NSTEMI Invasive Treatment: Rationale and Timing
-
Upload
cardiositeindia -
Category
Health & Medicine
-
view
908 -
download
0
Transcript of NSTEMI Invasive Treatment: Rationale and Timing
NSTEMI INVASIVE TREATMENT-RATIONALE AND TIMING
- Dr. DEV PAHLAJANI MD,FACC,FSCAIHOD, INTERVENTIONAL CARDIOLOGY
BREACH CANDY HOSPITAL, MUMBAI
ACS: Common pathophysiology
Ruptured fibrous cap with luminal and intraplaque occlusive thrombus
The TIMI unstable angina risk score
0/1 2 3 4 50
10
20
30
40
50
60
4.78.3
13.2
19.9
26.2
40.9
TIMI Risk Score for UA/NSTEMI
D/M
I/UR
by
14 D
ays
(%)
Antman RM et al JAMA 2000, 284, 835
% Population 4.3 17.3 32.0 29.3 13.0 3.4
6-7
SABATINE AND ANTMAN TIMI RISK SCORE FOR UA/NSTEMI
RITA-3: invasive vs conservative strategies in non-ST-elevation ACS
Lancet 2002;360:743
Death Myocardial in-farction
Refractory Angina
Triple endpoint0%
5%
10%
15%
20%
4.6% 3.8%
6.5%
9.6%
3.9% 4.8%
11.6%
14.5%
Invasive (n=895)Conservative (n=915)
P=0.5 P=0.29
P<0.0002
P<0.0001
Event rates at one year
RITA-3: invasive vs conservative strategies in non-ST-elevation ACS
0
5
10
15
20
25
Cum
ulat
ive
perc
enta
ge
0 1 2 3 4 5Follow-up time (years)
OR 0.7895% CI 0.61-0.99, p=0.044
20.0%
16.6%
Lancet 2005;366:914
15.1%
12.1%
OR 0.7695% CI 0.58-1.00, p=0.054
0
5
10
15
20
25
0 1 2 3 4 5Follow-up time (years)
Death or nonfatal MI Death
Conservative (n=915)Invasive (n=895)
Meta-analysis for CV death or MI
Overall
FRISC-II (N=2457)
ICTUS (N=1200)
RITA-3 (N=1810)
Study
0.81 (0.71, 0.93)
0.79 (0.66, 0.95)
0.99 (0.72, 1.35)
0.75 (0.58, 0.96)
0.81 (0.71, 0.93)
0.79 (0.66, 0.95)
0.99 (0.72, 1.35)
0.75 (0.58, 0.96)
Hazard ratio (95% CI)
0.5 0.75 1 1.33 2
Favors routine invasive Favors selective invasiveHazard ratio
0.1 1 10
Odds Ratio (95%CI)
Invasive strategy in non-ST elevation ACSRe-hospitalisation for unstable angina
Invasive better Conservative better
N=7966P=0.00001Heterogeneity p=0.01
OR 0.54(95% CI 0.48-0.61)
NNT 16
Adapted from JACC 2006;48:1319
Inv Con
17.1% 28.2%
17.1% 23.6%
11.0% 13.7%
6.5% 11.6%
9.4% 17.9%
7.2% 10.7%
11.4% 17.5%
Trial FUmonths
FRISC2 24
TRUCS 12
TACTICS 6
RITA 3 12
VINO 6
ICTUS 12
TOTAL
FRISC score (sum of): Age>65, male gender, diabetes, previous MI, ST-depression, elevated troponin / Il-6 / CRP
Lancet 2006;368:998
High risk (score 4-7) N=622RR (95%CI) 0.79 (0.64-0.97)
Medium risk (score 2-3) N=1092RR (95%CI) 0.72 (0.55-1.13)
Low risk (score 0-1) N=369RR (95%CI) 1.26 (0.66-2.40)
Years since randomisation
Deat
h or
myo
card
ial i
nfar
ction
(%)
41 5320
10
20
30
40
0
32.7%
41.6%
14.6%
20.4%
10.3%8.2%
ConservativeInvasive
FRISC-2: cumulative risk of death or MIby risk score
Δ8.9%
Δ5.8%
RITA-3: cumulative risk of death or MIby risk score
Lancet 2005;366:914
0
10
20
30
40
50
0 1 2 3 4 5
Cum
ulat
ive
perc
enta
ge
Follow-up time (years)
0
10
20
30
40
50
