invasive evaluation timing in nstemi (1)
TRANSCRIPT
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PCI in NSTEMIPCI in NSTEMI
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Case ---Mr BCase ---Mr B
68 yr old68 yr oldHistory of HTN, hyperlipaedimiaHistory of HTN, hyperlipaedimiaOn regular aspirinOn regular aspirinPresented with acute chest pain to one of Presented with acute chest pain to one of peripheral hospitalsperipheral hospitalsST depression in lateral leadsST depression in lateral leadsBP 141/80 and P 86BP 141/80 and P 86Trop T +Trop T +Cr 1.2Cr 1.2
TIMI risk scoreTIMI risk score
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65 yrs or more65 yrs or more3 or more risk factors3 or more risk factorsPrior coronary stenosis more than 50%Prior coronary stenosis more than 50%ST deviation ST deviation Raised enzymesRaised enzymesUse of aspirin in prior 7 daysUse of aspirin in prior 7 days2 or More angina episode in last 24 2 or More angina episode in last 24 hrs hrs
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GRACE risk scoreGRACE risk score
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GRACE SCOREGRACE SCORE
77
Case ---Mr BCase ---Mr B
TIMI score: 4---TIMI score: 4---20% risk at 14 days of: all-cause 20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe mortality, new or recurrent MI, or severe recurrent ischemia.recurrent ischemia.
GRACE score: 144---3% in hospital death or 17% GRACE score: 144---3% in hospital death or 17% IH death or MI.IH death or MI.
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WHAT WHAT SHOULD WE SHOULD WE
DO?DO?
992014 ACC/AHA NSTEMI-ACS guideline
ESC 2015ESC 2015
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INVASIVE INVASIVE VS VS
CONSERVATIVECONSERVATIVE1111
TIMI IIIBVANQUISH
MATE
INVASIVE STRATEGY are not SUPERIOR
TRIALS of PRE STENT ERA
RECENT TRIALSRECENT TRIALS
FRISC IIFRISC IIICTUSICTUSRITA 3RITA 3TACTICS TIMI 18TACTICS TIMI 18VINOVINO
RCT FOLLOW UP
Time from randomisation to
angio
GPIIb/IIIa use
Stent in Invasive
arm
FRISC II 60 < 7 days( mean 4 days)
10/10 61
ICTUS 36 24-48 hrs 94/75 88
RITA-3 60 <72 hrs, mean 2 days 9/NR 88
TACTICS-TIMI 6 4-48 hrs( 22 hrs) 94/59 83
VINO 6 First day strategy( 6.2 hrs)
0 50
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META analysisMETA analysisFor the index hospital admission there was no significant overall
difference between the invasive and conservative group with
respect to death, stroke or non-fatal MI
However, an invasive strategy significantly decreased the
composite of death and MI at 6-12 months follow-up, both late
(>2 yrs) death and late MI, and reduced thelong-term rate of re-
hospitalisation.
Procedure- related MI Procedure- related MI was significantly increased in the was significantly increased in the
invasive arm invasive arm
There was There was no difference in mortality at any time whether no difference in mortality at any time whether
angiography was undertaken very early angiography was undertaken very early (<24 hours from (<24 hours from
randomisation - ICTUS, TACTICS-randomisation - ICTUS, TACTICS-TIMI TIMI 18, VINO) or when 18, VINO) or when
undertaken later (>48 hours - RITA-3, FRISC-II).undertaken later (>48 hours - RITA-3, FRISC-II).
CONTD……………..
Trials not involving the routine use of GPIIbIIIa inhibitors (VINO, RITA-
3, FRISC-II) an invasive strategy significantly decreased intermediate (6-
12 months) MI and refractory angina, but not death at any time point, nor
the index admission MI.
CONTD……………..
CONTD…….CONTD…….
Trials with the routine use of GPIs (mainly based on TACTICS-TIMI 18 but Trials with the routine use of GPIs (mainly based on TACTICS-TIMI 18 but
including ICTUS - use of GPIs was 94% in the invasive arms of both trials) an including ICTUS - use of GPIs was 94% in the invasive arms of both trials) an
invasive strategy significantly invasive strategy significantly reduced in-hospital non-fatal MI, the composite of reduced in-hospital non-fatal MI, the composite of
death or non-fatal MI (but not death alone), death or non-fatal MI (but not death alone), suggesting that appropriate use of GPIs suggesting that appropriate use of GPIs
reduces in-hospital MI reduces in-hospital MI when added to an invasive strategy. It also reduced when added to an invasive strategy. It also reduced
rehospitalisation over 6-12 months follow-uprehospitalisation over 6-12 months follow-up
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CONTD…………CONTD…………
In the RITA-3 trial there was no difference between management strategies for In the RITA-3 trial there was no difference between management strategies for
those at lowest risk, but those those at lowest risk, but those at highest risk at highest risk who were managed by an early who were managed by an early
invasive strategy had a significantly reduced risk of death or MIup to 5 years invasive strategy had a significantly reduced risk of death or MIup to 5 years
follow-up.follow-up.
