New Guidelines on Acute Coronary Syndromes: Key Takeaways for Cardiologists

Podcast Transcript

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Venugopal Menon, MD:

Hi, good morning. My name's Venu Menon, and I'm the director of the Coronary Intensive Care Unit at Cleveland Clinic. This past year, we had the new ACC/AHA guidelines on acute coronary syndrome, which is a much-awaited document, because the last one was published way back in 2013. Dr. Tamis-Holland here on my right, an interventionalist at the Cleveland Clinic, and myself had the privilege of being co-authors on this document.

We are joined today by Dr. Donna Kimmaliardjuk, one of our cardiovascular surgeons who really specializes in using arterial conduits for bypass surgery. We thought we’d discuss some of the salient features about the guidelines in this discussion today. So, I might start with you, Jackie. What was unique about the guidelines this time around, as compared to previous reiterations of the same?

Jacqueline Tamis-Holland, MD:

Yeah, so I think there are two big things. The first is that we combined the STEMI and the non-STEMI documents into one document. The reason for that is because a lot of the assessment, the initial assessment, and the subsequent care is very similar, and much of the evidence-based to support care is very similar across the acute coronary syndrome spectrum.

The other thing that's interesting is that we really intentionally chose, unlike the European Society of Cardiology Guidelines, we intentionally chose to focus only on patients with type 1 infarction, so those patients with plaque rupture or plaque erosion. So, patients with perhaps SCAD or perhaps coronary embolism or vasospasm, the evidence base is really not there, so our focus is on treating patients with type 1.

Venugopal Menon, MD:

I know one of the things that we've really moved to now is, both in the setting of STEMI and non-STEMI, we're really realizing the importance that all of the patients come with an index infarction and revascularizing that index infarct is critical. The importance of the non-infarct vessels and the stenosis in them, in terms of both short-term and long-term events, is significant, and the data is strongly suggestive of that. What is your feeling about how the guidelines address the non-infarct vessel in both the STEMI and the non-STEMI situation?

Jacqueline Tamis-Holland, MD:

There's a wealth of data regarding how to manage the non-infarct artery in patients with STEMI. Over the last 10 years, we've literally done a complete change in our approach. It used to be a class three, and now it's a class one indication to do multi-vessel PCI routinely for patients with non-infarct artery disease. When you do it, the guidelines would suggest it can be done either at the time of primary PCI or as a stage procedure, with a little bit of favoring of doing it at the time of primary PCI based on some more recent data. But for the most part, they encourage multi-vessel PCI if patients have appropriate anatomy.

Interestingly, they do give a 2A recommendation to say that if you have complex anatomy, this class one recommendation doesn't apply, and the patient should be considered for surgery. So if you did a PCI of a right coronary artery occlusion and they have complex left main disease, we are not saying that they should be getting multi-vessel PCI of the left main disease. There should be a discussion about what the best treatment is. For non-STEMI, and I'm going to let Dr. Kimmaliardjuk talk more about this. We actually struggled a lot because the vast multi-vessel PCI should be done in appropriate patients who have multi-vessel disease, but there’s a large body of patients who have multi-vessel disease that are more appropriate for a bypass surgery. Since this isn't a time-sensitive procedure as in STEMI, where you have to get the artery open immediately, we give a class one recommendation to say first have a heart team discussion, decide with the best modality for treatment is and then consider it. So Donna, why don't you tell us about that?

Donna Kimmaliardjuk, MD:

Yeah. Well, I think that that's the key is the whole heart team discussion and that's something that you and I have been heavily involved in establishing here, and is so beneficial for the patient, obviously foremost, but for the team too, to understand each other's decision making and what goes into our decision making and our thought process and what factors we're considering for CABG or for multi-vessel PCI in these patients who have non-STEMI.

Venugopal Menon, MD:

Up to 15% of people in clinical trials of non-STEMI ECS undergo index bypass surgery in that setting. That's especially important for those who are diabetic, who have decreased LV function, multi-vessel disease, CABG in the long run certainly wins out in terms of reducing recurrent MIs and death. So surgeons are still in the game here, Donna, in that perspective.

Jacqueline Tamis-Holland, MD:

I would say, actually the flip side of it is, is that if you look at the studies comparing multi-vessel PCI to CABG, so all of those studies from years ago, about 30 to 40% of them were in ACS. So, the inclusion criteria for those patients where they could have had an ACS, and so we should not be always thinking multi-vessel PCI on every non-STEMI.

Venugopal Menon, MD:

Now, one thing that actually has implications on the surgery side, but also definitely in the cardiology side is the use of dual antiplatelet therapy in this setting. So, more and more, the guidelines now probably shirk away from using initial dual antiplatelet therapy, two-way indication when angiography is done within 24 hours after initial presentation. What do you think about those changes, Jackie?

Jacqueline Tamis-Holland, MD:

Yeah, I think they're really important. We weren't as strong as the ESC. We gave it... It was a 2A or 2B. I thought it was a 2B.

Venugopal Menon, MD:

2B.

