Amr Hassan Mostafa, MD, FSCAI

A. Professor of Cardiology

Cairo University

Cairo, Egypt

Egypt Combat MI, March 24-25, Cairo Sheraton

Definitions – Acute coronary syndrome

Any constellation of clinical symptoms that are compatible with acute myocardial ischemia.

It encompasses a spectrum from

AMI NSTEMI UA NSTEMI – acute process of myocardial

ischemia resulting in myocardial necrosis.The initial ECG does not show ST elevation

CK- MB or Troponin Troponin elevated or not

ACS without persistent

ST-segment elevation

ACS with persistent ST-segment elevation

Non ST Elevation Acute Coronary Syndrome

A heterogeneous population Varying risks of early and long-term

adverse events Early risk stratification at admission is

essential for a tailored therapeutic strategy

Various ACS risk scores are

available

Why be concerned re risk stratification………

Are the symptoms a manifestation of ACS?

Therapy/ site of care will vary dependent on diagnosis

To determine prognosis/short term survival

To determine need for early revascularization

ACS Risk Scores

TIMI: Thrombolysis In Myocardial Infarction

PURSUIT: Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin

GRACE: Global Registry of Acute Coronary Events

ACS Risk Scoring TIMI

Age - Use of aspirin Risk Factors - Known CAD > 1 episode rest pain - ST segment deviation Cardiac risk markers

PURSUIT Age, Sex - CCS class in last 6/52 Signs of CCF - ST depression on ECG

GRACE Age - Heart rate and systolic BP Creatinine - CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers - ST segment deviation

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

ACC/AHA/SCAI 2007 PCI Guidelines Focused Update

9

TIMI Risk Score for UA/NSTEMI

TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe

Recurrent Ischemia Requiring Urgent Revascularization

Through 14 Days After Randomization, %

0-1 4.7

2 8.3

3 13.2

4 19.9

5 26.2

6-7 40.9

TIMI, Thrombolysis in Myocardial Infarction.

King SB III, Smith SC Jr., et al. J Am Coll Cardiol 2008;51:172-209. Table 4. Available at: http://content.onlinejacc.org/cgi/content/full/51/2/172

Antman et al. JAMA 2000;284:835-842

ACS Risk Scoring TIMI

Age - Use of aspirin Risk Factors - Known CAD > 1 episode rest pain - ST segment deviation Cardiac risk markers

PURSUIT Age, Sex - CCS class in last 6/52 Signs of CCF - ST depression on ECG

GRACE Age - Heart rate and systolic BP Creatinine - CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers - ST segment deviation

Thresholds of Risk

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

2.4 1.90-3.00

Pre-hosp arrest 4.3 2.80-6.72

-2 –1 0 1 2 3 4 5 6 7 8

Multivariable Risk Model

Discharge Risk score – An Audit Standard ?

Unique Features of GRACE

Multi-national perspective Full spectrum of coronary syndromes Increased data on demographics,

presentation, management and outcome Regular audits of data quality Feedback to participating sites 6-month follow-up

ACS Risk Scoring TIMI

Age - Use of aspirin Risk Factors - Known CAD > 1 episode rest pain - ST segment deviation Cardiac risk markers

PURSUIT Age, Sex - CCS class in last 6/52 Signs of CCF - ST depression on ECG

GRACE Age - Heart rate and systolic BP Creatinine - CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers - ST segment deviation

 Distribution of the 30-day and 1-year endpoint rates in the different risk groups

de Araújo Gonçalves P et al. Eur Heart J 2005;26:865-872

© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oupjournals.org

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

AntmanGRACE

DeathRate(%)

ACC/AHA/SCAI 2007 PCI Guidelines Focused Update

Confounding Factors Risk scores are largely developed from

registries & not CRT’s High risk pts usually receive more

aggressive antithrombotics & early revascularisation

Risk scores can only predict short term prognosis as they do not include important coronary anatomic or physiologic information

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

25

20

15

10

5

0

0 5-49 50-85 >85

Severity of Luminal Stenosis (%)

Frequency (%) of 5 yearVessel Occlusion or

Myocardial Infarction

<50%

50-70%

>70%

68%

18%

14%

Severity of Underlying Luminal Stenosis

in Patients with anAcute Myocardial Infarction

LuminalStenosis

Frequency

Degree of Stenosis in the Culprit Lesionof Acute Myocardial Infarction

ACS Risk Scoring

TIMI Age - Use of aspirin Risk Factors - Known CAD > 1 episode rest pain - ST segment deviation Cardiac risk markers

PURSUIT Age, Sex - CCS class in last 6/52 Signs of CCF - ST depression on ECG

GRACE Age - Heart rate and systolic BP Creatinine - CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers - ST segment deviation

ACS Risk Scores

Balance between complexity and utility Score that include continuous variables

more powerful but more complex to computeSimple PC/PDA programmes now available

Objective data more robust

•GRACE most powerful and has most objective data

Risk AssessmentIn

Acute Coronary Syndromes

Evaluation of Treatment BenefitIn

Acute Coronary Syndromes

Take Home Message

• All risk scores were developed to predict short term prognosis

• GRACE risk scoring appears the most predictive of short & intermediate term prognosis

• GRACE risk scoring includes CHF & renal dysfunction at the time of presentation with ACS

Take Home Message

• 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