Optimizing treatment for ACS patient with 3 vessel disease & complete heart block

Optimizing treatment 
for ACS patient with 3 vessel disease 
& complete heart block 
Dinh Duc Huy, MD, FSCAI 
Nguyen Ngo Thanh Phuong, MD 
Tam Duc Heart Hospital 
HỘI NGHỊ KHOA HỌC TIM MẠCH TOÀN QUỐC 2015 
Case presentation 
• Mr. D C T, 63 years old 
• BMI 24 (H 170cm, BW 70kg) 
• Smoker (+), 50 pack years 
• Hypercholesterolemia (+) 
• HTN (+), DM (+) for 10 years 
• Chest pain sometimes 
• Weakness and fatigue on exertion 5 days before 
• Shortness of breath on admission day 
• Alert 
• No neurological sign 
• HR 37 bpm 
• BP 141/47 mmHg 
• RR 20 bpm 
• SpO2 96% 
• Regular S1, S2 
• Clear lungs 
• No lower limbs edema 
Case presentation 
• WBC 7.71k/uL 
• HGB 11.7 g/dL 
• PLT 171K/uL 
• Creatinin 222 umol/L, 
eGFR:27ml/ph/1.73m2 
• hs-CRP 4.3mg/L 
• AST 41 U/L ALT 25 U/L 
• Cholesterol 2.58 
• HDL-C 0.72 LDL-C 1.6 
• TG: 1.74 mmol/L 
• NT proBNP 9330pg/ml 
• hs-TnT 126.4->113.8 pg/ml 
On admission ECG 
 Monitoring ECG: BAV II intermittent BAV III 
Imaging findings 
Chest Xray 
• CTR: 0.5 
• Normal pulmonary 
vascularity 
Echocardiography 
• LVEF 73%; LV42/24mm 
• No RWMA; No thrombus 
• Moderate Aortic Stenois 
• Gd trans Ao= 42/14 mmHg 
• MR (+) 
• sPAP 25mmHg 
Vascular Ultrasound 
• Carotid: no stenosis 
• Normal ABI 
• Lower limbs arteries: 
 Right: 40-50%% 
stenosis of mid- 
superficial femoral artery 
caused by stable plaque 
 Left: 50% stenosis & 
diffuse stenosis after the 
bifurcation of the 
popliteal artery. 
TREATMENT: 
 TPM/PPM? 
 Coronary angiogram? When? 
 PCI/CABG before or after PPM? 
 Anti-platelet therapy? (Pretreatment? Clopidogrel or 
New drugs [Pasugrel/Ticagrelor] to be combined 
with Aspirin?) for how long? 
  
Case management 
DIAGNOSIS: 
 NSTEMI-HTN- T2DM-CKD 
 Intermittent BAV II-III 
1. The optimal timing of ticagrelor or clopidogrel for patients 
scheduled for an invasive strategy has not been adequately 
investigated, no recommendation for or against pretreatment 
2. Based on the ACCOAST results, pretreatment with prasugrel is 
not recommended (TIMI major bleeds were significantly 
increased in the pretreatment group at 7 days. 
Bellemain-Appaix A et al. BMJ 2014;349:g6269 
Pretreatment in NSTE-ACS + PCI (RCTs) 
TRANSLATE ACS Registry: 9251 ACS patients 
Thienopyridine naive, undergoing PCI- Real life PCI 
Effron MB et al. J Am Coll Cardiol. 2014;63(12_S) 
Recommendations for management of new bundle branch block and atrio-ventricular conduction disorders in ACS 
Euro Intervention 2014 
 Prompt opening of the infarct vessel is often sufficient to 
reverse new-onset ischaemic conduction disturbances. This is 
especially true for atrioventricular (AV) block in the setting of 
inferior infarctions. 
 Temporary pacing is indicated for symptomatic life-
threatening bradycardia not resolving after successful 
reperfusion and after medical treatment in the presence of 
high-degree AV block and intraventricular conduction defects. 
