strive teleconf presentation aug15 2007

ACS Critical Pathways 2007 Teleconferences

August 15, 2007

This activity is co-provided by the Network for Continuing Medical Education and EduPro Resources LLC.

This activity is supported by an educational grant from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.

STRIVETM

2

Faculty

Christopher P. Cannon, MDAssociate Professor of Medicine

Harvard Medical School

Senior Investigator, TIMI Study Group

Associate Physician, Cardiovascular Division

Brigham and Women’s Hospital

Boston, Massachusetts

STRIVETM

3

The Network for Continuing Medical Education and

EduPro Resources LLC require that CME/CNE faculty

disclose, during the planning of an activity, the existence

of any personal financial or other relationships they or

their spouses/partners have with the commercial

supporter of the activity or with the manufacturer of any

commercial product or service discussed in the activity.

Disclosure Statement

STRIVETM

4

Christopher P. Cannon, MD, has received research support from Accumetrics, AstraZeneca Pharmaceuticals LP, GlaxoSmithKline, Merck & Co., Inc., Merck/Schering-Plough Pharmaceuticals, sanofi-aventis, and Schering-Plough Corporation.

The team from Doylestown Hospital reports it has no relationships to disclose.

The NCME staff reports it has no relationships to disclose.

Faculty Disclosure Statement

STRIVETM

5

Update of the ACC/AHA ACS Guidelines: UA/NSTEMI

Christopher P. Cannon, MD

STRIVETM

6

Polling Question #1Have you implemented a formal plan to incorporate the new UA/NSTEMI guidelines into your institution’s ACS pathways?

2) Updated ACS pathways plan has not been discussed

3) Updated ACS pathways plan discussed but not initiated

4) Updated ACS pathways plan initiated; full implementation expected ≤6 months

5) Updated ACS pathways plan initiated; full implementation expected >6 months

STRIVETM

7

What’s New Since 2002?

Background:

• 1.57 million hospital admissions for ACS annually

• 1.24 million UA/NSTEMI cases

• As previously, risk scores guide serial clinical decision making

Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.

2007 ACC/AHA UA/NSTEMI Guideline Revision

STRIVETM

8

Risk Stratification• Integral prerequisite to decision making

a) Intensive initial assessmentb) Continuous clinical assessmentc) Targeted ECG and marker data

• Risk based on contingent probabilitiesa) Probability of obstructive CAD causing ischemiab) Risk given presence of obstructive CAD

• Risk scores should be a routine part of assessment throughout the hospital course and periodically after discharge


Anderson JL, et al. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.

STRIVETM

9

Risk Assessment Dependent on Contingent Probabilities

Likelihood of obstructive CAD as cause of symptoms

– Dominated by acute findings

Examination Symptoms Markers

– Traditional risk factors are of limited utility

Does this patient have symptoms due to acute ischemia from obstructive CAD?

Risk of bad outcome

– Dominated by acute findings

Older age very important

Hemodynamic abnormalities critical

ECG, markers

What is the likelihood of death, MI, heart failure?


Anderson JL, et al. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.

STRIVETM

10

Selection of Strategy: Invasive Versus Conservative Strategy

• An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is indicated with refractory angina or hemodynamic or electrical instability (Class I, Level of Evidence: B)



STRIVETM

11

Selection of Strategy: Invasive Versus Conservative Strategy (cont)

• 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 during 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



STRIVETM

12

Selection of Strategy: Invasive Versus Conservative Strategy (cont)

• In initially stabilized patients, an initially conservative (ie, 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)



STRIVETM

13

Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy

Proceed to Diagnostic Angiography

ASA (Class I, A)Clopidogrel if ASA intolerant (Class I, A)

Diagnosis of UA/NSTEMI Is Likely or Definite

Invasive StrategyInitiate A/C Rx (Class I, A)

Acceptable options: enoxaparin or UFH (Class I, A) bivalirudin or fondaparinux (Class I, B)

Select Management StrategyProceed With an

Initial Conservative

Strategy

Prior to AngiographyInitiate at least one (Class I, A) or both (Class IIa, B) of the following:

ClopidogrelIV GP IIb/IIIa inhibitor

Factors favoring administration of both clopidogrel and GP IIb/IIIa inhibitor include:Delay to angiography

High risk featuresEarly recurrent ischemic discomfort

Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol. 2007;50:652-726.


