7 Intracranial bleeding 2154 0.6 0.5 1.0 0.2 0.8 0.8 1.0 Airway bleeding 3185 1.3 0.7 1.0 2.2 2.3 7.1 7.1 Gastrointestinal bleeding 4637 0.9 1.5 1.9 3.1 2.1 3.8 5.1 Urinary tract bleeding 3051 1.0 0.9 1.3 1.7 1.6 2.0 2.4
**Incidence Rate, Unadjusted, % per Patient-year
Hansen, Sørensen et al, Arch Intern Med. 2010;170(16):1433-1441
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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
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Antiplatelet therapy in patients requiring warfarin
Current CCS guidelines on antiplatelet therapy:
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ASA desensitization and plan to proceed to
Multivessel PCI
– Desensitization completed without difficulty next day – BMS stenting performed
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PCI to RCA with 3 DRIVER (BMS) stents:
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PCI to Cx with DRIVER stent (BMS):
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No issues post procedure