Speakers discuss Diagnosis and Management of Acute Coronary Syndrome


 Symposium on Acute Coronary syndrome by PCS

Speakers discuss Diagnosis and
Management of Acute Coronary Syndrome

By Mubarak Ali

KARACHI: Due to tremendous advancement in the field of medicine, future is computerized treatment and chances of errors will be small. Patient and physicians contact will be focused to contact with computerization. Future of cardiologists looks very bright in Pakistan. This was stated by Prof. Kaleemuddin Aziz, Pioneer Pediatric cardiologist of the country while speaking as chief guest at a Symposium on Acute Coronary Syndrome (ACS) organized by Pakistan Cardiac Society Karachi Chapter at local hotel here on 17th November 2018. Prof. Azhar Masood Faruqui who was the guest of honor at the occasion in his remarks stated that PCs is doing a wonderful job by organizing CME and other awareness programs. ACS, he stated is a very important subject and its definition has changed a lot. Concept of ACS is based on pathological concepts. Meeting was very well attended by senior and junior cardiologist from various hospitals of the city.

Prof. M Ishaq in his welcome remarks said that Prof. Kaleemuddin Aziz introduced the pediatric cardiology specialty and professional ethics. Prof. Azhar Masood Faruqui has played an important role in the upgradation of NICVD which is an institute of international repute. Prof. Mansoor Ahmed also lauded the services of Prof. Kaleemuddin Aziz and Prof, Azhar Farouqui and stated that we are proud of their achievements. ACS, he stated is a killer disease and management of ACS can save precious lives.

Prof. Kaleemuddin Aziz, Prof. Ejaz Ahmed Vohra, Prof. M. Ishaq, Prof. Mansoor Ahmed,
Prof. Asad Pathan, Dr. Khalid Iqbal Bhatti, Dr. Riffat Sultana, Prof. Arifur- Rehman, Prof.
Tariq Ashraf, Prof. Nawaz Lashari, Prof. Khalida Soomro, Prof. Sultana Habib and Dr. Abdul
Rasheed Khan photographed with other participants of a Symposium on Acute Coronary
Syndrome (ACS) organized by Pakistan Cardiac Society Karachi Chapter

at local hotel in Karachi on 17th November 2018.

Prof. M. Ishaq was the first speaker who talked about evaluation of chest pain in emergency room. Basic goal in acute chest pain in emergency he said is to differentiate between life threatening and Trival causes and target should be to recognize this problem. ACS, NASTFMI, STEMI is a life threatening causes of chest pain. Proper history is extremely important, ECG, ACS, Arrathmias PE, Chest X-Ray is also very important. A normal ECG does not always exclude ACS and history is the most important. Typical and atypical are two types of pains. Family history is very important. For diagnosis ECG is the standard single best test to identify with AMI but sensitivity is far from ideal. Chest pain is very common & has a wide differential. First try to identify life threatening causes. Remember that troponin levels Do Not always confirm or exclude ACS. History, he pointed out is the most important diagnostic tool. Physical exam, labs, EKG and imaging are mandatory to establish the diagnosis. In case of doubt, the benefit should go to the patient. Whenever you are stuck, ask for help, your seniors are there to help you. It is better safe than sorry, never ever dismiss any chest pain, no matter how atypical it may sound without doing preliminary assessment and tests. Patients clinical profile & your personal judgment complimented with a senior’s input will help in making a rational conclusion, he concluded.

Dr. Khalid Iqbal Bhatti speaking at the occasion said that Aortic, Esophageal/GI, Lungs & Pleura, Muscculo-Skeletal, neurological and psychological factors are the major common causes of chest pain. Pulmonary embolisms and ACS are the most dangerous pain that can kill the patients, he added.

Dr. Tariq Farman talking about Cardio Biomarkers said that a biomarker is a substance used as an indicator of a biologic state. Three important criteria for biomarkers are accurate repeated measurement at reasonable cost, must provide additional information and should aid treatment. Cardiac biomarkers are protein molecules released in the blood stream from damaged muscle. Characteristics of an ideal Cardiac Biomarkers includes high cardio specificity, help in making correct diagnosis, readily available at reasonable cost and play a designed role in the treatment and management of patients. Cardiac biomarkers are helpful in making the correct diagnosis. However, in addition to these biomarkers clinical history, ECG and Echo findings must be considered for making the right diagnosis and suggesting the correct treatment strategy.

Dr. Riffat Sultana speaking about stress testing said that indication for exercise testing includes Elicit abnormalities not present in test, estimate functional capacity, estimate prognosis of CAD, likely hood of coronary artery disease, extent of coronary artery disease effect of treatment.

Prof. Tariq Ashraf highlighted the NASTEMI Guidelines and stated that quick and prompt response will help to save the life of the patients. In centers experienced with radial access, a radial approach is recommended for coronary angioplasty and PCI. It is recommended that centers testing ACS patients implement a transition from transfemoral to transradial access. Proficiency in the femoral approach should be maintained for IABP insertion and structural as well as peripheral procedures.

