this program is brought to you by Emory University good morning everyone welcome to Heart and Vascular Grand Rounds hope everybody had a nice Easter weekend uh today it's really exciting that we have three of our own uh speakers here from Emory and uh this really is a treat for us uh and very important because uh this is we're going to talk about the ACS guidelines and this is the first time that we've had three of our Emory uh cardiology faculty on the guidelines so just very exciting and congratulations to all three of you our speakers this morning uh Dr tenvir Rab Dr abby Goyel and Dr ema Eidenzo i'm going to keep the introduction very brief uh so Dr izzy Denzo is a preventive cardiologist director of Emory Center for Heart Disease Prevention uh Dr abby Goyal professor of cardiology and Rollins School of Public Health and chief quality officer for heart and vascular service line and Dr tanvir Rab professor and interventional cardiologist and section chief currently at Emery Decar Hospital i'm going to turn it over to Dr rab and uh thank you so much for doing this this morning for us thank you very much uh thank you good morning to all of you uh for attending um it's also important to add that FA Merchant was a reviewer for this document so there actually four member faculty members involved the order will be that Abby will talk about diagnosis initial assessment of ACS all followed by ACS management of catlab antiplatal antibiotic therapies and then will talk about ACS management outside of catlab secondary prevention take-home messages and just for to remind everyone that class one is based on clinical trials the benefit far exceeds the risk and the treatment is effective should be chosen over anything else on the other extreme class three is harm again based on clinical trials that you should not be doing or performing procedure or giving drugs that that are contindicated in the middle there's class 2A where the is the benefits through observation in some registries suggests that it is more useful and beneficial than the risk whereas class 2B there's weak evidence that sometimes the risk is greater than benefit or benefit may equal risk and general in these cases may be reasonable should be considered or may not be considered and that's a class 2B and without much ado I'll go on to Abby and we'll stop sharing and so Abby can start It's a it's a pleasure to be here with our own home audience here and for those watching on YouTube i'll cover the diagnosis and initial assessment of acute coronary syndrome sections only six slides so we can hopefully get through this we'll let that animations play out and so um when there's a non-lusive thrombus due to plaque erosion or plaque rupture that manifests on the ECG potentially as ST depression as we know or T-wave inversion it may be electrically silent particularly in patients with left circumlex disease if it's biomarker positive that's called type one and STEMI if it's biomarker negative it's called unstable anga we use um as perhaps just a little under half of the centers in the US we use high sensitivity troponin assays and so this entity of unstable anga is diminishing I wouldn't say it's gone uh it still happens but with the very sensitive assays markers will usually be positive if there's some mioardial injury but this this we we still see it and we still need to be aware of it if you have a completely olusive thrombus that presents on the ECG as ST segment elevation and two or more contiguous leads uh this will be biioarker positive if you were to draw biomarkers but we know that if you're presenting with an inclusive thrombus where you have eskeemic symptoms um with ST elevation you don't wait to draw enzymes you need to pursue immediate reprofusion therapy primary PCI or um uh reprofusion therapy via thrombolyis in rural centers and uh so that would lead to a diagnosis of STEMI or type one and STEMI we did stipulate in the guideline uh this time what about left bundle uh and it's important to note new left bundle should not be considered diagnostic of STEMI in isolation meaning without symptoms clinical correlation is required A new left bundle in an asymptomatic patient is not a STEMI equivalent we took the step of actually articulating that in the document because we note that the majority of patients coming in with a left bundle probably have heart failure or some other diagnosis and if you dig enough you probably can find evidence of uh an old left bundle so we really encourage the uh linkage of the left bundle on an ECG making sure it's new and uh it has to be associated with symptoms i'll transition briefly to this for the fellows uh you're probably have seen some um version of this this is the Emory protocol for how we classify uh elevated troponins you can click on you can Google Emmery tarponin and click on the first link and that'll pull it up this is also a QR code code that you can scan i'll leave that up for about 30 seconds so you can do so as I talk it's important to note that this document really covers only the type one and stemmies and the stemis which we'll show on subsequent slides here it does not cover type two MIS supply demand mismatch and it does not cover non-eskeemic myioardial injury uh which is uh actually not es schemic in its mechanism as at all as a cause of tropponin elevation so the important uh take-home point from this is we should not automatically equate a tropponin elevation which is defined as above the 99th percentile and emory that's above 20 in men for hs traroponin above 15 in women we should not automatically equate that with an an STEMI you have to go through the steps of equating it uh with symptoms and then think of mechanism for that to occur with the animation play out here the prehosp assessment for the management u of suspected ACS uh this suspected ACS uh is uh anyone who is having chest pain uh the ED at Emory uses a protocol the rapid ECG criteria where they define suspected ACS as anyone who's 30 years or older with chest pain uh and then anyone who's 50 years or older with chest pain shortness of breath weakness or palpitations it's kind of broadened out but if you suspect ACS in the field then our EMS colleagues will obtain a 12 lead ECG and their target to do so is within 10 minutes of first medical contact if they find a STEMI their directive is to take the patient immediately to a PCI capable hospital if one is in range uh and uh