Jacqueline Tamis-Holland, MD:

But yeah, I thought it was a 2B. We basically say that the data doesn't suggest, in the current stage of contemporary PCI, that patients really derive a huge benefit from upfront loading. And that if you're going to go for cath, which is pretty much angiography, which is pretty much within 24 hours, most of the patients go with the 24 hours, it really should be not loaded in case they have triple vessel disease, they can get surgery in a timely manner. If for some reason there's going to be a delay in angiography then it might be appropriate say load those. I think that's where the 2B comes in, that if there is a delay to angiography, preloading may be appropriate.

Venugopal Menon, MD:

Donna, from your perspective, when you do see a patient who's come in with a non-STEMI, we've loaded them with a dual antiplatelet drug like Clopidogrel or Ticagrelor, what is your approach to that patient, 1) in a very urgent patient who's hemodynamically unstable, and 2) in the patient who's otherwise doing well and can certainly wait to get their surgery.

Donna Kimmaliardjuk, MD:

Those are obviously much easier when they're doing well and they can wait so you can let for that washout, depending on what agent. Ticagrelor, I prefer three days, Clavix, five days. Again, it's going to be surgeon to surgeon preference, but that's usually fairly safe. That's ideal because even when I do this off pump, there's still that risk of bleeding from the mammary bed or from the vein harvest site or the radial harvest site or your anastomosis. So, there is a bleeding risk, but of course in those patients where they are sick, we do not have that luxury of time, as I say.

I have taken and will take patients more urgently. Ideally, if I can wait 24 hours from their last Ticagrelor dose, I find that does help make the bleeding much more manageable intra-op, that we can do it safely. So, it becomes down to, again, that risk benefit in every case and really that discussion between the attending cardiologist, the interventional cardiologist, if it's not under an interventional cardiologist and the surgeon, to really decide together what do we think is safest for the patient to A) open up the vessel and give them a good result, but B) without putting them at extreme risk.

Venugopal Menon, MD:

That's great. And the other part, which was unique to these guidelines, because we've always talked about mechanical complications in the setting of MI, which is really a significant challenge, although we've been lucky in that the incidence of that is really going down. For the first time, the guidelines really emphasize that these patients really belong in a surgical center. If they present to a small community hospital, they should come to a surgical center just because, at the end of the day, they probably do need definitive repair and they need a real discussion on if they need support. What is the optimal time of surgery? And how do we do it in this current era? So, what do you think about that recommendation, Donna, in terms of really emphasizing the importance of having surgeons by the bedside when we do see mechanical complications?

Donna Kimmaliardjuk, MD:

You've touched on all those great points. Absolutely, I think that's really important. I'm really glad the guidelines have addressed that in this most recent iteration because we do see that we're able to get these incredibly sick patients, whether it be papillary muscle rupture, VSD, these mechanical complications from an MI, we're able to get them through an operation when you have a center that deals with things like Impella all the time, or has a shock team available where the cardiologist and the surgeon and the perfusionists and ICU are all available to get the patient here safely, quickly, assess what needs to be done, get an OR ready quickly.

So, I think that's absolutely a thing that I support in the guidelines. I think we know that the data is showing that there are good outcomes. We, I think, know that we have good outcomes when we can get patients here and either upgrade them to an Impella 5.5 if they're on a CP or expedite an OR or support them with complex PCI if they don't have a mechanical complication. But absolutely, I think that's an important thing for patient outcomes to get them to a center of excellence where you have a cardiac surgery team that is capable of addressing the mechanical complications.

Venugopal Menon, MD:

The other vulnerable population with MI that we really haven't made too much of a dent in is the patient with cardiogenic shock. The last time we really had a breakthrough was with the SHOCK trial, which showed that early revascularization saves lives in this population. But it's been two decades since, and then we suddenly have the DanGer trial where with the micro-axial flow pump, in very select patients with shock, those who are not comatose after a cardiac arrest, the use of this device does appear to save lives with adjunct revascularization.

I think folks were really hoping you would have a randomized clinical trial, it's a breakthrough, it's saving lives, class one indication, and Jackie, you end up giving it a 2A.

Jacqueline Tamis-Holland, MD:

[laughter] It wasn't just me.

Venugopal Menon, MD:

Talk a little bit about it.

Jacqueline Tamis-Holland, MD:

Yeah. So that was a big struggle. We had some difficulty deciding for exactly that reason. We think of a class one recommendation as one in which there's perhaps a mortality benefit and DanGer Shock showed a mortality benefit. But you also have to weigh all of your recommendations against the potential for risks, and there was significant risk. There was an increased risk for renal replacement therapy, vascular injury, bleeding and other complications. I think that the balance is that it's in the finish line. There's probably going to be increasingly more data to support it, but we didn't feel it was enough to give it a class one at the time, given the potential risks.

But I do think that on an individual patient basis, you’re going to consider, you’ve got someone with a lactate of eight and their blood pressure's really low. You’re going to almost certain give it. You've got someone who’s 85, who's a high bleeding risk, who has a lactate of two perhaps, or 2.5, or something that would meet the inclusion criteria for DanGer Shock, perhaps you're going to try to support them a little bit first with medical therapy before you do that.