 Permanent pacing is considered for disturbances that persist 
beyond the acute phase after the myocardial infarction. 
Case management 
•TPM 
•TVD- SYNTAX score 22 
CABG or PCI 
For revascularization? 
Tỷ lệ biến cố tim mạch nặng 
theo điểm số SYNTAX score 
NEJM 2009; 360: 961-72 
CABGvs. PCI for 
patients with 
three-vessel disease: 
final 5-year follow up 
of the SYNTAX trial 
European Heart Journal 
doi:10.1093/eurheartj/ehu213 
Conclusion- 
Five-year results of 
patients with 3VD treated 
with CABG or PCI using 
the first-generation 
paclitaxel-eluting DES 
suggest that 
CABG should remain the 
standard of care 
Our patient treatment- 3 VD PCI with DES 
• TPM (+) 
• DES in RCA, LCx, LAD 
• Good result post PCI 
• All TIMI 3 flow 
• Normal sinus rhythm 
3 days after PCI 
Antiplatelet therapy for ACS patient 
1. Which is the best option of antiplatelet 
therapy for ACS patient undergoing PCI? 
2. Should we do pre-treatment? (perhaps NO) 
3. Can we give Ticagrelor for patient with 
complete heart block? 
4. How long should we prolong DAPT? 
CURE. NEJM 2001;345:494-502 
Fox et al. Circulation. 2004;110:1202-1208, 
CURE study- Corner stone for DAPT in ACS: 
Clopidogrel+ ASA are better than ASA alone 
Clopidogrel 
C
V
D
/M
I/
S
tr
o
k
e 
0.20 
4 
0.15 
0.10 
0.05 
0.0 
100 200 300 
PCI Group 
Placebo 
RR: 0.72 (0.57-0.90) 
Medical Rx Group 
Placebo 
Clopidogrel 
RR: 0.80 (0.69-0.92) 
0.20 
4 
0.15 
0.10 
0.05 
0.0 
100 200 300 
CV
D
/M
I/
St
ro
ke
0.20 
4 
0.15 
0.10 
0.05 
0.0 
100 200 300 
CABG Group 
Placebo 
Clopidogrel 
RR: 0.89 (0.71-1.11) 
CV
D
/M
I/
St
ro
ke
RR 0.80, p<0.001 
Clopidogrel 
(9.3%) 
Placebo 
(11.4%) 
C
V
 D
e
at
h
, M
I, 
S
tr
o
k
e 
Months of follow-up 
 0 3 6 9 1
2 
0.0 
0.02 
0.04 
0.06 
0.08 
0.10 
0.12 
0.14 
Wiviott et al. New Eng J Med 2007; 357 No benefit with prior stroke, age > 75, weight < 60kg 
• Multicenter, double-blind, 
randomized trial 
• 18,624 ACS patients 
• Ticagrelor (180-mg loading 
dose, 90 mg twice daily 
thereafter) and clopidogrel 
(300-to-600-mg loadingdose, 
75 mg daily thereafter) 
Wallentin L et al. N Engl J Med 2009;361 
02
4
6
8
10
12
14
16
0 60 120 180 240 300 360
Same major bleeding with Ticagrelor vs. Clopidogrel 
in PLATO study 
HR: 1.04 (95% CI, 0.95–1.13) X
u
ất
 h
u
yế
t 
n
ặn
g 
ch
u
n
g 
 (
%
) 
10 
5 
0 
15 
0 60 120 180 240 300 360 
Clopidogrel 
Ticargrelor 
11.2% 
11.6% 
P= 0,43 
X
u
ất
 h
u
yế
t 
n
ặn
g 
ch
u
n
g 
 (
%
) 