with the goal of trying to open up the artery within 90 minutes of first medical contact which is when the the paramedics or the EMTs arrive at the patient's side if the ECG is not diagnostic for a STEMI then you transport to a local ED and you um further assess the patient in the hospital it is important though that they should be obtaining serial ECGs in the field even if the first one is not diagnostic because it can certainly change into a STEMI or sometimes you have a non-diagnostic ECG and they can become a STEMI shortly thereafter and the serial ECGs is important because we know that every 30 minute delay is associated with a 7.5% relative risk of one-year death in patients with STEMI uh hence the real importance of getting them to a center where primary PCI can be done if the patient presents initially to the hospital and does not call EMS this uh unfortunately still happens and about 40% of patients who present with STEMI around the country about 60% are calling 911 about 40% walk into an ED which is not ideal because some of them end up not making it to the ED if they're having an active STEMI um and so that is uh an effort of active uh systems of care and political local political engagement to try and reduce the barriers for for people to call 911 with suspected ACS if you suspect ACS you get an ECG within 10 minutes when they walk into the hospital that's a class one recommendation and if STEMI um is uh diagnosed we'll let this play out here then they need to immediately go for reprofusion therapy uh at a PCI center they would immediately go to the kath lab for PCI uh if they're at a rural center and not in range of uh um another PCI center then they may get fibbrronolyis which I'll cover on the next slide here if they don't have a STEMI then they get serial ECG monitoring and serial cardiac troponins and uh then they go into a clinical decision pathway used to define risk as intermediate low and high risk i'll actually use this part to segue into another part of the Emmery protocol uh this is a continuation of the slide I showed earlier on tropparonin classification this is my second to last slide in the section this is what uh again if you googleonin or you use the QR code here it'll pull up this Emory emergency department protocol this is for uh the main Emery hospitals along with Grady uh Emery Decar Hospital uses a different assay and so the numbers are going to be slightly different for Emry Decator Hospital the important thing to note is that our protocol is this is not just a tropponin protocol this is also a chest pain and an ECG protocol like the guidelines continue to recommend and so I won't go into this in detail but the point is if they come in with eskeemic symptoms and they have a STEMI you follow the local STEMI protocol if they have high-risisk features that are not a STEMI on the ECG they're called high risk and may have a type 1N STEMI and cardiology needs to definitely be consulted at that stage uh if they have very low tropponins um and uh uh their ECG does not show uh high-risisk findings they can be discharged from the ED considered low risk with early outpatient follow-up and then middle-of the road features if they have dropponas that are elevated but not very high and not overly concerning ECG findings they may go to the CDU for further testing this is my final slide here reprerfusion at non-PCI capable centers if a STEMI uh is not present uh when the patient presents this is at a center that cannot do 24 PCI a 24/7 PCI then um if a STEMI is not present then you don't want to immediately give fibbronlyis obviously you need to further work them up but if a STEMI is present then you need to first ask is there a contra indication to fibbronolyis uh such as hypertensive emergency recent neurosurgery uh history of hemorrhagic stroke etc if any of those contraindications are there then you need to transfer to a PCI capable immediately a stat transfer for primary PCI uh if there is no contraindication and uh you have um uh you're within 12 hours of symptoms and there's going to be a delay in transferring to get a patient to a cath lab then you want to administer fibbrinolyis uh if however um uh there is uh a delayed uh presentation from symptom onset then they can go to a PCI capable center for primary PCI and that's a class 2A recommendation with that I'll transition over to Dr rab uh for his section and I'm going to stop sharing my slides here thank you thank you Abby so I want to talk to you about gatlab management antiplatlet and antiquaginal therapies the document uh decided to combine both for STEMI and non- STEMI since many of the therapies are very similar uh in in both arms so we focused uh on management of patients presenting with cardiac arrest because of a common problem and these are patients who have achieved return of spontaneous circulation uh and are now present to the emergency room it's very difficult to to give a class of recommendation based on poor prognostic features only because we will not have clinical trials and most of this is are based on observation and registry so poor prognostic features to remind everyone includes unwitness arrest no bystander CPR non-shockable rhythm CPR more than 30 minutes time to ros greater than 30 minutes RTL PH less than 7.2 lactate greater than 7 age greater than 85 and stable disease on diialysis so in terms of guideline recommendations if the patient has achieved ros and is awake and is stem and is present stem it's like any other stem go to the catal primary PCI class indication if the patient is comeomaos but has return of spontaneous circulation and stemic on the ECG if he has fewer of these poor prognostic features meaning may have had a brief period of rest or defer related very quickly but still comeos should consider primary PCI as class one however the patient is comeomaos has stemi but has a poor prognostic features these patients need to be assessed and primary pan may be reasonable if you want to take them to cat lab and therefore we give that a class 2B now if they're come to and have have no stem on the ECG immediate corney is not recommended based on five different smaller trials going on to antiplate therapy during hospitalization as far as oral therapy goes everybody should get an aspirin it's a class one in patients the ACS initial oral loading dose of aspirin followed by daily lowd dose aspirin recommended to reduce death and maze and then