Βελτιώνοντας την έκβαση στο NSTEMI : Αξιολόγηση και αποτελεσματική

επαναγγείωση

ΠΕΤΡΟΣ Σ. ΔΑΡΔΑΣ, MD, FESC

ΚΛΙΝΙΚΗ ΑΓΙΟΣ ΛΟΥΚΑΣ

35ο ΠΑΝΕΛΛΗΝΙΟ ΚΑΡΔΙΟΛΟΓΙΚΟ ΣΥΝΕΔΡΙΟ, ΑΘΗΝΑ 2014

Acute Coronary Syndromes

1.41 million hospital admissions for ACS in 2010

STEMI

NSTEMI

(biomarker +)

50%

NSTEMI (troponin+)

22%

Unstable angina

28%

NSTE-ACS

Heart Disease and Stroke Statistics – 20014 Update. Circulation. 2014;129:e28–e292..

UA and NSTEMI: Pathophysiology

Ruptured plaque with non occlusive thrombus

Myocardial Infarction

NSTE-ACS

Secondary Prevention/

Long-Term ManagementManagement Prior to

NSTE-ACS

Onset of NSTE-ACS-Initial recognition and management in the

ED by first responders or ED personnel

-Risk stratification

-Immediate management

Hospital Management-Medication-Conservative versus invasive strategy

-Special groups

-Preparation for discharge

Final Dx

Cardiac Biomarker

ECG

Working Dx

Presentation Ischemic Discomfort

ACS

No ST Elevation

NQMI

STEMINSTEMIUA

Unstable Angina

QwMI

ST Elevation

Noncardiac

Etiologies

* *

Acute Coronary Syndromes

Early Risk Stratification

History and Physical Examination

EKG

Biomarkers

Risk Scores

Conservative vs. Invasive Management

Timing of Invasive Management

Treatment of Non-ST-Elevation ACS

Outline

Early Risk Stratification

History and Physical Examination

EKG

Biomarkers

Risk Scores

Conservative vs. Invasive Management

Timing of Invasive Management

Treatment of Non-ST-Elevation ACS

Outline

Biomarkers: Diagnosis

Recommendations COR LOE

Cardiac-specific troponin (troponin I or T when a

contemporary assay is used) levels should be measured at

presentation and 3 to 6 hours after symptom onset in all

patients who present with symptoms consistent with ACS to

identify a rising and/or falling pattern.

I A

Additional troponin levels should be obtained beyond 6

hours after symptom onset in patients with normal

troponins on serial examination when electrocardiographic

changes and/or clinical presentation confer an intermediate

or high index of suspicion for ACS.

I A

With contemporary troponin assays, creatine kinase

myocardial isoenzyme (CK-MB) and myoglobin are not

useful for diagnosis of ACS.

III: No

BenefitA

Immediate Management (cont’d)

Recommendations COR LOE

In patients with possible ACS and a normal ECG, normal

cardiac troponins, and no history of CAD, it is reasonable to

initially perform (without serial ECGs and troponins)

coronary CT angiography to assess coronary artery

anatomy (Level of Evidence: A) or rest myocardial

perfusion imaging with a technetium-99m

radiopharmaceutical to exclude myocardial ischemia. (Level

of Evidence: B)

IIa

A

B

Prognosis: Early Risk Stratification

Recommendations COR LOE

Risk scores should be used to assess prognosis in patients

with NSTE-ACS. I A

TIMI Risk Score* for NSTE-ACS

TIMI Risk

Score

All-Cause Mortality, New or Recurrent MI, or

Severe Recurrent Ischemia Requiring Urgent

Revascularization Through 14 d After

Randomization, %

0–1 4.7

2 8.3

3 13.2

4 19.9

5 26.2

6–7 40.9

*The TIMI risk score is determined by the sum of the presence of 7

variables at admission; 1 point is given for each of the following variables:

≥65 y of age; ≥3 risk factors for CAD; prior coronary stenosis ≥50%; ST

deviation on ECG; ≥2 anginal events in prior 24 h; use of aspirin in prior 7

d; and elevated cardiac biomarkers.

Antman EM, et al. JAMA 2000;284:835–42

GRACE Risk Model Nomogram

To convert serum creatinine level to micromoles per liter, multiply by 88.4.

Early Risk Stratification

Risk Score App

GRACE risk score 2.0

• provides prognosis at six months, one year, and three years

• developed in over 30,000 patients with ACS and validated externally in a registry of nearly 3000 patients

• Risks are given directly as propabilities

VERY HIGH-RISK PATIENTShigh risk that formal early risk stratification is not necessary These patients typically need to

proceed to urgent coronary angiography

• Cardiogenic shock

• Overt heart failure (HF) or severe left ventricular dysfunction

• Recurrent or persistent rest angina despite intensive medical therapy

• Hemodynamic instability due to mechanical complications (eg, acute mitral regurgitation, ventricular septal defect)

• Unstable ventricular arrhythmias

Early Risk Stratification

History and Physical Examination

EKG

Biomarkers

Risk Scores

Conservative vs. Invasive Management

Timing of Invasive Management

Treatment of Non-ST-Elevation ACS

Outline

Cumulative Percentage

Fox KAA et al. J Am Coll Cardiol 2010;55:2435–45

Pint-HR = 0.10High risk: 13% of pts

HR: [95%CI] =

0.68 [0.53, 0.86]

Risk diff =

–11.1% [–18.4%, –3.8%)

Int risk: 34% of pts

HR: [95%CI] =0.81 [0.66, 1.01]

Risk diff =

–3.8% [–7.4%, –0.1%)

Low risk: 53% of pts

HR: [95%CI] =

0.80 [0.63, 1.02]