In the FRISC-II trial, an invasive strategy significantly reduced the
composite of death or non-fatal MI in those with either ST depression or
troponin elevation (higher risk), but not in those without (lower risk),
suggesting that the benefit of an invasive strategy was mostly in higher risk
people.
CONTD…….CONTD…….In TACTICS TIMI trial benefit is confined to higher risk In TACTICS TIMI trial benefit is confined to higher risk
patientspatients
Quality of life outcomes are better in early invasive Quality of life outcomes are better in early invasive
group( FRISC II & RITA 3)group( FRISC II & RITA 3)
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in the in the ICTUSICTUS trial an early invasive strategy trial an early invasive strategy did not did not confer benefit confer benefit
and there was no evidence that treatment effect was influenced and there was no evidence that treatment effect was influenced
by risk at randomization. Interpretation of the ICTUS trial is by risk at randomization. Interpretation of the ICTUS trial is
influenced by a high rate of early angiography and influenced by a high rate of early angiography and
revascularization in the conservative arm of the trialrevascularization in the conservative arm of the trial
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INVASIVE STRATEGYINVASIVE STRATEGYHOW MUCH EARLY IT HOW MUCH EARLY IT
SHOULD BE?SHOULD BE?
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RCTs ---Timing of invasive evaluationRCTs ---Timing of invasive evaluationIn Pts with NSTEMIIn Pts with NSTEMI
TrialTrial Yr of Yr of enrolmenenrolmentt
No of PtsNo of Pts ScoringScoring Timing Timing (hours)(hours)
11 ISAR-ISAR-COOLCOOL
2000-022000-02 410410 Positive enzyme Positive enzyme or ST depression or ST depression >1mm>1mm
2.4 Vs 862.4 Vs 86
22 ABOARDABOARD 2006-082006-08 352352 TIMI>3TIMI>3 1.2 Vs 21 1.2 Vs 21
33 TIMACSTIMACS 2003-082003-08 30313031 GRACEGRACE 14 Vs 50 14 Vs 50
44 LIPSIA LIPSIA NSTEMINSTEMI
2006-2006-20102010
602602 GRACEGRACE 2 vs 10-2 vs 10-4848
TIMACS trial TIMACS trial 14 hr Vs 52 hr14 hr Vs 52 hr
Early versus Delayed Invasive Early versus Delayed Invasive InterventionIntervention
in Acute Coronary Syndromesin Acute Coronary Syndromes
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TIMACS trial TIMACS trial N Engl J Med 2009;360:2165-N Engl J Med 2009;360:2165-
75.75.3031 ACS patients3031 ACS patients
Early (≤24 hours) Vs delayed intervention (≥36 Early (≤24 hours) Vs delayed intervention (≥36 hours).hours).
Primary outcome: a composite of death, MI, or Primary outcome: a composite of death, MI, or stroke at 6 m. stroke at 6 m.
Secondary outcome: death, MI, or refractory Secondary outcome: death, MI, or refractory ischemia at 6 mischemia at 6 m
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..
TIMACS trial May 2009TIMACS trial May 2009N Engl J Med 2009;360:2165-75N Engl J Med 2009;360:2165-75
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TIMACS trial May 2009TIMACS trial May 2009N Engl J Med 2009;360:2165-75.N Engl J Med 2009;360:2165-75.
