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09.5 Hard Cases of NSTEMI Achmad Lefi MD FIHA

This document discusses the case of a 59-year-old male presenting with NSTEMI. It outlines his risk assessments using the GRACE and TIMI scores, which indicate a high ischemic risk. Guidelines for invasive strategy based on risk criteria from the ESC and AHA are presented. Options for revascularization like PCI are discussed. The document concludes with performance indicators for monitoring quality of care for NSTEMI patients.

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Emdan Sengadji
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37 views29 pages

09.5 Hard Cases of NSTEMI Achmad Lefi MD FIHA

This document discusses the case of a 59-year-old male presenting with NSTEMI. It outlines his risk assessments using the GRACE and TIMI scores, which indicate a high ischemic risk. Guidelines for invasive strategy based on risk criteria from the ESC and AHA are presented. Options for revascularization like PCI are discussed. The document concludes with performance indicators for monitoring quality of care for NSTEMI patients.

Uploaded by

Emdan Sengadji
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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HARD CASES OF NSTEMI

ACS INTERACTIVE CASE


ACHMAD LEFI, MD, FIHA, FAsCC
NSTEMI vs STEMI : Pathophysiology
Prognosis of NSTEMI : Dont Underestimate
Prognosis: Poor Undertreated
Probability of dying

Days after presentation


Case
Male, 59 years old
Anamnesa
Blood pressure: 100/60 mmHg
Rh -/- Wh-/-
Risk factor: Dyslipidemia,Smokers (30 years)
Laboratorium:
CKMB: 667.8
Troponin I: 8.7
ECG (5/10/2016)
Whats your working Diagnosis???

a. STEMI
b. NSTE-ACS with ongoing ishaemia or
haemodynamic instability
c. NSTE-ACS without ongoing ischaemia or
haemodynamic instability
d. NSTE-ACS unlikely
Whats next step?
Risk Assesment & ECG Monitoring
Method for risk asssessment
ECG motoring : < 24 hours vs > 24 hours
Method for Risk Assessment
Ischaemic Risk Assessment Bleeding Risk Assessment

GRACE Risk Score CRUSADE Bleeding


TIMI Risk Score Score
Ischaemic Risk Assessment
GRACE Score & TIMI Score

Patient GRACE Score TIMI Score


Score 114 5 points
Result
Ischaemic Risk Assessment
Bleeding Risk Assessment
CRUSADE
Enter Values in drop-down boxes below:
Baseline 37 39.9 Prior Vascular Yes
Hematokrit Disease
GFR: Cockcroft- 91 120 Diabetes No
Gault Mellitus
Heart rate on < 71 Signs of CHF No
admission on admission
Systolic Blood 91 100 Sex No
pressure on
admission
Recommended duration of
monitoring

Clinical Presentation Unit Rhythm Monitoring


Unstable Angina Regular ward or None
discharge
NSTEMI at low risk for Intermediate care unit or 24 hour
cardiac arrhytmias coronary care unit
NSTEMI at intermediate Intensive/coronary care > 24 hour
to high risk for cardiac units or intermediate care
arrhthmias unit
Management of NSTEMI
Anti thrombotic
Anticoagulan
Invasive stragtegy
Do we need invasive strategy ?
Risk criteria mandating invasive strategy in
NSTE-ACS
Determine Risk Criteria
ESC Guideline AHA guideline

Immediate - Haemodynamic instability or cardiogenic shock - Refactory angina


invasive - Recurrent or ongoing chest pain refractory to - Signs or symptoms of HF or new or
(within 2 h) medical treatment worsening mitral regurgitaion
- Life-threatening arrhytmias or cardiac arrest - Hemodynamic instability
- Mechanical complications of MI - Recurrent angina or ischemia at rest or
- Acute heart failure with refractory angina or ST with low-level activities despite intensive
deviation medical therapy
- Recurrent dynamic ST or T- wave changes, - Sustained VT or VF
particularly with intermittent ST-elevation
Class of Recommendation: I
Level of Recommendation: C

Early invasive - Rise or fall in cardiac troponin compatible with MI - None of the above, but GRACE risk score
(within 24 h) - Dynamic ST or T- wave changes (symptomatic or > 140 Temporal change in Tn
silent) - New or presumably new ST depression
- GRACE Score > 140
Class of Recommendation: I
Level of Recommendation: C
Delayed - Diabetes mellitus - None of the above but diabetes mellitus,
invasive - Renal insufficiency (eGFR <60 mL/min/1,73 m2) Renal insufficiency (GFR < 60
(within 25 - LVEF < 40% or congestive heart failure mL/min/1,73 m2)
72 h) - Early post-infarction angina recent PCI - Reduced LV systiolic function (EF < 0,40)
- Prior CABG - Early postinfarction angina
- GRACE risk score > 109 and < 140 - PCI with 6 mo
- Or recurrent symptoms or known ischaemia on - Prior CABG
non-invasive testing - GRACE risk score 109 140; TIMI score
Class of Recommendation: I 2
Level of Recommendation: A
Where is the position in Flow chart?
ESC Guideline

Source:
Roffi, M., et al. 2015.
2015 ESC Guidelines for
the management of acute
coronary syndromes in
patients presenting
without persistent ST-
segment elevation. Eur.
Heart J. :159
Where is the position in Flow chart?
AHA Guideline

Source: Amsterdam, et al. 2014. 2014 AHA/acc


guideline for the management of patients with
Non-ST-Elevation acute coronary syndromes: A
report of the American College of
Cardiology/American Heart Association Task
Force on Practice Guidelines. J. Am. Coll.
Cardiol. 64(24):e139e228.
Coronary Angiography
Revascularisasi modalities
PCI vs CABG
Percutaneus Coronary Intervention
(PCI)
Hospital discharge and post
discharge management
When to discharge :
Longterm management :
Measurement of cardilogist profesional
performance : Whats indicators ?
Variations in the application of evidence-based strategies
are associated with significant differences in outcome.
Underutilization of evidence-based treatments is common.
Adherence to guidelines has been correlated with
improvements in patient outcomes in ACS, including
reduced mortality.
Continuous monitoring of performance indicators is
strongly encouraged to enhance the quality of treatment
and minimize unwarranted variations in evidence-based
care.
Performance measures in NSTE-ACS
Compliance of using aspirin, ticagrelor/prasugrel/clopidogrel,
fondaparinux/bivalirudin/UFH/enoxaparin, beta-blocker at discharge
in patients with LV dysfunction, statins, ACE-inhibitor or ARB in
patients with systolic LV dysfunction or heart failure, hypertension or
diabetes
Compliance of using early invasive procedures in intermediate -to
high- risk patients
Smoking cessation advice/conselling
Enrolment in a secondary prevention/cardiac rehabilitation
programme
Development of regional and/or national programmes to measure
performance indicators systematically and provide feedback to
individual hospitals
Conclusion
Facing NSTEMI had to do diagnosis
validation, risk assessment (ischemic,
bleeding), management, medical treatment,
invasive strategy (based on risk criteria)
Thank You
For Your Kind Attention
Ischaemic Risk Assessment
GRACE SCORE
Ischaemic Risk Assessment
TIMI Risk Score

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