STRIVETM

14

Initiate clopidogrel (Class I, A) Consider adding IV eptifibatide or tirofiban (Class

IIb, B)

Conservative StrategyInitiate A/C Rx (Class I, A):

Acceptable options: enoxaparin or UFH (Class I, A) or fondaparinux (Class I, B), but enoxaparin or fondaparinux are preferable (Class IIA, B)

Select Management Strategy

ASA (Class I, A)Clopidogrel if ASA intolerant (Class I, A)

Diagnosis of UA/NSTEMI Is Likely or Definite

Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy

Proceed With Invasive Strategy

(Continued on slide 18)



STRIVETM

15

Initial Conservative Strategy: Early Hospital Care

• ASA; clopidogrel if intolerant (I, A)

• Anticoagulant therapy should be added to antiplatelet therapy as soon as possible after presentation (I, A)

– Enoxaparin or UFH (I, A)

– Fondaparinux (I, B)

– Enoxaparin or fondaparinux preferable (IIa, B)

• Initiate clopidogrel, loading dose + maintenance dose (I, A)

– Consider IV eptifibatide or tirofiban (IIb, B)



STRIVETM

16

Initial Conservative Strategy: Early Hospital Care (cont)

Beta-blocker therapy

– Initiate oral therapy within first 24 h unless HF, low-output state, increased risk for cardiogenic shock, or relative contraindications (I, B)

– IV therapy for high blood pressure without contraindications (IIa, B)

– IV therapy may be harmful with contraindications to beta blockade, signs of HF or low-output state, or other risk factors for cardiogenic shock (III, A)



STRIVETM

17


• Lipid management– Fasting lipid profile within 24 h (I, C)– Statin (in absence of contraindications) should be given regardless

of baseline LDL-C predischarge (I, A)

• ACE inhibitor (oral)– Within 24 h with pulmonary congestion or LVEF ≤40, in absence of

hypotension (systolic blood pressure <100 mm Hg or <30 mm Hg below baseline) or known contraindications (I, A)

– ARB if ACE intolerant (I, A)– Can be useful without pulmonary congestion or LVEF <0.40 (IIa, B)– No IV ACE inhibitor in first 24 h because of increased risk of

hypotension (III, B)



STRIVETM

18

Any subsequent events necessitating angiography?

EF >0.40

Evaluate LVEF

Low Risk

Continue ASA indefinitely (Class I, A) Continue clopidogrel for at least 1 month (Class I, A) and ideally up

to 1 y (Class I, B)Discontinue IV GP IIb/IIIa if started previously (Class I, A)

Discontinue A/C Rx (Class I, A)

(Class I, B)

Proceed to Dx Angiography

Yes

EF ≤0.40Stress Test

(Class I, A)

No

Not Low Risk

(Class IIa, B)

Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy

(Continued from slide 14)

(Class I, A)

(Class IIa, B)

(Class I,

B)



STRIVETM

19


• If LVEF is <0.40, it is reasonable to perform diagnostic angiography (IIa, B)

• A stress test should be performed for assessment of ischemia (I, B)

– If the patient is classified as not low risk, diagnostic angiography should be performed (I, A)

• Measurement of BNP or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS (IIb, B)



STRIVETM

20

• Continue ASA (Class I, A)• Loading dose of clopidogrel if not

given preangiography (Class I, A)• Discontinue IV GP IIb/IIIa after

at least 12 h if started preangiography (Class I, B)