you have to add a P2 Y12 inhibitor so P2 Y12 inhibitor is a class one indication the patient with ACS or P2 Y12 inhibitor should be administered in addition to aspirin reduced mace and then there's a contra indication to plastic is a class three if the patient had a history of stroke at TIA plastic should not be given now in terms of intervenous uh therapy a class 2B has been given to kangalore so among patients with ACS undergoing PCI who have not received P2Y12 inhibitor intervenous gangalore may be reasonable to reduce perial schemic events and such patient maybe those who are comos who have had a cardiac arrest or are vomiting on the table this drug could be used so it's a class 2B may be reasonable now what about introvenous glyoprotein 2B3 inhibitors it's a class 2A so in patient with ACS undergoing PCI with large thromis burden no reflow or slow flow adjunctive use of introvenous and then we added this time based on three small trials intraornary glyoprotein 2B3 inhibitor is reasonable to improve cer success reduced for size and class three for harm in patients ACS glyoprotein 23 inhibitor should not be administered routinely due to lack of schema benefit and increased risk of bleeding and previous the advantage of the potent P212 inhibitors The use of glyoportin TV3 is almost nil now what about oral p212 inhibitors in patient with stemi potent p2y12 inhibitor should be used so therefore we say in class one in patient stemi m with primary PCI practical tagore should be administered to reduce mace and strength thrombosis now in patients stemi m prime pci clitical is still recommended to reduce mace and st thrombosis when press and tag are not available cannot be tolerated or contraindicated and then patient stemi manual fillary therapy clopidal only should be administered to concurrently reduce death and wage because the bleeding risk with prostic really is quite significant patients who received fillary therapy and therefore chlorop is a drug given a class one indication what about patient non stemi ACS once again potent p2 vital inhibitors in patients non stemi ACS undergoing PCI plasagular is recommended use mace stem thrombosis blast one now there's a group of patients non STI ACS who have just managed conservatively with medical therapy only such as some elderly patients some or patients who have established coronary disease is not immenable to revascularization but still have a non- stemic these patients should get taggar to reduce mace and unless that's a possible indication once again when uh when when when can still be used to reduce mace when press or trigular are not available cannot be tolerated or contraindicated that's a class one now in some patient Nost ACS plan for invasive strategy with timing of angography anticipated to be greater than 24 hours upstream treatment of critical attack gag may be considered to reduce mace and this is a class 2B indication parental anticoagulation so if PCI is not immediately planned class one patient non stemacs invenous and fraction should be is useful to reduce schemic events again a class one patient non STEMI ACS in whom an early invasive approach is not anticipated either Oxar of funox are recommended as alternatives to infraction hepin for those patient to undergo vascularizations class one the patient ACS undergoing conneascization either with cabbage or PCI same admission parental anticoagulation should be continued until revascularation is completed to reduce the schemic events going on to PCI best to be performed in patients with ACS undergoing PCI introvenous infraction hepin is useful reduce schemic events in class One class one again in patients STEMI only undergoing PCI this was bright for trial a large trial balin is useful as an alternative to unfractured hepin to reduce mortality and bleeding and certainly this is very important patients who have hepin allergy or hit balin again is very useful for us it's a class one for class 2B in patient non stem ACS and PCI valid is given a lower rate as class 2B is maybe reasonable as an alternative to fracture help reduce bleeding And class 2B for inoxiperin intervenous enoxipin may be considered as an alternative to infraction hepin type PCI reduce schemic events and these are patients say may receive subq hepin during the hospitalization is maybe reasonable to convert them to enoxquipin for the procedure now class three harm in patients ACS funics should not be used sporti because of the risk of cath thrombosis what about priming PCI and stemming so the P does a patient have cardiogenic shock or hemodynamic instability and the answer is yes emergency revascularation of the corporate vessel of PCR cabbage is indicated to improve survival that's class one patient is not in shock and presents less than 12 hours if hospital transfer is not required perform priming PCI with goal to first contact device activation less than 90 minutes that's a class one if hospital transfer is required perform primary PCI with goal of first minute contact device activation less than 12 minutes as a class one if the time of presentation is 12 to 24 hours may still be reasonable to perform primary PCI to improve clinical outcomes this is a class 2A if it's more than 24 hours and the patient has ongoing schemic symptoms severe heart failure life-threatening arhythmias primary PCI still reasonable to improve clinical outcomes as a class 2A with patients having no symptoms and the vessels oluded primary PCI should not be performed due to lack of benefits class three what about corianderography and PCI after fibic therapy so patients chief fibbrolytic therapy you should transfer PCI cable center immediately after fability therapy is completed that's a class one if there suspected fail reperusion which means ongoing schemic symptoms persistent est segment elevation less than 50% resolution of ST segments in the anterior less or less than 70% of the fails or if they have hemodynamic electrical instability immediate angography rescue PCI is recommended to reduce the risk of death or recurrent MI if the patient has repused early angography is recommended within 2 to 24 hours with intent to perform PCI to reduce rates of death or MI that's a class one now what about non STEMIA ACS rational and timing for routine invasive or selective invasive approach just to remind folks that routine invasive means there's intention to revascularize during that hospitalization selective