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Risk Assessment in Acute Coronary Syndromes

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Published on : Mar 14, 2014
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Slide 1 - British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in Cardiology Associate Director of Wellcome Trust Clinical Research Facility
Slide 2 - Case 1 46 year old woman Family history of ischaemic heart disease, hypertension, smoker and hypercholesterolaemia No prior history of angina 3 episodes of chest pain 12 hours prior to admission Already taking aspirin and statin on admission ECG normal Troponin I 1.2 µg/L
Slide 3 - Case 1 Commenced on medical therapy and settles Would you manage the patient with: (a). In-patient coronary angiography and revascularise (b). Conservative treatment and consider angiography/revascularisation if symptoms recur
Slide 4 - Case 2 79 year old man Non-smoker, hypertension and no risk factors Chronic stable angina for 15 years with known single vessel disease (angiogram 10 years ago) One episode of rest pain prior to admission Not taking aspirin ECG - minor ST depression on admission Troponin I <0.1 µg/L
Slide 5 - Case 2 Commenced on medical therapy and settles Would you manage the patient with: (a). In-patient coronary angiography and revascularise (b). Conservative treatment and consider angiography/revascularisation if symptoms recur
Slide 6 - TIMI Risk Score Age ≥ 65 years ≥3 Risk factors for coronary artery disease Significant coronary stenosis ST Segment deviation Severe anginal symptoms (≥2 anginal events in last 24 hours) Prior aspirin use (within last 7 days) Elevated serum cardiac markers Antman et al. JAMA 2000;284:835-842
Slide 7 - Antman et al. JAMA 2000;284:835-842
Slide 8 - Antman et al. JAMA 2000;284:835-842 TIMI Risk Score and Benefit with LMW Heparin
Slide 9 - Case 1 Case 2 Age ≥65 0 1 ≥3 Risk factors for CAD 1 0 Significant CAD 0 1 ST Segment deviation 0 1 Angina ≥2 times within 24 hrs 1 0 Prior aspirin use 1 0 Elevated cardiac markers 1 0 Total TIMI Score 4 3 14 Day Event Rate 20% 13% TIMI Risk Score
Slide 10 - Other Risk Factors and Scores
Slide 11 - Robust data on in-hospital & 6-month outcomes in over 12,000 patients in 14 different countries In well-characterized patients with ACS: In-hospital to 6 month rates of: death: ST-MI 12%, Non-ST-MI 13%, UA 8% Stroke: 1.5 to 3% Recurrent hospitalization for cardiac event: 17 to 20% Unselected patients reveal substantially higher event rates than those entered into recent trials A major challenge exists in the application of proven therapies to the full spectrum of patients with ACS GRACE Registry
Slide 12 - SBP (per 20 mmHg increase) 0.7 0.69-0.78 Initial serum creatinine 1.2 1.15-1.35 Heart rate 30bpm 1.3 1.16-1.48 Initial cardiac enzyme + 1.6 1.32-2.00 Age (per 10 yr) 1.7 1.55-1.85 Killip class 2.0 1.81-2.29 ST deviation 2.4 1.90-3.00 Pre-hosp arrest 4.3 2.80-6.72 Multivariable Risk Model
Slide 13 - Comparison of TIMI Risk Scores for Death: Antman Data Vs. GRACE Data 0 1 2 3 4 5 6 7 0/1 2 3 4 5 '6/7 TIMI Risk Score Antman GRACE Death Rate (%)
Slide 14 - Outcome of “low-risk” patients with ACS Presentation with UA in the absence of dynamic ECG changes, no troponin elevation, no arrhythmia nor hypotension 6 month outcome: 16.6% readmission 8.7% revascularised 2.2% deaths 0.2% MI “Low-risk” is not no risk
Slide 15 - FRISC II Study Wallentin et al. Lancet 2000;356:9-16.
Slide 16 - RITA-3 Study Fox et al. Lancet 2002;360:743-751
Slide 17 - Fox et al. Lancet 2002;360:743-751 Meta-analysis of Intervention Trials
Slide 18 - Who Should We Target For Invasive Intervention?
Slide 19 - MEN ≥65 YEARS CHRONIC ANGINA NON-SMOKERS CHEST PAIN at REST (TROPONIN +VE) ST DEPRESSION FRISC II et al. Lancet 1999;354:708-715
Slide 20 - Case 1 Case 2 Age 1.00 0.66 Sex 1.26 0.64 Smoking 1.34 0.66 Angina > 3 months 0.95 0.59 ST Segment deviation 0.94 0.66 Elevated cardiac markers 0.73 0.80 14 Day TIMI Event Rate 20% 13% Benefit from Intervention No Yes 6 Month Risk Reduction Based on FRISC Dataset
Slide 21 - ppt slide no 21 content not found
Slide 22 - Risk Assessment In Acute Coronary Syndromes Evaluation of Treatment Benefit In Acute Coronary Syndromes
Slide 23 - Single Vessel Disease Two Vessel Disease Three Vessel Disease 75% Left Main Stem 95% Left Main Stem 0.0 0.5 1.0 1.5 2.0 2.5 Harzard Ratio Survival Benefits of Revascularisation
Slide 24 - 25 20 15 10 5 0 0 5-49 50-85 >85 Severity of Luminal Stenosis (%) Frequency (%) of 5 year Vessel Occlusion or Myocardial Infarction Degree of Stenosis in the Culprit Lesion of Acute Myocardial Infarction
Slide 25 - Conclusions Risk scores need to be carefully applied Risk scores may be population dependent and not reflect ‘true life’ populations Low risk is not no risk High risk does not equate to most benefit from intervention Is the benefit of interventional strategies for acute coronary syndromes derived from revascularising patients with prior stable angina and prognostically significant disease?