• Continue IV UFH for at least 48 h (Class I, A) or enoxaparin or fondaparinux for duration of hospitalization (A); either discontinue bivalirudin or continue at a dose of 0.25 mg/kg/h for up to 72 h at physician‘s discretion (Class I, B)

• Continue ASA (Class I, A)

• Discontinue clopidogrel 5-7 d prior to elective CABG(Class I, B)

• Discontinue IV GP IIb/IIIa 4 h prior to CABG (Class I, B)

• Continue UFH (Class I, B); discontinue enoxaparin 12-24 h prior to CABG; discontinue fondaparinux 24 h prior to CABG; discontinue bivalirudin3 h prior to CABG. Dose with UFH per institutional practice(Class I, B)

• Continue ASA (Class I, A) • Loading dose of clopidogrel

if not given preangiography (Class I, A)

and• IV GP IIb/IIIa if not started

preangiography (Class I, A)

• Discontinue A/C Rx after PCI for uncomplicated cases (Class I, B)

Antiplatelet and A/C Rx

at physician’s discretion

(Class I, C)

No significant obstructive

CAD on angiography

CAD on angiography

PCICABG

Management After Diagnostic Angiography in Patients With UA/NSTEMI


Select Post Angiography Management Strategy


Medical Therapy

STRIVETM

21

Long-term Antithrombotic Therapy at Hospital Discharge After UA/NSTEMI

Medical Tx Without Stent

Bare Metal Stent

Drug-Eluting Stent

ASA 162-325 mg/d for at least 1 mo, then 75-162 mg/d indefinitely

(Class I, A) and

Clopidogrel 75 mg/d for at least 1 mo (Class 1, A) and ideally up to

1 y (Class I, B)

Add: Warfarin (INR 2.0- 2.5) (Class IIb, B)

Continue with dual antiplatelet tx as above

Indication for Anticoagulation?

ASA 75-162 mg/d indefinitely (Class I, A)

and Clopidogrel 75 mg/d for at

least 1 mo (Class I, A) and up to 1 y (Class I, B)

ASA 162-325 mg/d for at least 3-6 months, then

75-162 mg/d indefinitely (Class I, A)

andClopidogrel 75 mg/d for at

least 1 y (Class I, B)

/ UA NSTEMI Patient Groups at

Discharge



STRIVETM

22

Medical therapy without stenting– ASA 75-162 mg/d indefinitely (I, A)

and– Clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 y (I, B)

Bare metal stent– ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely (I, A)

and – Clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 y (I, B)

Drug-eluting stent

– ASA 162-325 mg/d at least 3 (sirolimus) to 6 (paclitaxel) mo, 75-162 mg/d indefinitely (I, A)

and – Clopidogrel 75 mg/d at least 1 y (I, B)


More Aggressive Long-termAntiplatelet Therapy


STRIVETM

23

Discharge Planning: Secondary Prevention• Clopidogrel, initial conservative strategy

– Continue at least 1 mo (I, A)

– Continue ideally up to 1 y (I, A)

• ACE inhibitor

– Continue indefinitely with HF, LV dysfunction with LVEF <0.40, hypertension, or diabetes (I, A)

– Reasonable in absence of LV dysfunction, hypertension, or diabetes (IIa, A)

– Reasonable with HF and LVEF >0.40 (IIa, A)

– Consider ACE/ARB combination with persistent HF and LVEF <0.40 despite conventional therapy including ACE or ARB (IIb, B)

• ARB should be administered at discharge (I, A) and long-term (IIa, B) with ACE inhibitor intolerance and signs of HF with LVEF <0.40 (I, A)



STRIVETM

24

Discharge Planning: Secondary Prevention (cont)

Aldosterone receptor blockade should be prescribed long term if without significant renal dysfunction or hyperkalemia, already on ACE inhibitor, with LVEF <0.40, and either symptomatic HF or diabetes (I, A)

Lipid management

– Statin regardless of baseline LDL-C (I, A) initiated prior to discharge (I, A)

