Cardiovascular disorders

I./4.6.: Therapy

I./4.6.1.: On-site, or primary medication

The therapy consists of two stages. The first one includes on-site care, which is decisive for the outcome. For that very reason, recognition of an acute infarction and initiation of acute care are mandatory for every doctor. Primary care includes in part the recognition of the disease and initiation of a medication, in part the appropriate managing of the patient. In case of a patient with STEMI the diagnosis should be established at the site, and also a decision should be made there on the place of the patient’s further care.

Inhibition of platelet aggregation: letting the patient to chew 250 to 500 mg non-enteric aspirin, if he/she has taken no aspirin previously, or administration of an intravenous aspirin preparation, as well as use of a P2Y platelet receptor blocking agent, what currently means the use of clopidogrel (the availability more effective preparations such as prasugrel or ticagrelor is very limited, primarily due to causes of financing). The dose of clopidogrel depends on the planned reperfusion therapy. If thrombolysis is to be performed, it is 300 mg; if an intervention with catheterization, so the recommended dose is 600 mg. No loading dose is used prior thrombolysis of a patient who is older than 75 years, or when no reperfusion therapy is planned at all. Clopidogrel treatment of these patients starts directly with the maintenance dose (75 mg).

In addition to platelet aggregation inhibiting therapy, after having ensured a venous access, an analgesic is administered, if needed an opiate (of the opiates, morphine preparates are preferred due to their beneficial hemodynamic effect, reduction of the preload). If the patient is not in a shock, or his/her infarction does not affect the right ventricle, so sublingual nitroglycerine should also be administered, followed by that in an intravenous infusion. Nitrate has a beneficial effect due to its analgesic, or if needed antihypertensive effects and by reducing the preload in case of a failure of the left heart.

In patients with an inferior infarction, the infarction of the right ventricle should also be thought of, and if this is confirmed, its administration is contraindicated, as a reduction of the filling pressure of the right ventricle may even lead to the development of a shock with a potentially fatal outcome. Due to their platelet aggregation-increasing effect, the use of non-steroidal anti-inflammatory drugs is strictly forbidden; and when the patient has taken such medication, it must be discontinued. While giving nasal oxygen and monitoring the patient; his/her immediate transport to a hospital should be organized.

I./4.6.2.: Hospital care

Timely reperfusion therapy is one of the main purposes of hospitalization.

I./4.6.2.1.: Hospital care of patients with STEMI

In patients with STEMI, regarding that there is a complete coronary occlusion, a cessation of that is necessary as early as possible. The most effective way for this is primary percutaneous coronary intervention (PCI). If a cardiologic laboratory that performs this intervention can be reached within 2 hours, the patient should be transported there directly from the site with an ambulance car capable for monitoring, defibrillation and resuscitation and controlled by an emergency paramedic/doctor. Based on the 2010 recommendation of the European Cardiologic Society for myocardial revascularization, in patients with STEMI a primary PCI is indicated not only within 12 hours, but also over 12 hours, if the patient has yet chest pain or ECG alteration suggesting ischemia.

Primary PCI is also indicated between 12 and 24 hours in patients who show no more chest pain. In patients with a cardiogenic shock there is no time limit (and also no age limit; the previous 75 years’ age is not mentioned any more in the novel recommendations). If no primary percutaneous coronary intervention is attainable within 2 hours, thrombolysis can be considered, on-site thrombolysis if the conditions are given. In case of an unsuccessful thrombolysis the patient should be sent to a rescue PCI already independently of any time limit. If the thrombolysis is successful, coronary angiography and PCI are also necessary, between 3 and 24 hours. (A PCI within 3 hours would be considered as a PCI facilitated by thrombolysis, which failed based on the studies ASSENT 4 and FINESSE).

I./4.6.2.2.: Hospital care of patients with NSTE-ACS

The up-to-date therapy of non ST elevation acute coronary syndrome (NSTE-ACS) is summarized by the most recent European recommendation of 2011. Patients should be divided to four groups according to indication and timing of the invasive assessment.

