CIACCMilano, 3 Dicembre 2011

Strategie di trattamento nelle Sindromi Coronariche Acute senza ST sopraslivellato

Corrado Lettieri U.O. di Cardiologia, Ospedale Carlo Poma, Mantova

NSTEACSRecomendations for invasive evaluation and revascularisation

ESC GUIDELINES 2007

High-risk features

Persistent or recurrent angina

with/without ST changes (≥2mm)

or deep neg. T resistant to anti

anginal treatment

Clinical symptoms of heart failure

or hemodynamic instability

Life-threatenting arrhythmias

(VF, VT)

Intermediate to high-risk features

Elevated troponin levels Dynamic ST- or T- wave changes

(symptomatic or silent)Diabetes mellitusRenal dysfunction (GFR<60 mLK/min/1,73m2)

Reduced left ventricular function (EF<40%)

Early post-infarction anginaPrior MIPCI within 6 monthsPrior CABGIntermediate to high GRACE Risk Score

Low-risk features

No recurrence of chest pain

No signs of heart failure

No new ECG changes

(arrival,6h,12h)

No elevation of troponins

(arrival,6h,12h)

URGENT EARLY NO / ELECTIVE

NSTEACSRecomendations for invasive evaluation and revascularisation

ESC GUIDELINES 2011

NSTEACSRecomendations for invasive evaluation and revascularisation

ESC GUIDELINES 2011

Patients (N): 920 2874 7018

Adapted from Cannon Circulation. 2003.

“early conservative”“early conservative” “early invasive”“early invasive”

TIMI IIIB

MATEVANQWISH

FRISC II

TACTICS-TIMI 18

VINO

RITA-3

TRUCS

ISAR-COOL

ICTUS

Strategia invasiva o conservativa nelle NSTEACS

Metha-analysis of contemporary randomized studies Early Invasive vs Conservative Therapy

Relative Risk of all-cause mortality

Bavry et al. JACC 2006;48:1319-25

Metha-analysis of contemporary randomized studies Early Invasive vs Conservative Therapy

Relative Risk of cardiovascular mortality at 5 years follow-up

Fox KA, et al. JACC 2010;55:2435-45

Early invasive vs selective invasive in NSTEACS

Kaplan-Meier estimates of the cumulative rate of the composite primary end point

of death, nonfatal MI or rehospitalization for anginal symptoms within 1 year

ICTUS

Winter, N Engl J Med 2005;353:1095-104

Cannon et al, Eur Heart J 2004;25:1471-1472

Relative mortality benefit with the revascularisation vs gradient in

rates of revascularisation between both randomisation arms

Strategia Invasiva vs Conservativa

NSTACS: early invasive? selective invasive?

Hirsch A, et al: EHJ 2009;30:645-654

Hirsch A, et al: EHJ 2009;30:645-654

NSTACS: early invasive? selective invasive?

Hirsch A, et al: EHJ 2009;30:645-654

NSTACS: early invasive? selective invasive?

Hirsch A, et al: EHJ 2009;30:645-654

NSTACS: early invasive? selective invasive?

Pazienti del braccio “early invasive”Pazienti del braccio “early invasive”

Hirsch A, et al: EHJ 2009;30:645-654

NSTACS: early invasive? selective invasive?

Rates of the Primary End Point of Death, Nonfatal MI, or Rehospitalization for an Acute Coronary Syndrome at Six Months, According to Baseline Characteristics

TACTICS-TIMI 18

Cannon et al., N Engl J Med 2001; 344:1879-87

Strategia Invasiva vs Conservativa

TIMI Risk ScoreTIMI Risk Score

PURSUIT Risk ScorePURSUIT Risk Score

GRACE Risk ScoreGRACE Risk Score

No Diabete, no eco, no IRCNo Diabete, no eco, no IRC

No Diabete, no ecoNo Diabete, no eco

No Diabete, no eco, no IRCNo Diabete, no eco, no IRC

CRUSADE Risk Score CRUSADE Risk Score

NSTEACS: ADERENZA ALLE LG

Coronarografia < 48 ore e rischio

NSTEACSScelta della strategia e disponibilità di risorse

Età < 55 55-59 60-64 65-69 70-74 75-79 80-84 85

RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO

Rischio della PCI in funzione dell’età

Batchelor et al. JACC 2000

mortalità/IMA/CVA

mortalità

RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO

COMPLICANZE “EXTRACARDIACHE”

< 80 aa

> 80 aa

Batchelor et al. JACC 2000

%

Anziani e trials: una visione distorta?

CRUSADE JACC 2005

= < 75aa

= 75aa

PCI, ASA, betablockers, heparin, GPIIbIIIa inhibitors

NSTEACSRecomendations for GP IIb/IIIa inhibitors

ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010

ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010

NSTEACSRecomendations for GP IIb/IIIa inhibitors

ESC GUIDELINES NSTEACS 2011

ESC GUIDELINES NSTEACS 2011

Durante PCI

Upstream

Routine