– Goal LDL-C <100 mg/dL (I, A), with <70 mg/dL reasonable (IIa, A)

– Treatment of triglycerides and non–HDL-C useful If TG 200-499 mg/dL, non–HDL-C should be <130 mg/dL

(I, B) TG ≥500 mg/dL, fibrate, or niacin before LDL-C lowering to

prevent pancreatitis (I, C)



STRIVETM

25


Blood pressure control

– <140/90 mm Hg (I, A)

– <130/80 mm Hg with diabetes mellitus or chronic kidney disease (I, A)

Smoking cessation and avoidance of exposure to environmental tobacco is recommended (I, B)

– Education, referral to programs, and pharmacotherapy is useful (I, B)



STRIVETM

26


NSAIDS

– Discontinue at UA/NSTEMI presentation (I, C)

– No NSAID, nonselective or COX-2 selective (except ASA), during hospitalization for patients at high risk of mortality, reinfarction, ↑ BP, HF, or myocardial rupture (II, C)

– At discharge, chronic musculoskeletal pain relief with acetaminophen, small dose narcotics, nonacetylated salicylates (I, A)

– Nonselective NSAID (eg, naproxen) reasonable if above strategies are insufficient (IIa, C)

– For intolerable discomfort, increasing COX-2 selectivity, lowest dose for shortest time (IIb, C)



STRIVETM

27


Discharge education/referral

– Medications, diet, exercise, smoking cessation, cardiac rehabilitation (I, C)

– Return appointment 2-6 wk low-risk medically treated or revascularized

patients (I, C) Within 14 days for higher-risk patients (I, C)

Menopausal hormone therapy (estrogen plus progestin or estrogen alone) should not be given de novo for secondary prevention of coronary events (III, A)

Antioxidant vitamin supplements (C, E, or beta carotene) and folic acid (with or without B6 and B12) should not be used for secondary prevention (III, A)



STRIVETM

28

Coming in the Fall 2007: New ACS Critical Pathways Workshops

Implementing Updated ACC/AHA Guidelines for ACS:

Achieving New Standards of Care

For more information and to register for a program near you, visit www.strivecme.com

and click on “Regional Programs” (on the left side of the page)

STRIVETM

29

Featured Institution

Doylestown HospitalDoylestown, Pennsylvania

STRIVETM

30

Polling Question #2

1) We are currently on the same item

2) We have since moved to the next item on the checklist

3) We have progressed by more than 1 item on the checklist

4) ACS pathways are up-to-date and regularly followed

If you participated in a previous teleconference, how much progress have you made since then?

(Please refer to the checklists on the next 3 slides.)

STRIVETM

31

Progress Checklist:Immediate Goals

Circulate discharge plan and other tools to all cardiology, ED, and CV nursing staff for comments

Circulate pathways to all cardiology, ED, and CV nursing staff for comments

Develop draft pathways

Assemble team and set up meeting of working group

STRIVETM

32

Progress Checklist:Short-term Goals/Activities

Grand rounds/conference: Cardiology/IM

Grand rounds/conference: Emergency Dept.

Grand rounds/conference: Nursing

Circulate memo

Launch critical pathways

Finalize critical pathways

STRIVETM

33

Progress Checklist:Long-term Goals/Activities

NRMI

AHA Get With The Guidelines

ACC National Cardiovascular Data Registry

CRUSADE

GRACE

REACH

Other

Monitor data: which registry?

STRIVETM

34

Question-and-Answer Session

STRIVETM

35

Concluding RemarksChristopher P. Cannon, MD

Next Program

Gregg C. Fonarow, MDWednesday, September 12, 2007

12:00 Noon Eastern Time (9:00 AM Pacific Time)

Report From the European Society of Cardiology (ESC) Congress 2007

strive teleconf presentation aug15 2007

Health & Medicine

uanstemi christopher

institutions acs pathways

risk assessment dependent

uanstemi cases

new uanstemi guidelines

marker data risk

risk of bad outcome

formal plan