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ISAR-COOL trialISAR-COOL trial2.4hr Vs 86hr2.4hr Vs 86hr
JAMA, September 24, 2003—Vol 290, No. 12 JAMA, September 24, 2003—Vol 290, No. 12 15931593
IntracoronaryIntracoronaryStenting With AntithromboticStenting With Antithrombotic
Regimen Cooling-Off trialRegimen Cooling-Off trial
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ISAR-COOL trialISAR-COOL trialJAMA, September 24, 2003—Vol 290, No. 12 JAMA, September 24, 2003—Vol 290, No. 12 15931593
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ISAR-COOL trialISAR-COOL trialJAMA, September 24, 2003—Vol 290, No. 12 JAMA, September 24, 2003—Vol 290, No. 12 15931593
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ISAR-COOL trialISAR-COOL trialJAMA, September 24, 2003—Vol 290, No. 12 JAMA, September 24, 2003—Vol 290, No. 12 15931593
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ABOARD trialABOARD trial1.2hr Vs 21hr1.2hr Vs 21hr
JAMA, September 2, 2009—Vol 302, No. 9 JAMA, September 2, 2009—Vol 302, No. 9 949949
The The AAngioplasty to ngioplasty to BBlunt the Rise oflunt the Rise ofTrTrooponin in ponin in AAcute Coronary Syndromescute Coronary Syndromes
RRandomized for an Immediateandomized for an Immediateor or DDelayed Intervention (ABOARD)elayed Intervention (ABOARD)
TrialTrial
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ABOARD trialABOARD trialJAMA, September 2, 2009—Vol 302, No. 9 JAMA, September 2, 2009—Vol 302, No. 9 949949
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ABOARD trialABOARD trialJAMA, September 2, 2009—Vol 302, No. 9 JAMA, September 2, 2009—Vol 302, No. 9 949949
LLeipzig eipzig IImmediate versus earlymmediate versus early and late and late PPercutaneouercutaneouSS coronary coronary
IInterventionntervention tritriAAl in NSTEMI (LIPSIA-NSTEMI l in NSTEMI (LIPSIA-NSTEMI
Trial)Trial)
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602 patients602 patientsImmediate invasive( <2 hr)Immediate invasive( <2 hr)Early invasive( 10- 48 hr)Early invasive( 10- 48 hr)selectiveselective
Primary OutcomePrimary OutcomePeak CK-MB activityPeak CK-MB activityArea under curve of CK MB releaseArea under curve of CK MB release
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Not Different
Secondary OutcomeSecondary Outcome
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A meta-analysis of randomized trials addressing the optimal timing (early vs. delayed) of coronary
angiography in NSTE-ACS.
(ELISA, ABOARD, ISAR-COOL, TIMACS)
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From the meta-analysis
DRUGS TO BE DRUGS TO BE USEDUSED
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ANTIPLATELET ANTIPLATELET REGIMENREGIMEN
CONTD…………..CONTD…………..
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CONTD……..CONTD……..
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UPSTREAM GPIIb/IIIa – should we UPSTREAM GPIIb/IIIa – should we use?use?
EARLY ACSEARLY ACSACUITY timing trialACUITY timing trial
- NEGATIVE - NEGATIVE TRIALTRIAL
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Anticoagulant StrategyAnticoagulant Strategy
4848
Contd………….Contd………….
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Bivaluridin is It better?Bivaluridin is It better?ACUITY trialACUITY trial
Three arm UFH/LMWH+ GPIIb/IIIaThree arm UFH/LMWH+ GPIIb/IIIa Bivaluridin+ GPIIb/IIIaBivaluridin+ GPIIb/IIIa BivaluridinBivaluridinIntermediate to high risk patients Intermediate to high risk patients
planned for PCIplanned for PCIPrimary composite ischemic endpoint Primary composite ischemic endpoint
are same but less major bleedingare same but less major bleeding
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CONTD…….CONTD…….
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Is there any problem with Is there any problem with FONDAPARINUXFONDAPARINUX
OASIS-5 trialOASIS-5 trialFondaparinux vs EnoxaparinFondaparinux vs EnoxaparinPrimary composite ischemic end point Primary composite ischemic end point
are similarare similarMajor bleeding less Major bleeding less
Increased catheter Increased catheter thrombosisthrombosis
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5353
Anticoagulant regimen during Anticoagulant regimen during PCIPCI
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5555
5656
PCIPCI
5757
CABGCABG
5858
ESC 2015 what is newESC 2015 what is new
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Take home messageTake home messageUnstable pts should have urgent cath Unstable pts should have urgent cath lab study +/- revascularizationlab study +/- revascularization
High risk pts should ideally have cath High risk pts should ideally have cath study +/- revascularization in 24hrsstudy +/- revascularization in 24hrs
Low - intermediate risk pt should Low - intermediate risk pt should have stress test to document have stress test to document ischaemiaischaemia