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CORONARY CIRCULATIONAND ACUTE CORONARY

SYNDROMES

LeRoy E. Rabbani, MD Director, Cardiac Inpatient ServicesDirector, Cardiac Intensive Care Unit

Professor of Clinical Medicine

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Cellular innateImmunity

Complement

Factor H tissue bindingInhibits neutrophil

migration anddegranulation

C3bBb degradation

Stimulates EC tosecrete MCP-1

Promotes monocyteadhesion and migration

Stimulates monocytephagocytosis of E-

LDL

Stimulates IL-1 receptorantagonist

Absorbs circulating LPS,platelet activatingfactors and IL-1

CRP

–

+ Binds C1q

Complementactivation and tissue

damageFoam cellformation

Mazer SP, Thromb & Thrombolysis in press

In Vitro Effectsof CRP

eNOS

NO

NFkB

IL-6

MCP-1

CRP

Tissue Factor

ET-1

ICAM-1

VCAM-1

E-selectin

Mazer SP, Thromb & Thrombolysis i n press

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Macrophage Foam CellsMatrix Metalloproteinases– Collagenase– Stromelysin– Gelatinase– Elastase

Tissue FactorCRPMyeloperoxidase

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TIMI Risk Score for UA/NSTEMI:7 Independent Predictors

1. Age ≥65 y2. ≥3 CAD risk factors (high

cholesterol, family history,hypertension, diabetes,smoking)

3. Prior coronary stenosis ≥50%4. Aspirin in last 7 days5. ≥2 anginal events ≤24 h6. ST-segment deviation7. Elevated cardiac markers

(CK-MB or troponin)Number of Predictors

0

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0/1 2 3 4 5 6/7

% D

eath

/ M

I / R

evas

c

TIMI = Thrombolysis in Myocardial Infarction.Antman EM, et al. JAMA. 2000;284:835-842.

ACC/AHA Guidelines Recommendations:NSTE ACS Patients at High Risk

of Death or MIAt least one of the following features must be present: Prolonged ongoing rest pain > 20 minutes

Elevated cardiac troponin (TnT or TnI > 0.1 ng/mL)

New or presumably new ST-segment depression

Sustained ventricular tachycardia

Pulmonary edema, most likely due to ischemia

New or worsening mitral regurgitation (MR) murmur

S3 or new/worsening rales

Hypotension, bradycardia, tachycardia

Age > 75 years

Braunwald E, et al. 2002. http://www.acc.org/clinical/guidelines/unstable/unstable.pdf.

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Balloon

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Lateral: Circumflex / Anterior:LAD

Vessel: RCA, Circumflex

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Vessel: RCA

RCA

V1-V3: LargeR + ST

DepressionPosterior

Circumflex,Diagonal

I, aVL,V5-V6Lateral

RCAV1-V3,

V3R-V6RRight Ventr.

RCA,Circumflex

II, III,aVFInferior

LADV1-V2Septal

LADV1-V4Anteroseptal

LAD, DiagonalV1-V6,1, aVLAnterolateral

V6Lateral

V3Anterior

aVFInferior

IIIInferior

LADV3-V4AnteriorV5

LateralV2 SeptalaVL

LateralII

Inferior

VesselsLeadsLocationV4

AnteriorV1 Septal aVRI

Lateral

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Goal

“Door-to-lytic”30 minutes

“Door-to-balloon” 90 minutes

Pharmacological Reperfusion for STEMIFibrinolysis Background/Limitations

Initial occluded artery remains (TFG 0/1), in~20% of patients → 2-fold ↑ in mortality1,2

Reocclusion occurs in 5-10% of patients → 3-fold ↑ in mortality 3,4

Reinfarction occurs in ~5% of patients → 3-fold ↑ in mortality 5

1.TIMI 1, Am J Cardiol 1998;62:179 2. GUSTO I Angio, NEJM 1993;329:1615) 3.Ohman et al., Circulation1990;82:781 4. HART II, Circ 2001;104:648; PENTALYSE, EHJ 2001;22:1716 5. TIMI 2, JACC 1995;26:900; TIMI 4 &5, Am J Cardiol 1997;80:696

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Percutaneous CoronaryIntervention (PCI)

The advantages of Primary PCIHigh 85-95% infarct vessel patency rateLow rates of recurrent ischemia,reinfarction, death, and strokeAvoidance of ICHShortened LOSAbility to treat lytic-ineligible patients

Nallamothu BK, et al. Circulation. 2005;111:761-767.

Transfer for PCI in STEMI:NRMI (1999–2002), 4278 Patients

28.4>4 h

55.42–4 h

16.2<2 h

4.2<90 min

% of PatientsDoor-to-Balloon Time

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*P<.05 for all.

Bradley EH, et al. N Engl J Med. 2006;355:2308-2320.

D2B: Strategies Associated With a SignificantReduction in Door-to-Balloon Time (“Code

90”)

8.6Having staff in the ED and cath lab use andreceive real-time feedback

14.6Having an attending cardiologist always on site

19.3Expecting staff to arrive at the cath lab within20 minutes after page

15.4Having the ED activate the cath lab whilepatient is still en route

13.8Having a single call to a central pageoperator activate the cath lab

8.2Having emergency medicine physicians activatethe cath lab

Mean reduction indoor-to-balloon

time (min)*Strategy

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