effect of early revascularization versus delayed revascularization versus medical therapy on...
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Effect of Early revascularization versus delayed revascularization versus medical therapy on inpatient mortality in patients with non ST elevation MI in a community hospital Setting
Owais Jeelani ,MBBS Mentor:Dr.A.Herle,MD,FACC
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Background
• Coronary heart disease is the leading cause of death in the United States, with myocardial infarction a common manifestation of this disease.
• Of all patients having a myocardial infarction, 25 to 35% die before receiving medical attention, most often from ventricular fibrillation. For those who reach a medical facility, the prognosis is considerably better and has improved over the years: in-hospital mortality rates fell from 11.2% in 1990 to 9.4% in 1999
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Background
• In 2006, approximately 1.2 million Americans
sustained a myocardial infarction. Of these, two third had a myocardial infarction without ST-segment elevation
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Background
• Randomized trials have shown that a routine invasive strategy is beneficial in high-risk patients with acute coronary syndromes.
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Non-ST Elevation ACSNon-ST Elevation ACS
Generally caused by partially occlusive,
platelet-rich thrombus
Unobstructedlumen
thrombus
Results from cross-linking of fibrinogen by platelet GP IIb-
IIIa receptors at sites of plaque rupture
platelet
fibrinogen
Rupturedplaque
GP IIb-IIIa
Artery wall
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Background
• In patients with myocardial infarction with ST-segment elevation, in which the infarct-related artery is usually occluded and there is ongoing transmural ischemia, it is well established that the earlier primary percutaneous coronary intervention can be performed, the lower the mortality.
• By contrast, in patients with acute coronary syndromes without ST-segment elevation (including unstable angina and myocardial infarction), the culprit artery is often patent, there is usually no ongoing transmural ischemia, and the patient may have a good response to initial medical treatment.
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Background
• Although meta-analyses of previous randomized trials that compared an invasive strategy with a conservative strategy in patients
with acute coronary syndromes have shown a benefit for an invasive strategy, the timing of angiography in the invasive-strategy group of these previous studies ranged from as early as 19 hours after randomization in one large trial to as late as 96 hours in another large trial.
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Invasive vs. Conservative Strategy for UA/NSTEMI – All Studies
TIMI IIIBTIMI IIIB
Conservative Invasive
VANQWISHVANQWISHMATEMATE
FRISC IIFRISC II
TACTICS-TIMI 18
TACTICS-TIMI 18
VINOVINO
RITA-3RITA-3
# Pts: 1140 1674 7018
TRUCS TRUCS
ISAR-COOL ISAR-COOL
ICTUSICTUS
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Background
• Given this wide variation in the timing, there remains substantial uncertainty regarding the optimal timing for intervention in such patients.
• Small, randomized trials comparing early intervention with delayed intervention have generated conflicting results.
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Background
• Although some observational analyses have suggested that earlier intervention, as compared
with delayed intervention, may reduce events, others have suggested that outcomes appear to be similar between the two approaches.
• Also, there has been a suggestion of a hazard
associated with routine early intervention.
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Study Objective
• Primary endpoint:
-Is early revascularization better than delayed revascularization or Medical therapy alone in reducing in hospital mortality in Patients with non ST elevation MI in a community care setting?
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Secondary endpoint
• What is the relative mortality of NSTEMI patients undergoing early revascularization vs delayed revascularization vs medical therapy alone?
• What is the relative length of hospital stay in the three groups studied?
• What percentage of coronary angiography patients actually underwent intervention (PCI or CABG)?
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Methods
• Retrospective Data Analysis of patients at Mercy Hospital who have documented non ST elevation MI from June 2008 to June 2009
• Institutional Review Board approval through the Catholic Health System
• 383 out of 591 patients reviewed were enrolled in the study after meeting the inclusion criteria
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Inclusion criteria
• Based on ICD Coding 410.71• Patients with non ST elevation MI with chest
pain at rest, lasting > 30 minutes and non-responding to sublingual nitroglycerin tablets in addition to elevated troponins greater than or equal to 0.1.
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Exclusion criteria
• Patients with ST elevation MI not fulfilling the above criteria.
• Patients with MI not fulfilling the above inclusion criteria
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Analysis of Data
• Mortality odds ratios used for the comparison of proportion of deaths in each arm (primary end point).
• Length of Stay comparison evaluated by mean number of days along with 95% confidence interval standard deviations.
• paired t-test with a p-value of <0.05 deemed statistically significant
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Results• Primary End-Point– There is statistically significant difference in in-
hospital mortality between patients treated with revascularization versus patients treated conservatively.
– This difference is reflected in patients >65 yrs of age.
– There is no statistically significant difference in in-hospital mortality in patients younger than 65 yrs.
– There is statistically significant difference in in-hospital mortality in males, patients with ischemic changes on EKG and patients having more than 3 risk factors.
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Results
• Primary End-Point -No statistically significant difference in in-hospital
mortality in patients treated with early revascularization versus patients treated with delayed vascularization
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Results
• Secondary Outcome– Statistically significant difference in hospital length
of stay in patients treated with re vascularization versus patients treated conservatively
– Statistically significant difference in hospital length of stay in patients treated with early revascularization versus patients treated with delayed revascularization.
– Statistically significant difference in hospital length of stay in patients >65 years treated with revascularization versus patients treated conservatively.
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Conclusion
Revascularization offers benefit in reducing short term mortality over medical therapy alone
Benefit is more pronounced in elderly high risk male patients.
Immediate catheterization and intervention does not offer a benefit over initial medical stabilization followed by delayed catheterization and intervention
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How are we doing?
• Comparison with Action registry data
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Thinking outside the box…
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References• 1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial
infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20
• 2. Mehta SR, Cannon CP, Fox KA, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA 2005; 293:2908-2917. Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, 3.Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006;48:1319-1325.
• 4.Cannon CP, Gibson CM, Lambrew CT, et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA 2000;283:2941-2947.
• 5.Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2008;117:296-329. [Erratum, Circulation 2008;117(6):e162.]
• 6.Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med 1992;326:310-318.
• 7.Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879-1887
• 8.Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet 1999;354:708-715.
• 9.Fox KA, Poole-Wilson P, Clayton TC, et al. 5-Year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005;366:914-920.
• 10.Spacek R, Widimsky P, Straka Z, et al. Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial. Eur Heart J 2002;23:230-238
• 11.Neumann FJ, Kastrati A, Pogatsa-Murray G, et al. Evaluation of prolonged antithrombotic pretreatment ("cooling-off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA 2003;290:1593-1599.
• 12.de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005;353:1095-1104
• 13.Riezebos RK, Ronner E, Ter Bals E, et al. Immediate versus deferred coronary angioplasty in non-ST-elevation acute coronary syndromes. Heart 2008 December 22 .
• 14.Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009;360:2165-2175.