invasive means that you will perform non-invasive testing as risk ratification before we proceed to angel food so if the patient unstable with very high and a very high risk patient with shock or symptoms signs of heart failure including worsening m regurgitation and pipema refractory hemodynamic and electrical instability such as sustained VTOVF immediate invasive strategy less than two hours of less than between good less than two hours of the onset of these symptoms should performed as a class one indication if the patient is a high risk non semia with grace risk score greater than 140 that's again we listed in the document as a reminder to people steeply rising troponent values and dynamic SD sampling changes routine invasive again recommended with timing sooner than later generally less than 24 hours as a class 2A if the patient has a brace risk score which is intermediate between 109 to 140 absence of ongoing skin symptoms stable down troponent again routine invasive is recommended with timing of angography sooner than later generally before hospital discharge or less than 72 hours that's a class 2A low risk non STEMI ACS grace score less than 109 Timmy risk score less than two absence of ongoing schemic symptoms flat troponins no dynamic changes routine invasive or selective invasive recommended and you can again proceed with coronaryraphy prior to hospital discharge or you can risk ratify them during hospitalization of recurrent symptoms and then proceed to angography what about catlab considerations radial approach is preferred to femininal approach to reduce bleeding vascular complication and mortality as a class one new for these guidelines for coronary stent implantation left men corer and complex lesions intracornary imaging with IVIS or optical coherence tomography is recommended for procedural guidance to reduce schemic risk or eskeemic events and this follows a chronic coronary disease guidelines in Europe for ESC which suggest a class one recommendation for the same so imaging now is a class one indication throughout now one other thing with a class three among patients stem prime PCI manual aspiration throbectomy should not be performed uh routinely this of no benefit so management non-fated art and STEMI we try both for STEMI and non STEMI we made the recommendation this document aim for complete revascularization so stemi is multi- vessel disease patients cardiogenic shock perform primary piatric culpit vessel only do not perform into non fluctuated vessel the time primary PCI because a higher risk of death of renal failure that's a class three with the patient's hemody stable after he can be evaluated or she or she can be evaluated for cabbage after successful PCR of the infared artery elective cabbage for significantly stenos non-infarated arteries involving the LD proximal LD left main is reasonable that's a class 2A for those who have low complexity multivessel disease after successful PCR in front artery PCI of nonfarrated arteries is recommended to reduce rates of death or MI that's class one in our document we state that it should be staged procedure and not in the same setting however if patients have multiple PCR significantly snows nonfargated arteries the time of prime PCI the time of prime PCR we may approach it uh and prefer that over stage approach but we gave that a class 2B indication preferring that should stage this procedure rather than do it at the same time what about non- STEMI ACS again patient's cargenic shock do the corporate vessel only do not do a non-fated artery that's a class three if you are the patient hemodynamic is stable motor vascization cabbage or multivi based complexity in patients coorbidities the you can proceed with PCR significantly snows non-fated arteries reduce risk of death or MI improve as quality of life that's a class one and only non- STEMI to be add this portion physiological assessment non-corporate stenosis may be considered regard cardiovascular decision such as class 2B the strength was not that great to give that a class one recommendation now what about cabbage we didn't really give a guideline recommendation but just said cabbage is preferred for multivor PCI in the following situations includes significant left men disease complex left men disease with severe dysfunction complex and diffuse CAD diabetes involvement of the LD proximal LD now we revamped this section ACS and cardiogenic shock so once again class one patient with ACS cardic sharp hemodynamic instability emergency revasculation of the corporate vessel by PCI or with cabage is indicated to improve survival irrespective of time for symptom onset and generally sooner the better class three harm once again we said PCI of non-infrop should not be performed new for this section in terms of mechanical circuitary support class 2A and selected highly selected patient stemic and severe or refractory cardic shock insertion of microax of vascular flow pump or the impella device is reasonable to reduce death again this is a very selected group of patients now class three we expanded this then patient MI and carenic shock the routine use of inotic balloon pump once again routine use or routine use of via ECMO is not recommended due to lack of survival benefit we recognized over usage of via ECMO in this country without any survival benefit and there are three trials for radio which do not improve survival in the patient therefore the class three recommended recommendation for do not use these routinely what about DAP strategies default strategy for the first 12 months uh aspirin P2Y12 inhibitor particularly potent inhibitors such as TAGlor or press post PCI is preferred as class one in terms of bleeding reduction strategies you could still use data with aspirin taggel for the first month discontinue aspirin of the one to three months post PCI and be on single monotherapy with taggelore is class one if patients are oral anticoagulant with along with DAP discontinue aspirin one to four weeks post PCI and do a single agent a single monotherapy and that should be really be clitical and a roll antiquagin for the rest of a year another strategy for DAP was a class 2B if patients are on aspirin or ticular press you could deescalate potency of the P12 P2 vital inhibitor one month post PCI and just stay on aspirin at a low intensity P2 such as critical is a class 2B also for class 2B in high bleeding risk post PCI a patient