Prof. Nawaz Lashari talking about the patients who qualify for thrombolysis said that immediate transfer to a PCI capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non PCI capable hospital with an FMC to device time system goal of 120 minutes or less. In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non PCI capable hospitals when the anticipated FMC to device time at PCI capable hospital exceeds 120 minutes because of unavoidable delays. The proposed time windows system goal, for any individual patient every effort should be made to provide reperfusion therapy as rapidly as possible. When fibrinolytic therapy is indicated or chosen as the primary reperfusion strategy, it should be administered within 30 minutes of hospital arrival. Reperfusion therapy is reasonable for patients with STEMI and symptoms onset within the prior 12 to 24 hours who have clinical and or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population. Each community should develop a STEMI system for care following the standards developed for Mission Lifeline including ongoing multidisciplinary team meeting with EMS, non PCI capable hospitals, and PCI capable hospitals. Patients who are not high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non PCI capable facility may be considered for transfer to a PCI capable facility as soon as possible where either PCI can be performed when needed or as a pharmacoinvasive strategy.

Prof. Faisal Ahmed talked about Acute Coronary Syndrome with Cardiogenic shook and stated that coronary reperfusion is the mainstay evidenced based therapy intervention with Coronary Syndrome. Early reperfusion PCI/CABG decreases mortality. MCS is helpful in prompt recognition of disease and its management in CCU /ICU is helpful.

Dr. Khursheed Hasan discussed acute coronary syndrome and heart failure and pointed out that heart failure is a frequent complication of acute coronary syndrome and is associated whit poor prognosis. Incidence of HF was similar in STEMI and non STEMI in GRACE Registry approximately 15%. Up to 10 % of ACS patients develop HF during hospitalization and these patients have worse prognosis. Talking about medical management he said that ACE inhibitors are recommended in patients with LVEF ≤ 40% after stabilization to reduce the risk of death, recurrent MI and hospitalization for heart failure. Beta blocker is recommended in patients with an LVEF ≤40% after stabilization to reduce the risk of death, recurrent MI and hospitalization for heart failure. Mineralocorticoid receptor antagonists are recommended to reduce the risk of heart failure. Mineralocorticoid receptor antagonists preferably eplerenone are recommended to reduce the risk of cardiovascular hospitalization and death in patients with LVEF≤40. NESTEMI and HF is common situation with high mortality, high risk patient profile and underutilization of evidence based interventions. Coronary angiography to assess for assessment and extend of CAD and appropriate revascularization mode is decided by heart team approach, he concluded.

Prof. Asad Pathan discussed (STEMI) who qualify for primary PCI. Goals of reperfusion therapy in STEMI includes, restore flow in culprit artery, optimize myocardial perfusion, reserve left ventricular function, diminish mechanical and electrical complications and improve survival. Atypical ECG presentation that deserve prompt management in patients with signs and symptom of ischemia are LBBS, Ventricular paced rhythm, patients without diagnostic CT-segment elevation but with persistent ischemic symptoms, isolated posterior myocardial infarction and ST segment elevation in lead aVR.

Reperfusion therapy. Prof. Asad Pathan stated is indicated in all patients with symptoms of ischemia ≤ 12 hours duration and persistent ST segment elevation. A primary PC strategy is recommended over fibrinolysis within indicated time frames. If primary PCI cannot be performed timely after STEMI diagnosis, fibrinolytic therapy is recommended within 12 hours of symptoms in patients without contra-indications. Talking about access to STEMI care road-blocks, he pointed out that lack of dedicated STEMI care systems, lack of instantaneously available ECG facility at first point of medical contact, lack of public and patient awareness, lack of physician readiness, lack of equipped ambulance system network for patients transport and self pay for even emergency medical services besides lack of medical insurance, patients are not aware of symptoms of myocardial infarctions, and ignore symptoms besides lack of trust in doctors and health care system.

While discussing Interventions following fibrinolysis Prof. Asad Pathan said that emergency angiography and PCI if indicated is recommended in patients with heart failure/Shock. PCI is indicated immediately when fibrinolysis has failed <50% ST segment resolution at 60-90 minutes or at any time in the presence of haemodynamic or electrical instability or worsening ischemia. Angiography and PCI of the IRA if indicated is recommended between 2 and 24 hours after successful fibrinolysis. Emergency angiography and PCI if indicated in the case of recurrent ischemia or evidence of reocclusion after Initial successful fibrinolysis.

Prof. Sultana Habib, speaking about acute coronary syndrome in young women in Pakistan said that women have a higher prevalence of angina compared to men yet have an overall lower prevalence of atherosclerosis and obstructive artery diseases. Despite relatively less CAD, women have more adverse prognosis compared to men. Management of CAD in women includes, lifelong interventions, revascularization, pharmacotherapy, evidenced based therapies for risk reduction. To prevent deaths and MI efforts should be made to reduce symptoms.

Dr. Rafiq Khan presented the cases based on beating heart CABG which he stated is a challenging task, it requires skills and experience. Sometimes it is the only way to acquire good results as in heavy calcified aorta, CABG on beating heart with aorta non touch technique with total arterial grafting. Beating heart CABG is better than conventional CABG due to complications and risk due to HLM or ECC and the arrest especially in high risk work candidates. Beating heart CABG is also better than MV PCI as restenosis in MV PCI is 40% more than in beating heart. We should do both pump and off pump CABG wherever, whichever is indicated or contra indicated, he concluded.

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