• (i) Patients belonging to the first group should be sent to a coronary angiography immediately, similarly to those with STEMI. These include patients with, in addition to NSTE-ACS, chest pain not responding to therapy, hemodynamic instability, or malignant arrhythmia, deep ST depression in leads V 2 to 4, indicating posterior transmural ischemia. In the latter patients a complete occlusion of the circumflex coronary branch (CX) can often be observed during coronary angiography.

• (ii) The second group includes patients with high risk, with GRACE scores over 140, based on the risk stratification of GRACE (Global Registry of Coronary Events), or have another high risk factor (biomarker positivity, previous coronary revascularisation, diabetes mellitus, impaired left ventricular function, impaired renal function). Based on the recommendations of the new NSTE-ACS guideline, in this group the performance of coronary angiography within 24 hours is advised.

• (iii) The third group includes patients with a GRACE score under 140, and although no risk factors, but with recurring thoracic complaints, or the loading test is positive. (It should be noted that the conventional methods of loading tests – bicycle ergometry or treadmill – are, due to their low sensitivity, not recommended for confirming/excluding coronary heart disease by the recent recommendations; methods of first choice include exercise echocardiography, scintigraphy, or perfusion MR examination, if available.) In this group the performance of coronary angiography within 72 hours is recommended.

• (iv) Finally, no invasive assessment is necessary at the beginning for the other patients.

When surveying the recommended invasive indications for patients with STEMI and NSTE-ACS, one can see that currently a significant part of patients with an acute coronary syndrome undergo coronary angiography and revascularization (including PCI). In patients with STEMI the revascularisation is almost exclusively percutaneous coronary intervention, and less than 1% of patients undergo CABG (coronary artery bypass grafting) surgery. About 10% of patients with NSTE-ACS undergo an emergency or urgent CABG operation.

This is explained by a difference between the two populations; in patients with NSTE-ACS a more extensive, two- or three-vessel-disease with multiple lesions is present in a larger part of patients, at the same time often no single lesion can be made responsible for the acute symptoms, and a healing is only attained by a complete revascularisation. The above detailed acute cardiac catheterization care should be considered as resolved in the decisive part of Hungary with the18 hemodynamic centers; the last larger “white spot” is to be covered by the starting work at the center of Gyula in 2013.

I./4.6.2.3.: Further hospital care

The tasks of the hospital (and then the rehabilitation) treatment include the initiation of medicinal „basis-therapy”: beta-blocker, angiotensin convertase enzyme-inhibitor (ACEI) or, if this is contraindicated, angiotensin receptor blocker (ARB), statin, aldosterone antagonist therapy in patients with an impaired left ventricular function, and the continuation of dual antiplatelet therapy.  Also here belongs the recognition and care of impairments and complications caused by the infarction, such as cardiac failure, arrhythmias, mechanical complications as a rupture of the mitral framework, perforation of the ventricular septum, rupture of a free ventricular wall (this latter is usually acute, but rarely a covered form of it, which causes no acute collapse of the circulation may also develop in the first weeks). The presence of any residual ischemia should be assessed during the hospitalization, and decision should be made on the necessity of a further revascularization.

I./4.6.2.4.: Rehabilitation

Rehabilitation is an extremely important part in the care of patients with an acute coronary syndrome; it includes a change of lifestyle, cessation of smoking, physical rehabilitation and further optimization of the medicinal therapy. In Hungary this is currently performed mostly in an inpatient setting, however there is an ever increasing demand for a more up-to-date, outpatient form of rehabilitation that facilitates the necessary early return of patients to their everyday lives. After that a regular cardiologic care and follow up are essential for, among others, establishing an appropriate understanding of the disease and ensuring compliance with the taking of medicines; in this field there are very serious shortcomings: according to data of the National Health Insurance Fund just 50% of patients who underwent an acute coronary syndrome take out a statin after a year following the event. Permanent complex cardiologic care and a development of it are essential for attaining a significant improvement in the cardiovascular morbidity/mortality in Hungary.