with aspirin p212 inhibitor you can stop either the aspirin or p2 y12 inhibitor one month postci stay on a single agent with aspirin or p212 monotherapy finally electrical complication and prevention of cocardic death after ACS ventricle arhythmias in patient postMI an IC device recommended in selected patients with an LVF equal to less than 40% at least 40 days postMI and at least 90 days post revascularization reduce death there's a class one this is a old guideline and we just took it off from the 2017 AC HRS guideline so we did not change that terms of ventricle arhythmias another class 2A indications patient post ACS ICD implantation reasonable patient with clinically relevant ventricle arhythmias more than 48 hours and within 40 days postMI to improve survival now we gave a 2B in patient ventricle arhythmias early after MI usefulness of a temporary variable card defibrillator also known as a life vest device uh or other devices available in the market this is it's uncertain that you should use these devices particular patients with an LVF equal to less than 35% improved survival is class 2B what about brady arhythmias in patients presenting with an acute MI sustained evidence of second degree mob type 2 a block highrade AV block alternating bundle branch block or third degree AV block persistent or infernodal permanent pacings indicated that's a class run so thank you for your attention I'll stop sharing and hand it over to for her section all right thanks so I'm going to uh take over here from Tanvir and talk about some of the management outside of the kath lab and secondary prevention and then I'll wrap up with the take-home points so first things we know that in patients with ACS highintensity statin is recommended because uh randomized control trials have shown that there's an incremental benefit with reduction in mace with use of high intensity statins compared with moderate intensity statins for those who have LDL cholesterol levels above 70 uh we know that uh there is benefit in further reduction in mace when you add non-statin therapies so that is based on data from the improve it fouryear odyssey outcomes and clear outcomes trial where they enrolled patients who had LDL cholesterol greater than 70 now how about people who have LDL cholesterol less than 70 but we know that the addition of non-statin treatment is reasonable in and has been shown to further reduce mace events with a relative risk ratio of about 6% and again that's based on data from improve it where they added a zettoi to uh sveastatin uh and as well as from data from furry and odyssey outcomes where patients who had LDL cholesterols less than 50 had better outcomes without the negative effect of uh higher rates of hemorrhagic stroke muscle events or neurocognitive events what about beta blockers we know that all patients who uh have an ACS events who are hospitalized should be started on a beta blocker now there may be some reasons early on during a hospitalization where it may be contraindicated but really we included this here because we wanted to ensure that you revisit this issue prior to the patient being discharged from the hospital that you do consider getting them on a beta blocker if at least some of these initial uh clinical issues that prevented your adding the medication are resolved aces and ARBs are also addressed in this guideline patients who are high risk defined as those who have an EF less than 40% hypertension diabetes or presenting with a STEMI with an anterior inffort that an as ARB is recommended an MRA is recommended for those who have an EF less than 40% but have diabetes or are presenting with heart failure symptoms because that has been shown to have clinical benefit in reducing mortality and overall cardiovascular events what about anemia when they looked at studies of patients who had acute coronary syndrome they found that actually following a more liberal strategy of transfusing to a hemoglobin of 10 actually reduced cardiovascular events compared to what we typically see in those who are chronically ill or undergoing surgery where we transfuse to a hemoglobin of eight so this is a little bit different than what we typically do in our clinical practice and so I wanted to highlight that here that we're really um recommending transfusing to a hemoglobin of 10 and that's regardless of whether the patient has acute or chronic anemia um it is important that we are evaluating uh ejection fraction for patients prior to discharge and sometimes there are some challenges with getting this done um in uh the hospital but it really is important because we are trying to risk stratify those individuals who may benefit from sooner um evaluation within 3 months if their EF is low and then identifying those individuals who develop complications from ACS whether that's papillary muscle rupture or VSSD now these individuals will have clinical symptoms but we definitely want to define that and then more importantly you want to identify those patients who may have an LV thrombus as a result of their acute coronary inffort because this is really going to alter your medical therapy and this is important to know prior to discharge now what modality we use to um assess the EF is really left up to the clinician and that was really because um each hospital system may have um barriers to getting particular tests so you can do that using a cardiac MRI or an echo cardiogram but as long as you do this prior to discharge I'll let this move forward here so here we all know that cardiac rehabilitation is important for patients post ACS it has been shown to improve um uh functional status reduce morbidity and mortality it i I just want to remind the traineees on on the call that importantly it is more than just exercise training and we really need to be reinforcing this when we're talking to patients that this is more than just you uh presenting to have an individualized supervised exercise program here we're also talking about nutrition education we're talking about risk factor modification it's an opportunity to review medications as well to ensure adherence and identify any challenges that patients may be having and it really does provide some psychosocial support for the patients who have all experienced a very lifechanging event now while cardiac rehab is recommended not everybody will have access to cardiac rehab either due to geographics or financially they may not be