TỐI ƯU ĐIỀU TRỊ HỘI CHỨNG VÀNH CẤP - Optimizing treatment for ACS patient with 3 vessel disease & complete heart block Dinh Duc Huy, MD, FSCAI Nguyen Ngo Thanh Phuong, MD Tam Duc Heart Hospital

HỘI NGHỊ KHOA HỌC TIM MẠCH TOÀN QUỐC 2015

Optimizing treatment
for ACS patient with 3 vessel disease
& complete heart block
Dinh Duc Huy, MD, FSCAI
Nguyen Ngo Thanh Phuong, MD
Tam Duc Heart Hospital


Case presentation
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Mr. D C T, 63 years old
BMI 24 (H 170cm, BW 70kg)
Smoker (+), 50 pack years
Hypercholesterolemia (+)
HTN (+), DM (+) for 10 years
Chest pain sometimes
Weakness and fatigue on exertion 5 days before
Shortness of breath on admission day


Case presentation

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Alert
No neurological sign
HR 37 bpm
BP 141/47 mmHg
RR 20 bpm
SpO2 96%
Regular S1, S2
Clear lungs
No lower limbs edema

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WBC 7.71k/uL
HGB 11.7 g/dL
PLT 171K/uL
Creatinin 222 umol/L,
eGFR:27ml/ph/1.73m2
hs-CRP 4.3mg/L
AST 41 U/L
ALT 25 U/L
Cholesterol 2.58
HDL-C 0.72
LDL-C 1.6
TG: 1.74 mmol/L
NT proBNP 9330pg/ml
hs-TnT 126.4->113.8 pg/ml


On admission ECG

Monitoring ECG: BAV II intermittent BAV III


Imaging findings
Chest Xray
• CTR: 0.5
• Normal pulmonary
vascularity
Echocardiography
• LVEF 73%; LV42/24mm

• No RWMA; No thrombus
• Moderate Aortic Stenois
• Gd trans Ao= 42/14 mmHg
• MR (+)
• sPAP 25mmHg

Vascular Ultrasound
• Carotid: no stenosis
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Normal ABI

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Lower limbs arteries:
 Right: 40-50%%
stenosis of midsuperficial femoral artery
caused by stable plaque
 Left: 50% stenosis &
diffuse stenosis after the
bifurcation of the
popliteal artery.


Case management
DIAGNOSIS:

NSTEMI-HTN- T2DM-CKD

Intermittent BAV II-III

TREATMENT:
 TPM/PPM?
 Coronary angiogram? When?
 PCI/CABG before or after PPM?
 Anti-platelet therapy? (Pretreatment? Clopidogrel or
New drugs [Pasugrel/Ticagrelor] to be combined
with Aspirin?) for how long?
…


1. The optimal timing of ticagrelor or clopidogrel for patients
scheduled for an invasive strategy has not been adequately
investigated, no recommendation for or against pretreatment
2. Based on the ACCOAST results, pretreatment with prasugrel is
not recommended (TIMI major bleeds were significantly
increased in the pretreatment group at 7 days.


Pretreatment in NSTE-ACS + PCI (RCTs)

Bellemain-Appaix A et al. BMJ 2014;349:g6269


TRANSLATE ACS Registry: 9251 ACS patients
Thienopyridine naive, undergoing PCI- Real life PCI

Effron MB et al. J Am Coll Cardiol. 2014;63(12_S)


 Prompt opening of the infarct vessel is often sufficient to

reverse new-onset ischaemic conduction disturbances. This is
especially true for atrioventricular (AV) block in the setting of
inferior infarctions.
 Temporary pacing is indicated for symptomatic lifethreatening bradycardia not resolving after successful
reperfusion and after medical treatment in the presence of
high-degree AV block and intraventricular conduction defects.
 Permanent pacing is considered for disturbances that persist
beyond the acute phase after the myocardial infarction.
Recommendations for management of new bundle branch block and atrio-ventricular conduction disorders in ACS
Euro Intervention 2014


Case management

•TPM
•TVD- SYNTAX score 22

CABG or PCI
For revascularization?


Tỷ lệ biến cố tim mạch nặng
theo điểm số SYNTAX score

NEJM 2009; 360: 961-72


CABGvs. PCI for
patients with
three-vessel disease:

final 5-year follow up
of the SYNTAX trial
European Heart Journal
doi:10.1093/eurheartj/ehu213

ConclusionFive-year results of
patients with 3VD treated
with CABG or PCI using
the first-generation
paclitaxel-eluting DES
suggest that
CABG should remain the
standard of care


Our patient treatment- 3 VD PCI with DES

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TPM (+)
DES in RCA, LCx, LAD
Good result post PCI
All TIMI 3 flow
Normal sinus rhythm
3 days after PCI

Antiplatelet therapy for ACS patient
1. Which is the best option of antiplatelet
therapy for ACS patient undergoing PCI?
2. Should we do pre-treatment? (perhaps NO)
3. Can we give Ticagrelor for patient with
complete heart block?
4. How long should we prolong DAPT?


