Invasive evaluation of NSTE-ACS Timing of Coronary Angiography+/-RevascularizationDr Zhihua (Michael) ZhangInterventional fellowWellington HospitalDec 2011

Case ---Mr B

68 yr oldHistory of HTN, hyperlipaedimiaOn regular aspirinPresented with NSTEMI to one of peripheral hospitalsST depression in lateral leadsBP 141/80 and P 86Trop 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?

In the day of admissionNext day During the hospital admissionConservative Mx

ESC Management guideline of NSTEMI 2000In high risk pts, coronary angiography should be performed during the initial hospitalization.

ASAP in unstable pts with major arrhythmias haemodynamic instabilityPost-MI unstable anginaor a history of prior bypass surgery

ESC Management guideline of NSTEMI 2007

Early (

RCTs ---Timing of invasive evaluationIn Pts with NSTEMI

ISAR-COOL trial2.4hr Vs 86hrJAMA, September 24, 2003Vol 290, No. 12 1593

IntracoronaryStenting With AntithromboticRegimen Cooling-Off trial

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

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

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

ABOARD trial1.2hr Vs 21hrJAMA, September 2, 2009Vol 302, No. 9 949

The Angioplasty to Blunt the Rise ofTroponin in Acute Coronary SyndromesRandomized for an Immediateor Delayed Intervention (ABOARD)Trial

ABOARD trialJAMA, September 2, 2009Vol 302, No. 9 949

ABOARD trialJAMA, September 2, 2009Vol 302, No. 9 949

ABOARD trialJAMA, September 2, 2009Vol 302, No. 9 949

TIMACS trial 14 hr Vs 52 hrEarly versus Delayed Invasive Intervention in Acute Coronary Syndromes

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

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

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

A meta-analysis of randomized trials addressing the optimal timing (early vs. delayed) of coronary angiography in NSTE-ACS.

(ELISA, ABOARD, ISAR-COOL, TIMACS)

From the meta-analysis

ESC Management guideline of NSTEMI 2011

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

In the day of admissionNext day In the index admissionConservative Mx

Can we practically follow the guideline recommendations?

Bed lock in Wellington

Weekend presentations

Weather

Thank you for your attentionQuestions and comments

GRACE SCORE

ABOARD trialJAMA, September 2, 2009Vol 302, No. 9 949

From 2000-2011Trend of recommendations for invasive evaluation

Take home messageUnstable 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

GRACE SCORE of Mr B

ESC Management guideline of NSTEMI 2002Coronary 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.