0 1 2 3 4 5Follow-up time (years)
4a High risk quartile – lower4b High risk quartile – upper
1 Low risk quartile2 Medium risk quartile3 Medium risk quartile
Invasive group Conservative group
Risk score: age, diabetes, prev MI, smoking, pulse rate, ST depression, angina grade, gender, LBBB, randomised treatment
48.5%
35.4%
6.1%
29.2%
31.3%
6.6%
RITA 3 -10 YRS GRACE SCORE
Prognostic values of Recurrent Ischemia in ACS
Prognostics value of Baseline Troponins in ACSGUSTO-IIA: 30 day mortality
Prognostic value of TN & ECG INACS
B-Type Natriuretic Peptide Predicts Outcomes in Patients with ACS
Inflammatory Markers and long-term Mortality in Acute Coronary Syndrome: FRISC Substudy
Invasive vs. Conservative
• Invasive strategy is favoured over conservative management
• Unresolved Issues –– Optimal timing– need to balance the risks of intervention for
unstable plaque – risk of new ischemic events while waiting to
perform an invasive procedure
Milosevic A, et al. J Am Coll Cardiol Intv 2016
Cumulative incidence of primary endpoint of death or MI at 30 days for immediate versus delayed. Dashed black line intersecting the X axis denotes
the median time to angiography (61h) in patients undergoing delayed invasive intervention
Milosevic A, et al. J Am Coll Cardiol Intv 2016
Variable ImmediateIntervention (n = 162)
DelayedIntervention (n = 161)*
HR (95% CI) p Value
30 daysDeath or MI 4.3 13.0 0.32 (0.13–0.74) 0.008Death, MI, or recurrent ischemia) 6.8 26.7 0.23 (0.12–0.45 <0.001
Death 3.1 3.1 0.98 (0.28–3.37) 0.97MI 2.5 9.9 0.24 (0.08–0.70) 0.01Recurrent ischemia 3.7 15.5 0.24 (0.10–0.57) 0.001Major bleeding 0.6 0.6 0.99 (0.06–15.89) 0.99 31 days to 1 yrDeath or MI 2.6 6.5 0.39 (0.12–1.27) 0.12Death, MI, or recurrent ischemia 9.3 9.3 0.99 (0.45–2.19) 0.71Death§ 1.9 2.6 0.74 (0.17–3.31) 0.69MI 0.6 4.3 0.15 (0.02–1.22) 0.07Recurrent ischemia 6.5 2.2 2.99 (0.82–10.85) 0.06Major bleeding 0.0 2.5 0.01 (0.01–46.38) 0.301 yrDeath or MI 6.8 18.8 0.34 (0.17–0.67) 0.002Death, MI, or recurrent ischemia 15.4 33.1 0.28 (0.15–0.51) <0.001Death 4.9 5.6 0.87 (0.34–2.26) 0.78MI 3.1 13.8 0.21 (0.08–0.55) 0.002Recurrent ischemia 9.9 16.9 0.28 (0.12–0.63) 0.002Major bleeding 0.6 3.1 0.20 (0.02–1.68) 0.14
Clinical Outcomes Up to 1 Year
Cumulative incidence of the combined primary endpoint of death or new myocardial infarction at 30 days and thereafter for patients undergoing
immediate versus delayed invasive intervention.Milosevic A, et al. J Am Coll Cardiol Intv 2016
Risk criteria mandating invasive strategy in NSTE-ACS2015 ESC Guidelines
NSTEMI NSTEMI 2015
NSTEMI ESC 2015
NSTEMI ESC 2015
Conclusions
• Invasive treatment superior to conservative• In high score immediate approach within 2
hours• Biomarkers, recurrent ischemia, ECG and
hemodynamic changes determine the approach
• Long term outcomes better in high risk