able to afford the copay for cardiac rehab and so homebased cardiac rehab gets a class 2A recommendation and that's really just to ensure that everybody gets access to cardiac rehab it is important that we address clinical inertia we know that patients uh are started on statins that that is easy for us to do start them on high intensity statins in a hospital but then what happens after they leave uh we do see that there's a high rate of statin dis discontinuation whether due to perceived side effects or patients misunderstanding of their medication and so this is just a reminder that we a should be checking lipid uh levels 4 to 8 weeks after either initiation of therapy or addition of other lipid lowering therapies and then if the LDL cholesterol is high this is our opportunity to intensify therapy uh but if it is low please do not discontinue the statin and I have seen this uh many a times and I'm sure some of you have as well uh when I see my patients in clinic post acute coronary inffort coachesine uh it gets a class 2B recommendation in our guidelines um from the cold cut trial we saw that patients who were uh randomized to cultine plus guideline directed medical therapy versus medical excuse me um usual care alone that those who received lowd dose cultesine had a reduction in mace events and so it is recommended that you it is reasonable to consider the addition of cultine after ACS we do know that patients who have influenza are at increased risk for uh cardiovascular events and uh morbidity as well uh specifically influenza infection may contribute to aogenesis and plaque destabilization thereby precipitating an ACS event and so influenza vaccine has been shown to reduce the risk of death and mace and so that is why it gets a class one recommendation in our guidelines while we know that COVID infection pneumonia also increased risk of cardiovascular events and deaths in patients with ASCBD uh we there wasn't really enough randomized control data for uh patients specifically who had ACS for this to be included in the guideline now we do recommend that you follow national guidelines and CDC recommendations about the use of um pneumonia and COVID 19 vaccinations for all patients but specifically for ACS uh we recommend influenza vaccination within at least a year from the event and really we should try to do that during the hospitalization uh what about post- discharge followup and really um coordinating care in the outpatient setting we've talked a little bit about clinical assessments and referral to cardiac rehab really what I want to drive home here is addressing social determinance of health this is really our opportunity in the clinic to identify those barriers to medication adherence to um compliance or follow up with cardiac rehab identifying for patients if co-pay is an issue so you can connect them with um some resources so that they can get medications uh covered even if it's partially and then obviously engaging family members or whoever the patient identifies as a trusted um caregiver so that we make sure that the entire network that is caring for this patient has a good understanding of their cardiovascular uh disease and how to manage their care so I'll summarize by including some of these take-home messages from all of our sections here first and foremost dual antiplatelet therapy is recommended tagalar and Prazigal are preferred over clipil for patients who have uh ACS undergoing PCI 12 month therapy uh is what we're recommending for patients who has ACS so aspirin and whatever your choice of the P2i12 is continuously for 12 months unless they have a high risk for bleeding if they do have high risk for bleeding there are a number of strategies that we've included here in the guidelines that will help to reduce that risk whether you use a proton pump inhibitor transitioning to monotherapy with tiagraol after one month and for those who are on oral anti-coagulation discontinuing aspirin after 1 to four weeks and continuing with just a P2i 12 I've covered statin therapy again remember that if their LDL is above 70 uh please add non uh statin lipid lowering therapies more importantly it's reasonable to drive the LDL cholesterol even further because there is added benefit if you are going pursue an invasive approach um certainly for those who have non- STEMI who are at intermediate to higher risk of eskeemic events this is uh recommended and for those who are at lower risk further testing may be necessary to determine whether or not they would benefit from revascularization at that time a radial approach is preferred over femoral approach and intervascular imaging is recommended to guide PCI especially in those who have complex lesions complete revascularization as you heard from Tanvir is recommended whether you use cabbage or PCI really depends on the complexity of the disease and the comorbid conditions for your patient certainly for STEMI um PCI of uh other significant non-culprit lesions can take place whether at the same time or staged but c those patients who have ACS and cardiogenic shock we really should be focusing on revascularization only of the infraulated artery and deferring the non-infaculated arteries to another time microaxial flow pump is um can be beneficial for those patients who are presenting with MI and cardiogenic shock but we do need to take into consider consideration some of the risk um that come along with that so careful selection of patients is important as I mentioned transfusion for your ACS patient who has anemia uh has been shown to reduce cardiovascular events which should be transfusion to a goal of 10 remember to check the lipid panel of 4 to 8 weeks after initiation of statin or after addition of any other lipid lowering therapies uh let's uh address the clinical inertia that we're seeing so we can get our patients to go and prevent recurrent events and if your patient was referred to cardiac rehab in the hospital has not gone where you see them please reinforce that in the outpatient setting so with that I'll stop sharing and uh turn it back over to Puja all right great thank you so much uh for reviewing and summarizing all the key points that we needed to know about uh ACS and an update and congratulations to all three of you again and our reviewer for uh being involved in this i know it was a lot of work uh to be part of guideline writing committee so thank you so much and congratulations