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  • Invasive Evaluation Timing in NSTEMI

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    TIMI score: 4---20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia. GRACE score: 144---3% in hospital death or 17% IH death or MI. ASAP in unstable pts - with major arrhythmias - haemodynamic instability - Post-MI unstable angina - or a history of prior bypass surgery.

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    TIMI score: 4---20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia. GRACE score: 144---3% in hospital death or 17% IH death or MI. ASAP in unstable pts - with major arrhythmias - haemodynamic instability - Post-MI unstable angina - or a history of prior bypass surgery.

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    23 vues39 pages

    Invasive Evaluation Timing in NSTEMI

    Transféré par

    fatimahhassan241
    TIMI score: 4---20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia. GRACE score: 144---3% in hospital death or 17% IH death or MI. ASAP in unstable pts - with major arrhythmias - haemodynamic instability - Post-MI unstable angina - or a history of prior bypass surgery.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme PPT, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 39

    Invasive evaluation of NSTE-ACS Timing of Coronary Angiography+/Revascularization

    Dr Zhihua (Michael) Zhang Interventional fellow Wellington Hospital Dec 2011

    Case ---Mr B
    68 yr old History of HTN, hyperlipaedimia On regular aspirin Presented with NSTEMI to one of peripheral hospitals ST depression in lateral leads BP 141/80 and P 86 Trop T + Cr 125

    Case ---Mr B
    TIMI score: 4---20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia.
    GRACE score: 144---3% in hospital death or 17% IH death or MI.

    Case ---Mr B When should we refer/transfer this pt for coronary angiogram+/-revascularization?

    1. 2. 3. 4.

    In the day of admission Next day During the hospital admission Conservative Mx

    ESC Management guideline of NSTEMI 2000


    In high risk pts, coronary angiography should be performed during the initial hospitalization. ASAP in unstable pts with major arrhythmias haemodynamic instability Post-MI unstable angina or a history of prior bypass surgery

    ESC Management guideline of NSTEMI 2007


    Early (<72 h) coronary angiography followed by revascularization (PCI or CABG) in pts with intermediate to high-risk features is recommended (I-A). Urgent coronary angiography is recommended in Unstable pts (I-C).

    RCTs ---Timing of invasive evaluation In Pts with NSTEMI


    Trial Yr of No of Pts Scoring enrolment Timing (hours)

    1
    2 3

    ISARCOOL

    2000-02

    410

    Positive enzyme or ST depression >1mm

    2.4 Vs 86

    ABOARD 2006-08

    352

    TIMI>3

    1.2 Vs 21

    TIMACS

    2003-08

    3031

    GRACE

    14 Vs 50

    ISAR-COOL trial
    2.4hr Vs 86hr
    JAMA, September 24, 2003Vol 290, No. 12 1593

    Intracoronary Stenting With Antithrombotic Regimen Cooling-Off trial

    ISAR-COOL trial
    JAMA, September 24, 2003Vol 290, No. 12 1593

    ISAR-COOL trial
    JAMA, September 24, 2003Vol 290, No. 12 1593

    10

    ISAR-COOL trial
    JAMA, September 24, 2003Vol 290, No. 12 1593

    11

    ABOARD trial
    1.2hr Vs 21hr
    JAMA, September 2, 2009Vol 302, No. 9 949

    The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) Trial

    12

    ABOARD trial
    JAMA, September 2, 2009Vol 302, No. 9 949

    13

    ABOARD trial
    JAMA, September 2, 2009Vol 302, No. 9 949

    14

    ABOARD trial
    JAMA, September 2, 2009Vol 302, No. 9 949

    15

    TIMACS trial
    14 hr Vs 52 hr

    Early versus Delayed Invasive Intervention in Acute Coronary Syndromes

    16

    TIMACS trial
    N Engl J Med 2009;360:2165-75.

    3031 ACS patients Early (24 hours) Vs delayed intervention (36 hours). Primary outcome: a composite of death, MI, or stroke at 6 m. Secondary outcome: death, MI, or refractory ischemia at 6 m
    17

    18

    19

    TIMACS trial May 2009


    N Engl J Med 2009;360:2165-75.

    20

    TIMACS trial May 2009


    N Engl J Med 2009;360:2165-75.

    21

    A meta-analysis of randomized trials addressing the optimal timing (early vs. delayed) of coronary angiography in NSTE-ACS.
    (ELISA, ABOARD, ISAR-COOL, TIMACS)

    22

    23

    24

    From the meta-analysis

    25

    ESC Management guideline of NSTEMI 2011

    26

    Case ---Mr B When should we refer/transfer this pt for coronary angiogram+/-revascularization?

    1. 2. 3. 4.

    In the day of admission Next day In the index admission Conservative Mx

    27

    Can we practically follow the guideline recommendations?


    Bed lock in Wellington Weekend presentations
    Weather

    28

    Thank you for your attention


    Questions and comments

    29

    30

    31

    GRACE SCORE

    32

    ABOARD trial
    JAMA, September 2, 2009Vol 302, No. 9 949

    33

    34

    From 2000-2011 Trend of recommendations for invasive evaluation


    High risk pts
    2000 During the hospital admission < 72 hrs < 24 hrs

    Unstable pts
    ASAP

    2007 2010

    <1hrs <2 hrs


    35

    Take home message


    Unstable pts should have urgent cath lab study +/- revascularization High risk pts should ideally have cath study +/- revascularization in 24hrs Low - intermediate risk pt should have stress test to document ischaemia
    36

    GRACE SCORE of Mr B
    Age HR 60-69 ST deviation 70-89 Cardiac enzyme+ Yes Yes

    SBP
    Cr 140 CHF No GRACE Score: 155

    120-139
    106-

    Cardiac arrest

    No

    In hospital death:

    4%

    To 6 months:

    9%
    37

    38

    ESC Management guideline of NSTEMI 2002


    Coronary angiography should be planned as soon as possible, but without undue urgency. In most cases coronary angiography is performed within the 48 h, or at least within hospitalization period.

    39

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