CURE study- Corner stone for DAPT in ACS:
Clopidogrel+ ASA are better than ASA alone
PCI Group
Placebo
(11.4%)

0.12

0.20
CVD/MI/Stroke

CV Death, MI, Stroke

0.14

0.10
Clopidogrel
(9.3%)

0.08

0.06

0.04

Clopidogrel

RR 0.80, p<0.001
0

3

RR: 0.72 (0.57-0.90)

6
9
Months of follow-up

0.0

1
2

4

Placebo
0.10
Clopidogrel

100

200

300

Placebo

0.15
Clopidogrel
0.10
0.05
RR: 0.89 (0.71-1.11)

RR: 0.80 (0.69-0.92)
4

CVD/MI/Stroke

0.15

0.0

200

0.20

0.20

0.05

100

CABG Group

Medical Rx Group

CVD/MI/Stroke

0.10
0.05

0.02

0.0

Placebo

0.15

0.0

300

4
100
CURE. NEJM 2001;345:494-502
Fox et al. Circulation. 2004;110:1202-1208,

200

300

Wiviott et al. New Eng J Med 2007; 357

No benefit with prior stroke, age > 75, weight < 60kg


• Multicenter, double-blind,
randomized trial
• 18,624 ACS patients
• Ticagrelor (180-mg loading
dose, 90 mg twice daily
thereafter) and clopidogrel
(300-to-600-mg loadingdose,
75 mg daily thereafter)
Wallentin L et al. N Engl J Med 2009;361


15

Ticargrelor
10

Clopidogrel

11.6%
11.2%

5
P= 0,43

HR: 1.04 (95% CI, 0.95–1.13)
0
0

60

120

180

240

300

Major bleeding in PLATO

360

16

Xuất huyết nặng chung (%)

Xuất huyết nặng chung (%)

Same major bleeding with Ticagrelor vs. Clopidogrel
in PLATO study

Ticagrelor

14
12

13.4%

Clopidogrel 12.6%

10
8

6
P= 0,26

4

HR: 1.07 (95% CI 0.95–1.19

2
0

0

60

120

180

240

300

Major bleeding in
NSTE-ACS subgroup

1. Lindholm D, et al. J Am Coll Cardiol 2013;61(suppl 10):Abstract 901–903.

2. Wallentin L et al. N Engl J Med 2009;361:1045–1057

360


PLATO- Bradycardia Events

 Holter monitoring during the first week in 2866 patients
 Repeated at 30 days in 1991 patients
 Higher incidence of ventricular pauses in the 1st week, but not
at day 30; pauses were rarely associated with symptoms
 No significant difference to the incidence of syncope or
pacemaker implantation
Wallentin L et al. N Engl J Med 2009;361


Methods
7-day cECG recording initiated at the time of randomisation, which
was within 24 h of symptom onset, and then repeated at 1 month
after randomization during the convalescent phase.
The principal safety endpoint was the incidence of ventricular
pauses lasting at least 3 seconds.
J Am Coll Cardiol 2011;57:1908–16

cECG Assessment Patient CONSORT Diagram

J Am Coll Cardiol 2011;57:1908–16


Arrhythmias at Visit 1 (Week 1) and
Visit 2 (Day 30) for All Patients

 More ventricular pauses ≥3 s in patients assigned to ticagrelor
during the first week (5.8% vs. 3.6%; p=0.006)
 At 1 month, pauses ≥3 s were less and similar between treatments
(2.1% vs. 1.7%)
J Am Coll Cardiol 2011;57:1908–16


Other findings
• Week 1: 70 patients
(3.2% ) had 1 pause, 20
(0.6%) had > 4 pauses
• 1 month: 9 patients
(0.05%) had 1 pause, 17
(0.8%) had > 4 pauses

• There is a nocturnal
excess of pauses among
patients assigned to
ticagrelor, with a peak in
the frequency of

ventricular pauses at
night
J Am Coll Cardiol 2011;57:1908–16


Study conclusions
1. More patients treated with ticagrelor compared
with clopidogrel had ventricular pauses, which were
predominantly asymptomatic, sinoatrial nodal in
origin, and nocturnal and occurred most frequently
in the acute phase of ACS.

2. There were no differences between ticagrelor and
clopidogrel in the incidence of clinically reported
bradycardic adverse events, including syncope,
pacemaker placement, and cardiac arrest.
J Am Coll Cardiol 2011;57:1908–16