Acute Coronary Syndromes - Chronic Management Flashcards
Treatment goals for post-ACS
A. Lifestyle choices
1. Smoking cessation
2. Healthy diet
3. Regular exercise
4. Healthy weight
5. Psychosocial
B. Cardioprotection
1. Anti-thrombotics
2. Lipid lowering therapy
3. Cardiac remodelling prevention
- Beta blockers (controversial)
- Nitrates and CCB (no benefits)
- ACEI/ARBs
- MRA
4. Vaccinations
5. Medication adherence
C. Treatment targets
1. BP < 130 / 80
2. LDL targets < 1.4 mmol/L
3. HbA1c < 7%
Lipid lowering targets post-ACS
ESC 2023:
- LDL-C < 1.4mmol/L (< 55mg/dL)
- 50% or more LDL-C reduction from baseline
AHA:
- LDL-C < 1.8mmol/L (< 70mg/dL)
Newer research shows that patients who suffers from second CV event within 2 years may benefit from even lower LCL-C target of < 1.0mmol/L
Lipid lowering therapy trials in ACS
- High intensity statins - achieves 50% reduction
- Atorvastatin 40mg ON
- Rosuvastatin 20mg ON - IMPROVE-IT trial (ezetimibe)
- Ezetimibe 10mg OM early within 10 days ACS is safe and provided long-term benefits for CV outcomes
- Recommended for:
A. High LDL-C levels (>5) unlikely to reach target with statin therapy alone in no prior statin treatment
B. Failure or expected to fail to reach target despite maximally tolerated statin dose - ODYSSEY OUTCOMES (alirocumab PSCK9i)
- iInitiated as early as 1 month after ACS who failed LDL-C goal despite statin and ezetimibe
- Improvements in plaque phenotype and plaque regression in ACS patients treated with PCSK9 inhibitors
Beta blockers post-ACS
(Ongoing controversy on EF and duration)
Traditionally:
RCTs in 1980s pooled data demonstrated that post-MI beta-blocker therapy reduced the risk of death by >20%
Problems:
1. Pre-reperfusion era
2. Pooled data of STEMI and NSTEMI
3. Pooled data of preserved and reduced EF
Contemporary trials showed benefits in reduced EF but not preserved EF
A. CAPRICORN trial (Carvedilol post-infarct <40%)
- Cardiovascular mortality, all-cause mortality or nonfatal MI was lower in the carvedilol arm
- Coprimary endpoint of all-cause mortality was lower in the carvedilol arm but not statistically significant
B. REDUCE-AMI trial (Swedish registry)
- Beta-blockade with metoprolol or bisoprolol was not associated with decreased all-cause mortality or future AMI compared with usual care
–> Ongoing trials on preserved EF: REBOOT-CNIC, BETAMI, DANBLOCK
Duration of beta blockers - benefits restricted to 1 year
A. FAST-MI (French registry)
- Early β blocker associated with reduced 30 day mortality in ACS
- BUT discontinuation of β blockers at one year was not associated with higher five year mortality.
B. Ongoing trials to evaluate cessation after 6-12 months
- ABYSS trial, SMART-DECISION trial
Nitrates and calcium channel blockers in ACS
(No survival benefits)
Usage mainly for control of residual angina symptoms, with no survival benefits
A. ISIS-4 trial
- Oral nitrates had no survival benefit in MI patients
B. Extensive trials (total 28) on CCB
- No prognostic benefits
- Symptomatic for residual angina and for blood pressure control
ACEIs, ARBs in ACS
(ARNI has no benefit)
A. Very extensive trials and benefits in trandolapril, captopril, perindopril (EUROPA study), and ramipril (AIRE study)
- Improve outcomes in post-MI patients with additional conditions, such as clinical HF and/or LVEF ≤40%, diabetes, CKD, and/or hypertension
B. VALIANT trial (Valsartan)
- valsartan non-inferior to captopril in patients with a recent MI plus HF and/or LVEF ≤40%
C. PARADISE-MI (ARNI) - superiority in reducing HF
- Involves recent ACS (1–7 days) complicated by HF and/or LVEF ≤40%
- ARNI not associated with a significantly lower incidence of death from CV causes or incident HF
Mineralocorticoid receptor antagonist (MRA) in ACS
A. EPHESUS (Eplerenone with HF)
- Reduced mortality and CV hospitalizations in recent MI and LV dysfunction with symptoms of either HF or diabetes
B. REMINDER (Eplerenone without HF)
- Safety And Efficacy Of Early Treatment With Eplerenone in ACS without HF
- Significant reduction in the primary composite endpoint (study skewed positively by BNP reduction)
SGLT2i in ACS
SGLT2i efficacy well established in HFpEF and HFrEF
(EMPA-REG, DAPA-HF, EMPEROR-PRESERVED, EMPEROR-REDUCED)
Ongoing studies on SGLT2i in ACS
A. EMMY trial (empagliflozin in myocardial infarct)
- NT-pro BNP reduction over 26 weeks post-MI
- Significant improvement in echocardiographic functional and structural parameters
B. EMPACT-MI trial (empagliflozin)
- No significantly lower risk of first hospitalization for heart failure or death from any cause
GLP1 receptor agonist in prevention of ACS
- ELIXA (lixisenatide)
- LEADER (liraglutide)
- SUSTAIN-6 (semaglutide) and PIONEER 6 (oral semaglutide)
- EXSCEL (exenatide)
- Harmony Outcomes (albiglutide)
- REWIND (dulaglutide)
- Reduced MACE, CV death, all-cause mortality, MI, and stroke by 12%
- No increase in risk of severe hypoglycaemia, pancreatitis, or pancreatic cancer
- No statistically significant heterogeneity across subgroups
Vaccination in ACS prevention and post-ACS
Recommended for all ACS patients and should be given preferentially during index hospitalization
A. ACS prevention in stable ASCVD
- Reduced incidence of MI, improved prognosis in patients with HF, decreased CV risk in aged 65 years and older
B. FLUVACS study - influenza vaccination given early after an MI or in high-risk CAD
- Lower risk of all-cause death and CV death at 12 months
Emerging studies on colchicine
A. Colchicine Cardiovascular Outcomes Trial (COLCOT)
(similar to CONVINCE in stroke)
B. Low-dose Colchicine trial-2 (LoDoCo2)
A. COLCOT with low-dose colchicine (0.5 mg daily)
- Significant reduction of the primary composite endpoint (CV death, resuscitated cardiac arrest, MI, stroke, or urgent revascularization)
- BUT - higher incidence of pneumonia
B. LoDoCo2 trial
- Significantly lower primary endpoint rate (composite of CV death, MI, stroke, or ischaemia-driven coronary revascularization)
- BUT - non-CV death was higher
Anti thrombotic
ISIS 2
CURE
TRITAN TIMI and PLATO
