AN UPDATE ON ACUTE CORONARY SYNDROME

The theme of the scientific session was the current trends in the management of acute coronary syndrome. Dr. Rony Mathew, Dr. Moosa Kunhi and Dr. Jabir A,
from Lisie Heart Institute elaborated on current management of acute coronary syndromes. The informative deliberations helped the audience in updating themselves on this very important problem. Acute Coronary Syndromes comprise a group of disorders on a common pathophysiological platform. Unstable Angina (UA), Non ST elevation Myocardial Infarction (NSTEMI) and ST elevation Myocardial Infarction (STEMI) are the different manifestations of acute coronary syndromes.
Atherosclerotic plaque rupture, platelet aggregation and intracoronary thrombus formation is the pathological basis of acute coronary syndromes. An intracoronary thrombus can either be an occlusive or a non-occlusive thrombus. An incomplete thrombotic occlusion of the coronary artery leads to UA or NSTEMI. A complete occlusion of coronary artery by an intra-luminal thrombus leads to STEMI. Ischemia leading to myocardial injury as evidenced by elevated enzymes is the hallmark of Myocardial Infarction. Myocardial Infarction without ST elevation in ECG is NSTEMI and it is STEMI, if the ECG shows ST elevation. Acute coronary syndrome without evidence of myocardial injury is Unstable Angina. Dr. Rony Mathew, Head of the department of Cardiology, Lisie Hospital, spoke on the management of UA and NSTEMI. He described the pathophysiology of acute coronary syndromes. According to him risk stratification is very crucial in therapeutic decision-making and TIMI risk score is accepted worldwide in risk stratification. The risk stratification begins at the time of consultation and continues through the hospital course to the time of discharge. Clinical feature, cardiac enzymes & ECG changes are the tools utilized in risk stratification. The management is medical management or percutaneous coronary intervention (PCI) along with medical therapy. A combination of Aspirin and Clopidogrel is the standard antiplatelet therapy in all-acute coronary syndromes. High-risk group benefits from glycoprotien IIb IIIa inhibitors especially if PCI is planned. Current evidence favour the use of low molecular weight heparin and the data is in favour of enoxaparin. Other adjuvant drugs are Nitrates, Betablockers & Statins. Multiple large trials have shown the beneficial effect of high dose statin in Acute coronary syndromes and they are now mandatory in therapy. The high-risk patients are at risk of death, myocardial infarction and recurrent angina despite medical therapy. Dr. Rony stressed the need for an early invasive strategy in this high risk group. He presented the latest
data on early invasive strategy in acute coronary syndromes, which clearly shows a definite edge over medical therapy alone. He told that high-risk patients should be taken up for Coronary angiogram within 24 hours of UA or NSTEMI and they should undergo PCI if the coronary anatomy is suitable. Dr. Jabir A, from department of cardiology of Lisie hospital spoke on “Update in the management of STEMI”. He focused on percutaneous transluminal coronary angioplasty (primary angioplasty) in STEMI. Meta analysis of 23 trials in STEMI had shown the short term as well the long-term benefit of primary angioplasty in STEMI. Thrombolytic therapy, is time tested with proven efficacy, but has limitations. Once third of patients do not achieve reperfusion with thrombolytic therapy
and one third of the successfully reperfused patients develop reocclusion within 3 months. Most of the limitations of thrombolytic therapy are overcome by primary angioplasty. Hence if facilities are available, then primary angioplasty is the reperfusion of choice in STEMI. Trials have also shown the benefit of transporting patients with STEMI to centers with PCI facilities for primary angioplasty, rather than thrombolysis at the primary center. Rescue angioplasty is the treatment of choice in failed thrombolytic therapy or post infarction angina. He stressed that early institution of proper reperfusion therapy, is the key to successful management in STEMI. Dr. Moosa Kunhi, Head of the department of Cardiothoracic Surgery, Lisie Heart Institute presented the data on off pump Coronary Artery Bypass Grafting (CABG). He stressed on the benefits of off pump Coronary Artery Bypass Grafting and a video demonstration gave the audience an overall picture of this complex surgery. A Hybrid procedure combining CABG and PCI is likely to be the future treatment in coronary artery heart disease.