I want to ask you both, because you're both the shock experts, tell me about the use of MCS as a bridge to surgery and mechanical complications?

Venugopal Menon, MD:

I'll let Donna speak a little bit more about it. Having worked in a center with very experienced surgeons, clearly if you have a mechanical complication, you need to fix it as soon as possible. But when a really experienced surgeon tells me, "Listen Venu, I want to do this case, but the substrate is just too brittle, and the patient is too unstable for me to cross this bridge right now." I have to respect that opinion, especially coming from a person who I know has the experience to fix it.

The only solution there is, can we buy ourselves time? Because, clearly with time, there's healing, the inflammation subsides, there's granulation tissue, maybe the sutures stick a little better, maybe end-organ injury improves. So these support devices that we have, when used elegantly, and by elegantly, I mean, looking at where is the lesion, what is the ventricle that needs to be supported, can we get this person vasopressors and support the circulation. I think we can buy time. And in those people that we can buy time, I do think that a surgeon feels much more comfortable having 1) a strategy of primary repair, and 2) in case primary repair does not succeed, working with heart failure transplant colleagues to know, is there a possibility for a durable VAD in this situation?

Could this be one of those unique patients which we do once or twice a year, who might be a primary transplant patient in the absence of success. So, as a cardiologist, I am committed to buying myself time till my surgeons get the confidence to make that decision. That's the way I look at it.

Donna Kimmaliardjuk, MD:

Oh, yeah. Oh, absolutely. The use of things like Impella have really changed the game from even just when I started training just over 10 years ago to now staff, it has been a game-changer in allowing us to let the patient have some recovery and specifically let that tissue recover so you can actually have some fibrosis of that VSD that you can actually put your sutures to something that will hold. We've all seen where we try to do a repair, and the tissue won't hold the sutures, the patch fails, they're back with the VSD. So if we have the Impella and the appropriately selected patients who are stable enough to wait things out, let that tissue recover for a week or two, it's been a game-changer for us on the surgical side.

Venugopal Menon, MD:

Now I'm going to ask Jackie a philosophical question as we come to an end. Obviously, guidelines are really important. We are summarizing the data, summarizing the evidence, giving the best case scenario recommendations for our clinicians, but knowledge keeps evolving, right? So, the first thing is, let's say the area of beta blockers, we give a 1A indication based on the preponderance of data. Since the trial, data is continuing to emerge about +/- what the role of beta blockers are.

Let's say with dual antiplatelet therapy and bypass surgery, using not great data from CURE and other sub-studies, we gave a class one indication for DAPT in the guidelines post-CABG, but since then we've had the TACSI trial showing absolutely no benefit of Ticagrelor plus aspirin versus aspirin alone. How do we keep the guidelines a living document? So that when a clinician comes up and asks the question, it's actually relevant data, because what we just said four months ago certainly may not be as true even today.

Jacqueline Tamis-Holland, MD:

Yeah, that's a great question, and I think that we struggle with that, especially when a major new trial comes out, that clearly shows a deviation from standard of care and from the guidelines in terms of how we approach things. As clinicians, I think we need to balance the guideline recommendations, while recognizing that we need to individualize care. And if there's something new that's come out that doesn't support what we've previously had, recognizing that the guidelines can be one to two years behind, that we need to incorporate the updated information.

I know that the joint committee is working very hard on having much more regular updates. They have surveillance committees now around to constantly oversee the newer data, the newer research that came out and started to put together regular timelines for updates of the guidelines. So we hope it would be quicker. But in the meantime, they say all the time, guidelines should not replace individualized clinical judgement, and I think we need to take what we know from newer randomized trials and incorporate that into our decision-making.

Venugopal Menon, MD:

And I'll end with one other comment and have you comment, Donna. I think we have a worldwide audience for things like this. Jackie and I were at a recent meeting talking about the guidelines, and someone really spoke the stark truth in that, what we recommend in the guidelines probably applies to folks in North America and Western Europe, maybe 1/5 of the human population. There are parts of the world that don't have access to PCI and these devices and bypass surgery. So, how can we try to make our guidelines? We have to understand when we talk about this, that there are still large portions of the world that just don't have equitable access to care.

Donna Kimmaliardjuk, MD:

Exactly. Sometimes we talk about patients that are included in these trials that are shaping the guidelines, they’re not really the patients we're seeing every day, even here. You see patients like, "My God, they would never be included in this trial or that trial." So I want to apply guidelines, but again, it comes down to the individual assessment, individualized care for that patient. So, I think you do the best with the information you have and the access that you have. Again, if you have that ability to transfer to a larger center, I think that's the right thing to do. I would say there's no shame in that. That's a great thing for the patient. So, it's always that balance. It's always that balance of what you know versus what you can do, sometimes.

Venugopal Menon, MD:

So, with that little bit of humility, we discussed the ACC/AHA guidelines today, certainly some very important updates, a really important statement because it's the first one coming out in more than a decade in North America. It'll certainly make a difference in practice and consistency of care across the country, but it’s still an ever-changing world, and lots of work to be done. So, I hope you enjoy this talk.

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