Clopidogrel 
Ticagrelor 13.4% 
12.6% 
P= 0,26 
Major bleeding in PLATO 
Major bleeding in 
NSTE-ACS subgroup 
1. Lindholm D, et al. J Am Coll Cardiol 2013;61(suppl 10):Abstract 901–903. 
2. Wallentin L et al. N Engl J Med 2009;361:1045–1057 
HR: 1.07 (95% CI 0.95–1.19 
PLATO- Bradycardia Events 
Wallentin L et al. N Engl J Med 2009;361 
 Holter monitoring during the first week in 2866 patients 
 Repeated at 30 days in 1991 patients 
 Higher incidence of ventricular pauses in the 1st week, but not 
at day 30; pauses were rarely associated with symptoms 
 No significant difference to the incidence of syncope or 
pacemaker implantation 
Methods 
7-day cECG recording initiated at the time of randomisation, which 
was within 24 h of symptom onset, and then repeated at 1 month 
after randomization during the convalescent phase. 
The principal safety endpoint was the incidence of ventricular 
pauses lasting at least 3 seconds. 
J Am Coll Cardiol 2011;57:1908–16 
J Am Coll Cardiol 2011;57:1908–16 
cECG Assessment Patient CONSORT Diagram 
Arrhythmias at Visit 1 (Week 1) and 
Visit 2 (Day 30) for All Patients 
 More ventricular pauses ≥3 s in patients assigned to ticagrelor 
during the first week (5.8% vs. 3.6%; p=0.006) 
 At 1 month, pauses ≥3 s were less and similar between treatments 
(2.1% vs. 1.7%) 
J Am Coll Cardiol 2011;57:1908–16 
J Am Coll Cardiol 2011;57:1908–16 
• Week 1: 70 patients 
(3.2% ) had 1 pause, 20 
(0.6%) had > 4 pauses 
• 1 month: 9 patients 
(0.05%) had 1 pause, 17 
(0.8%) had > 4 pauses 
• There is a nocturnal 
excess of pauses among 
patients assigned to 
ticagrelor, with a peak in 
the frequency of 
ventricular pauses at 
night 
Other findings 
Study conclusions 
1. More patients treated with ticagrelor compared 
with clopidogrel had ventricular pauses, which were 
predominantly asymptomatic, sinoatrial nodal in 
origin, and nocturnal and occurred most frequently 
in the acute phase of ACS. 
2. There were no differences between ticagrelor and 
clopidogrel in the incidence of clinically reported 
bradycardic adverse events, including syncope, 
pacemaker placement, and cardiac arrest. 
J Am Coll Cardiol 2011;57:1908–16 
Our patient treatment 
1. In hospital 
 Ticargrelor (180 mg loading & 90 mg bd) 
 ASA 81mg qd 
 Atorvastatin 20mg qd 
 Lisinopril 10mg qd 
 Amlodipine 5mg qd 
2. Low dose beta blocker started during follow up 
3. Well, so far, 3 months after the index event, no 
chest pain, no sign and symptoms of HF; ECG 
maintains normal sinus rhythm 
DAPT for how long? 
A 1-year durationof DAPT with clopidogrel was associated with a 
26.9% RRR of death, MI or stroke (8.6% vs. 11.8%; 95% CI 3.9, 
44.4; P= 0.02) vs. 1-month DAPT in CREDO trial 
2015 ESC 
guidelines for the 
management 
of ACS in patients 
presenting 
without 
persistent ST-
segment 
elevation 
European Heart Journal 
doi:10.1093/eurheartj/ehv320 
Stronger antiplatelet therapy beyond 1 year in 
prior MI or angiographic-proven CAD 
European Heart Journal doi:10.1093/eurheartj/ehv377 (August 2015) 
Conclusions 
1. Early invasive strategy for high risk ACS. 
2. Revascularisation is often sufficient to reverse new-
onset ischaemic conduction disturbances. 
3. No clear benefit of pretreatment antiplatelet therapy. 
4. Treatment with ticagrelor (vs. clopidogrel) significantly 
reduced the rate MACCE without increasing the overall 
major bleeding or bradycardic adverse events. 
5. DAPT for 12 months after ACS. Need careful assessment 
of the ischaemic and bleeding risks if plan to prolong 
DAPT duration. 
Thank you for your attention!