i'm going to open it up for questions i'm sure we have lots of questions and while we're waiting um I'll go ahead and ask um maybe this is for either Dr rab or um Dr easy Denzo but you know whenever we discharge patients on DAP are you going ahead and adding a PPI um you know for people because most of our patients I feel like they're they're at risk of bleed um but I wanted to hear your thoughts about that and which PPI do you typically um reach for generally no I do not generally I do not unless they have symptoms in hospital and you know I mean there is some u some slight baggage with using omarzol but but that's not really true so either you can use omarzol or pantiparasol a lot of people prefer pentiparasol but I I routinely don't do that thank you hi this isra I have a question for ei has the college addressed a dental hygiene for secondary prevention or is there any studies where patients were sent to u every six month dental care and if they did better as compared to people who had poor dental hygiene yeah no that's not addressed in this particular guideline we know that obviously poor hygiene also is related to poor cardiovascular health so overall we should be recommending um just as preventative strategies good oral hygiene for our patients but in the setting of acute coronary syndrome no that's not addressed in in this uh guideline does Dr spencer King have a question or a comment uh hold on yeah I was just trying to see in the dark so I could type it in is there was there any place for CTA in the in the in the whole process of the guideline no we didn't we didn't look into that because you know these are acute corary events of patients come in uh I mean it used it there used to be like a you know a push for CTA in the ER uh way back and I just wondered with CTA being was there any is it nowhere in other words if you're going to look at the coronairus it's all invasive in in every category Dr king that is uh that falls under the rubric of the 2021 chest pain guidelines uh which um include CTA as an option for for working up patients with chest pain who who are not having um who are not who do not end up with a diagnosis of an acute coronary syndrome so yes CTA is certainly in the armamentarium that falls under the rubric of the 2021 chest pain guidelines since you said that unstable anga is disappearing but that that's curious to me because I I thought in the diagnostic codes the unstable anga seem to have taken over and stable seem to have disappeared uh so this is an acute tideline i get I get it but uh the u the use of the of the coding of unstable angus seems to be there no no that is it is it is yeah I don't think I said it's it's becoming a less frequent diagnosis in the setting of high sensitivity troponent assays it's it's still a legitimate diagnosis i mean we still see patients who come in with chest pain some dynamic ST changes and you you treat them with unstable anga that that is a recognized entity and is covered in this guideline so in this guideline the gatekeeper is the tropparon i mean it seemed like that some of them that were covered in the guideline that they're categories where your tropponin is not elevated so they don't this this guideline does include it does include non-ST acute coronary syndrome both N STEMI and unstable angula they're those are both included we did have a challenge for a number of the recommendations where the um you know we tried to stay true to a lot of the trials and a lot of the evidence and many of them really only looked at N STEMI or STEMI and just simply didn't include unstable angula and so at every recommendation we had to decide whether to extrapolate them to unstable anga uh and that's sort of taken on section by section but unstable anga is a rec is is a recognized entity and is included in this guideline gotcha uh Stan Sherman uh can y'all comment on the patient who has atrial fib and chronic anti-coagulation to begin with uh is tyagalore and prael the best drug still or not i I think that um that the preference is not to have potent P2 Y12 inhibitors because increased bleeding risk and as I've showed you in the DAP diagram it's preferable to to after one month if you go on triple therapy with aspirin anticoagnant and a P2 vital inhibitor if you stop the aspirin the preference is to be on proper not on more potent inhibitors thank you have a question so if somebody comes in and let's say they're being discharged on Berenta and you know what if I I know that for the first 30 days we can try to get them if they don't have insurance or if they have reasons but then what happens after that because if DAP is recommended for 12 months and you say you're seeing them as an outpatient how do you convert um you know what from like Berenta to Plavix or you know I wanted to hear your thoughts about that no I think it's not uncount problem but but pridigil now is available generic okay so I think that's less of an issue and taggler may new future go generic as well but if you have to convert out to proper then we just would suggest taking overloading 3 m per and go and send five propal after that it's part of the dap therapy but we try to get an important inhibitor at least for one month or give a prescription somehow or the other through coupons the other to get at least the potent drugs for the first 30 days uh there's a question from Dr walker um is there guidance on uh P2Y12 inhibition testing for patients on flavix we talked about it but you know the we do not recommend any form of genetic testing or any kind of currently available testing in this in this document genetic testing is is probably more superior in the current testing format that we have but it's difficult to do and TDS and not commonly available so no in terms of we've just felt that people were patient potent P2 Y20 inhibitors you know the the gen testing probably not be of value this is really more of value patient on cropical only and if the aim is to try to get them to potent drugs for the first month you know where most of thrombotic events occur probably as you convert to cropical yes they you may have that question is effective or not but no we do not specifically recommend any form of testing for each of our basically cropical you know just a 360 Dr bear has a question do you recommend loading dose of plavix in ED for non- STEMI so so nowadays you know we don't do that we suggest that uh that when patients come to