Risk diff =

–2.0% [–4.1%, 0.1%)

Selective invasive

Routine invasive

Selective invasive 2746Routine invasive 2721

24522485

23512410

21782235

20772166

20052079

542 3Follow-up time (years)

10

High

Intermediate

Low

50%

40%

30%

20%

10%

0%

5 Year FU After Routine vs. Selective Invasive

Strategy in ACS

FRISC-II, ICTUS, and RITA-3 (n=5,457)

CV Death or MI by risk group

O’Donoghue M. JAMA 2008;300:71-80

12-month follow-up

Early Invasive vs Conservative Treatment Strategies

in Women and Men with Unstable Angina and Non-

ST-Segment Elevation Myocardial Infarction:

A Meta-analysis

In NSTE ACS, an invasive strategy has a

comparable benefit in men and high-risk

women for reducing the composite end point

of death, MI, or rehospitalization with ACS

O’Donoghue et al., JAMA 2008; 300:71

Early Risk Stratification

History and Physical Examination

EKG

Biomarkers

Risk Scores

Conservative vs. Invasive Management

Timing of Invasive Management

Treatment of Non-ST-Elevation ACS

Outline

Cath >36 hrs

Median 50 hrs

N=1438

Cath <24 hrs

Median 14 hrs

N=1593

TIMACSTiming of Intervention in Patients with Acute Coronary Syndromes

3,031 patients with UA/NSTEMI

25% XO to early cath

Mehta SR et al. NEJM 2009;360:2165-75

Ischemia-Guided Strategy Versus Early Invasive

Strategies

Early Hospital Care

Factors Associated With Appropriate Selection of Early Invasive

Strategy or Ischemia-Guided Strategy in Patients With NSTE-ACS

Immediate

invasive

(within 2 h)

Refractory angina

Signs or symptoms of HF or new or worsening mitral regurgitation

Hemodynamic instability

Recurrent angina or ischemia at rest or with low-level activities despite

intensive medical therapy

Sustained VT or VF

Ischemia-

guided

strategy

Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])

Low-risk Tn-negative female patients

Patient or clinician preference in the absence of high-risk features

Early

invasive

(within 24

h)

None of the above, but GRACE risk score >140

Temporal change in Tn (Section 3.4)

New or presumably new ST depression

Delayed

invasive

(within

2572 h)

None of the above but diabetes mellitus

Renal insufficiency (GFR <60 mL/min/1.73 m²)

Reduced LV systolic function (EF <0.40)

Early postinfarction angina

PCI within 6 mo

Prior CABG

GRACE risk score 109–140; TIMI score ≥2

Risk Stratification Before Discharge for Patients

With an Ischemia-Guided Strategy of NSTE-ACS

Early Hospital Care

Risk Stratification Before Discharge for Patients With an

Ischemia-Guided Strategy of NSTE-ACS

Recommendations COR LOE

Noninvasive stress testing is recommended in low- and

intermediate-risk patients who have been free of ischemia

at rest or with low-level activity for a minimum of 12 to 24

hours.

I B

Treadmill exercise testing is useful in patients able to

exercise in whom the ECG is free of resting ST changes

that may interfere with interpretation.I C

Stress testing with an imaging modality should be used

in patients who are able to exercise but have ST changes

on resting ECG that may interfere with interpretation. In

patients undergoing a low-level exercise test, an imaging

modality can add prognostic information.

I B

Risk Stratification Before Discharge for Patients With an

Ischemia-Guided Strategy of NSTE-ACS (cont’d)

Recommendations COR LOE

Pharmacological stress testing with imaging is

recommended when physical limitations preclude adequate

exercise stress.

I C

A noninvasive imaging test is recommended to evaluate LV

function in patients with definite ACS. I C

Initial Antiplatelet/Anticoagulant Therapy in

Patients With Definite or Likely NSTE-ACS

Early Hospital Care

Antiplatelet and Anticoagulant Therapy:

Oral and Antiplatelet Agents

Recommendations COR LOE

It is reasonable to choose ticagrelor over clopidogrel for

P2Y12 inhibition treatment in patients with NSTE-ACS

treated with an early invasive strategy and/or coronary

stenting.

IIa B

It is reasonable to choose prasugrel over clopidogrel for

P2Y12 treatment in patients with NSTE-ACS who undergo

PCI who are not at high risk of bleeding complications.IIa B

Conclusions

• NSTEACS comprises >75% of all ACS admissions

• Early risk stratification should be performed using

symptoms, risk factors, EKG and biomarkers

• Risk scores: TIMI or GRACE

•A routine early invasive strategy results in

reduction in death, MI, and rehospitalization for

ACS, especially in high-risk pts

• Catheterization and revascularization within 12 to

24 hours may be preferred in high-risk pts

Cannon CP, et al. N Engl J Med 2001;344:1879–87.

Treatment of NSTEACS

LATE RISK STRATIFICATION

• among all major cardiac events that occur in the first six weeks, approximately one-fourth occur after discharge

• left ventricular ejection fraction

• in medically managed patients, stress testing to detect possible residual ischemia

59 male, Unstable anginahemodynamically stable, 2 episodes of pain last 24 hours, renal function normal, EF 55%

hs troponine +ve - mild ECG changesprevious PCI LAD – RCA, 3 risk factors

GRACE score 109 – TIMI risk score 5 (risk of event by 14 days 26.2%)

Unstable anginahs troponine +ve - no ECG changes

previous PCI LAD – RCA patent

Patent LAD stent Patent RCA stent

new lesion mid CxGRACE score 109 – TIMI risk score 5 (risk of event by 14 days 26.2%)

Pre PCI Post PCI