Acute Coronary SyndromesRisk-Stratification

• Pathophysiology• Diagnosis• Initial Therapy • Risk-Stratification• Invasive vs Conservative• Post AMI Care

Savonitto S, Ardissino D, Granger CB, et al. JAMA 1999;281:707–13 (127)

Kaplan-Meier Estimates of Probability of Death Based on Admission Electrocardiogram

Antman EM, Tanasijevic MJ, Thompson B, et al. N Engl J Med 1996;335:1342–9 (201)

Troponin I Levels to Predict the Risk of Mortality in Acute Coronary Syndromes

TIMI Risk Score – Cardiac Events by 14 Days(TIMI 11B, ESSENCE)

RISK SCORES

TIMI GRACE

History

AgeHypertensionDiabetesSmoking↑ CholesterolFamily historyHistory of CAD

Age

Presentatio

n

Severe anginaAspirin within 7 daysElevated markersST-segment deviation

Heart rateSystolic BPElevated creatinineHeart failureCardiac arrestElevated markersST-segment deviation

Antman EM, et al. JAMA 2000;284:835–42. Eagle KA, et al. JAMA 2004;291:2727–33. GRACE = Global Registry of Acute Coronary Events; TIMI = Thrombolysis in Myocardial Infarction.

GRACE Prediction Score – All-cause Mortality Within 6 Months of Discharge

Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727-33(168)

Acute Coronary SyndromesInvasive vs Conservative

• Pathophysiology• Diagnosis• Initial Therapy • Risk-Stratification • Invasive vs Conservative• Discharge Planning

Choose A Strategy

• Initial Conservative – Angiography only if patient fails medical management (refractory or resting angina) or has objective evidence of ischemia (stress testing)

• Initial Invasive – Angiography before failure of medical management or stress testing– Immediate angiography (ISAR-COOL) or– Deferred Angiography (all other trials – 12-48h)

Choose A Strategy - Rationale

• Initial Conservative – Early trials demonstrate similar efficacy (TIMI IIIB,

MATE, VANQWISH, RITA-2)– Aggressive antiplatelet and anticoagulant therapy

has reduced events

• Initial Invasive– Rapidly identify the 10-20% with nonocclusive

CAD and the 20% with 3v CAD

Less Events in Early Invasive Strategy

SELECTION OF INITIAL TREATMENT STRATEGY: INITIAL INVASIVE VERSUS CONSERVATIVE STRATEGY

Invasive Recurrent angina/ischemia at rest with low-level activities despite intensive medical therapyElevated cardiac biomarkers (TnT or TnI)New/presumably new ST-segment depressionSigns/symptoms of heart failure or new/worsening mitral regurgitationHigh-risk findings from noninvasive testingHemodynamic instabilitySustained ventricular tachycardiaPCI within 6 monthsPrior CABGHigh risk score (e.g., TIMI, GRACE)Reduced left ventricular function (LVEF < 40%)

Conservative

Low risk score (e.g., TIMI, GRACE)

Patient/physician preference in the absence of high-risk features

Choose A Strategy – Guidelines• Initial invasive

– Refractory angina or hemodynamic/electrical instability (Class I, B)

– Initially stabilized patients without contraindications and with elevated risk for events (Class I, A)

• Initial Conservative – May be considered in patients with elevated risk

(Class IIb,B)– May consider physician or patient preference

(Class IIb,C)– Women with low-risk features (Class I, B)

Selection of Strategy: Invasive vs. Conservative Strategy (1)

• An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated with refractory angina or hemodynamic or electrical instability (I, B).

Selection of Strategy: Invasive vs. Conservative Strategy (2)

• An early invasive strategy is indicated in initially stabilized patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (I, A). Scores indicating elevated risk include combinations of the following:– Recurrent angina/ischemia at rest or low-level activities– Elevated cardiac biomarkers– New/presumably new ST-segment depression– Signs or symptoms of HF or new/worsening mitral regurgitation– High-risk findings from noninvasive testing– Hemodynamic instability– Sustained ventricular tachycardia– PCI within 6 months– Prior CABG– High risk score– LVEF < 0.40

Selection of Strategy: Invasive vs. Conservative Strategy (3)

• In initially stabilized patients, an initially conservative (i.e., a selectively invasive) strategy may be considered in patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events, including those who are troponin-positive (IIb, B). The decision to implement an initial conservative strategy may consider physician and patient preferences (IIb, C).

• A conservative strategy is recommended in women with low-risk features (I, B).

SELECT MANAGEMENT STRATEGY:

INITIAL INVASIVE VERSUS INITIAL CONSERVATIVE

STRATEGY