Kathlab you know the the timing of effect of these drugs is you know four to six hours after of therapy most of the time to address STEMI usually get through the STEMI so the drugs are not quite important we really rely on the anti-coagulation that's given them to tide them over the time period now in terms of non- STEMI no we do not make any specific recommendations to load that if you look at the diagram we put in in patients whom where it might be delayed more than 24 hours performing diagnostic angography may consider propet at that time that's a class 2B recommendation but not loading the ER i think Tala had a question also let's see what Tala has many beta blocker trials were before the modern era are there recent trials and or was there discussion regarding benefits in ACS without low EF yeah you know when I I don't remember the exact date of the references that we used but the bigger issues that we used that um most of the older trials also included the use of IV beta blocker uh in patients who had acute coronary syndrome and we really recommended that um that had a negative um benefit in individuals who had congestive heart failure and really focusing on oral beta blockers for individuals in the acute coronary syndrome um and importantly titrating those as hemodynamics allowed um and so that's that's where the weight of our evidence was is focusing on oral beta blockers and avoiding the use of IV beta blockers because of the um negative outcomes and side effects that occurred in patients when they did enroll them in the clinical trials for patients who had ACS randomized to beta blocker use i'm just looking at the second part of her discussion uh obviously um for those who had um yes though did include individuals who did not have low ejection fraction yes the other thing I just wanted to add puja just as we u maybe wait for additional questions is that you know there are ongoing trials of oral PCSK9 inhibitors and I think that's going to be beneficial because some of the challenges that we face are that in the hospital setting the only thing we're able to do besides escalating the dose of your statin if the patient comes on a moderate intensity statin we put them on a high intensity or we add a zettoide that's really everything else because everything else requires prior authorization and so that's deferred to the outpatient setting so maybe you know if we do get some oral PCSK9 inhibitors are available on the market those are things that we could start in the hospital because many of these trials have shown that if you actually add the PCSK9 inhibitor even very early after the ACS event um and some of these trials include people who they were started on PCSK9 inhibitor in the hospital that there was a significant reduction in MACE events and that actually improves adherence because we know that whatever the patient is on in the hospital they're more than likely to be taking that when you see them about a year later uh and so that's on on the horizon hopefully and you don't think that that Oh sorry i was just going to say you don't think that oral would require prior i think eventually initially it obviously will but you know down the line I think it will be beneficial when we can start adding these medications in the hospital setting joe could you address the issue of LPA because you got a lot of Yeah yes i see yeah you know um certainly those of us in the prevention world are flooding and hitting you over the head with checking lipoprotein A in patients we know that the prevalence of elevated lipoprotein is about 20% in the general population uh but two things number one um we should not be checking that in the setting of an acute coronary uh syndrome or acute coronary presentation for our patients because lipoprotein A levels um can be um not accurate in the setting of acute inflammation so that's number one we did not include that in our guidelines because we just don't have um any randomized control trial about lipoprotein A uh levels and lowering them in the setting of ACS more importantly there are ongoing studies right now that are looking at a variety of medications that have been shown to lower lipoprotein A anywhere from 80 to 90% but the outcomes trials uh data are not there so hopefully that will be on the horizon pun intended um but uh for right now we do recommend when I say we uh in the preventive cardiology world we do recommend checking lip protein a in everyone at least once uh but it is not included in this guideline due to the lack of data uh specifically with outcomes trials and ACS patients pton had a comment about the pier trial you know we didn't we we there was a hard stop to trials after the ACC because we already had prepared the document and waiting for important trials to come out at ACC 24 and we stopped after that because the document had to be ready to for for further review and publication but the way the guidelines will be as important trials come along and there's reason to change segments will be changed on a modular level because we've made this into modular sections and they change and the changes will be will be brought out and and brought out to the general membership in the public online from ACC as we as as we change it and crit has a question for you should we lower LDA below 55 just after MI or everyone has chronic cardiovascular disease yeah you know we tend in America to lag behind those who are in Europe where they set a uh target LDL level of below 55 and we know that the lower the LDL level the lower the risk of uh cardiovascular events and so in my practice I target lowering the LDL cholesterol level below 55 including in those who have not had an ACS event and and we really should be doing that we have enough uh lipid lowering therapies available at this time that we should be able to achieve target levels for those uh outside of those who have FH where it may be a little bit more challenging you need multiple therapies okay great if there's no other questions or comments we're right on time so thank you so much for staying on time this is amazing that we had three speakers and you guys stayed on time and we had plenty of time for discussion so I really appreciate that and thank you everyone for joining uh don't forget to get your CME and I will see you next week um thank you have a good week all right thanks for having us thank you the preceding program is copyrighted by Emory University