british cardiac intervention society risk assessment in acute coronary syndromes dr david newby bhf...
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British Cardiac Intervention SocietyBritish Cardiac Intervention Society
Risk AssessmentRisk AssessmentInIn
Acute Coronary SyndromesAcute Coronary Syndromes
Dr David NewbyDr David Newby
BHF Senior Lecturer in CardiologyBHF Senior Lecturer in CardiologyAssociate Director of Wellcome Trust Clinical Research FacilityAssociate Director of Wellcome Trust Clinical Research Facility
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
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
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
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
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
Antman et al. JAMA 2000;284:835-842
Antman et al. JAMA 2000;284:835-842
TIMI Risk Score and Benefit with LMW Heparin
Case 1 Case 2
Age ≥65 0 1≥3 Risk factors for CAD 1 0Significant CAD 0 1ST Segment deviation 0 1Angina ≥2 times within 24 hrs 1 0Prior aspirin use 1 0Elevated cardiac markers 1 0
Total TIMI Score 4 3
14 Day Event Rate 20% 13%
TIMI Risk Score
Other Risk Factors and Scores
• 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
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
-2 –1 0 1 2 3 4 5 6 7 8
Multivariable Risk Model
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(%)
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
FRISC II Study
Wallentin et al. Lancet 2000;356:9-16.
RITA-3 Study
Fox et al. Lancet 2002;360:743-751
Fox et al. Lancet 2002;360:743-751
Meta-analysis of Intervention Trials
Who Should We Target ForInvasive Intervention?
•MEN
•≥65 YEARS
•CHRONIC ANGINA
•NON-SMOKERS
•CHEST PAIN at REST
•(TROPONIN +VE)
•ST DEPRESSION
FRISC II et al. Lancet 1999;354:708-715
Case 1 Case 2
Age 1.00 0.66Sex 1.26 0.64Smoking 1.34 0.66Angina > 3 months 0.95 0.59ST Segment deviation 0.94 0.66Elevated 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
Risk AssessmentIn
Acute Coronary Syndromes
Evaluation of Treatment BenefitIn
Acute Coronary Syndromes
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
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?