RISK STRATIFICATION IN PATINETS WITH NSTE -ACS. BY: DR. AYMAN ABDEL SAMAD. M.D CARDIOLOGY.

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1 بسم االله الرحمن الرحيم

2 RISK STRATIFICATION IN PATINETS WITH NSTE -ACS. BY: DR. AYMAN ABDEL SAMAD. M.D CARDIOLOGY.

3 1. NATURAL HISTORY: -The short-term mortality of patients with unstable angina has been shown to be lower(1.7% at 30 days) than that of patients with NSTEMI or STEMI. -long term outcomes-for both mortality &nonfatal events- are actually worse for patients with either unstable angina or NSTEMI compared with STEMI.

4 SHORT TERM OUTCOME is depenent on اstate the hemodynamic MEDIUM TERM OUTCOME ; transient ST segment shift LONG TERM OUTCOME Tn T&I longer term above and beyond conventional risk factors

5 Prognosis in Unstable Angina / NSTEMI PURSUIT trial data

6 Mortality in Non-ST ACS Patients With Myocardial Infarction During Hospitalization 20 Patients with MI within 72 hours (n=593) 18.3% 15 % Mortality 10 5 Patients without MI within 72 hours (n=8,868) 5.5% 12.8% (P = ) Days following randomization Fintel D, ACC, 2000

7 2-METHODS OF RISK STATIFICATIN. patients with UA/NSTEMI are a heterogeneous group, with a prognosis that ranges from An excellent outcome with modest adjustments in therapeutic regimen, high risk of death or MI : in which intensive treatment is needed.

8 High risk subgoups of patients, identified by: -clinical features. -electrocardiographic findings, or -cardiac(or vascular) markers. This group appear to derive greater benefit from more aggressive -antithrombotic or - interventional therapy or -both.

9 3-CLINICAL VARIABLES: -classification of unstable angina has been shown in several studies to be useful clinically in identifying high risk patients. -High risk groups of patients with unstable angina are those with : -Acute rest pain. -Post-MI unstable angina. -Secondary unstable angina.

10 4-RISK ASSESSMENT BY ECG : -The admission ECG is very useful in predicting long-term adverse outcomes. -Independent predictors of 1-year death or MI included: - LBBB -ST segment deviation > 0.05mv. -The presence of T wave changes > 0.1mV, was associated with a modest or no increase in subsequent death or MI.

11 GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG Findings in Patients With ACS Cumulative Mortality (%) ST ACS STEMI with fibrinolytics T-wave inversion Days From Randomization

12 26. EKG: ST Depression

13 New LBBB

14 Non-ST-Segment Elevation MI

15 5-RISK ASSESSMENT BY CARDIAC MARKERS. 1-Creatine kinase-mb NSTMI= elevated biomarkers of myocardial necrosis -NSTMI with elevated CK-MB or troponins, have a worse long-term prognosis than those with unstable angina..

16 CK/MB Rises 4-6 hours after injury and peaks at 24 hours Remains elevated hours Positive if CK/MB > 5% of total CK and 2 times normal Elevation can be predictive of mortality False positives with exercise, trauma, muscle dz, DM, PE

17 2-Myoglobin Rises 2-4 hours after injury and peaks at 6-12 hours Remains elevated hours Not cardiac specific Rise of 25-40% over 2 hours strongly predictive of MI

18 ROPONINS : ery specific and more sensitive than CK Rises 4-8 hours after injury Remains elevated for 7-10 days Provide very useful prognostic information

19 inear relationship between the level f troponin T or I & subsequent risk f death he higher the troponin, the higher he mortality risk

20 Death Death/MI ognostic Value of Troponin T r I in ACS: A Meta-Analysis Neg Pos (Trop I + T) RR 3.8 ( ) 20.8 RR 3.9 ( )

21 -A higher risk of MI was observed with lower els of troponin in several studies, & thus the rall rate of death or MI is equally high among ients with low or higher troponin values. -Troponin T & I are useful not only in gnosing MI but also in risk assessment & in geting therapies to high risk patients.

22 in I Levels and Mortality in Patients with NSTE-ACS % 6.0% 3.4% 3.7% 1.7 % 1.0% to < to < to < to < to < Cardiac troponin I (ng/ml)

23 REACTIVE PROTEIN: -CRP is very promising. Elevated CRP has related to -increased risk of death -MI -need for urgent revascularization. -levels of CRP in patients with ACS are ximately five times higher than those of stable ts.

24 -CRP was able to discriminate a high- & a -risk group: mortality for patients with an vated CRP was 5.8% versus 0.4% for patients hout elevated CRP. -Mortality can be stratified from.4% for patients with both markers negative.7% if either CRP or troponin was positive.1% if both were positive.

25 Predictive Value of hs-crp Mortality from ACS in FRISC Substudy Cumulative Probability of Death (%) CRP >10mg/l (n=309) CRP 2-10mg/l (n=294) CRP <2mg/l (n=314)

26 -CRP measured at the time of hospital charge has been found to be a strong predictor outcome over 3 to 12 month.

27 Other inflammatory markers ave offered consistent evidence of an ssociation between systemic inflammation & ecurrent adverse events, including erum amyloid A onocyte chemoattractant protein-1(mcp-1).

28 HITE BLOOD CELL COUNT: pler marker of inflammation vated WBC counts were ass. with gher risk of mortality & recurrent acute I is association was independent of CRP.

29 D40 LIGAND : 40L is a member of tumor necrosis factorha family of proteins. ressed on the platelet surface when platelets activated ubsequently cleaved, generating a soluble rolytic fragment termed scd40l.

30 -it has been found to be both prothrombotic roinflammatory & to have a role in rosclerotic process. -CD40L has been correlated with the ree of platelet activation, as measured by elet monocyte aggregates, & thus is a novel ker of platelet activation.

31 -TYPE NATRIURETIC PEPTIDE: -BNP is a neurohormone that is hesized in ventricular myocardium & released sponse to increased wall stress. -its actions include :natriuresis, dilation, inhibition of sympathetic nerve ity, & inhibition of the renin-angiotensin-

32 ype Natriuretic Peptide (BNP) 10 nd Mortality in ACS Patients P<.001 Quartile 4 (n=630) Days After Randomization Quartile 3 (n=632) Quartile 2 (n=632) Quartile 1 (n=631)

33 -BNP has prognostic value across the full pectrum of patients with ACS, including those ith UA/NSTEMI. -Measurement of BNP in patients with /NSTEMI is very important to our current ls for risk stratification.

34 ELOPEROXIDASE(MPO): PO is a hemoprotein expressed by trophils that possesses potent inflammatory properties & that promotes dation of lipoproteins in vascular atheroma. arker of.inflammation.role of neutrophil in vascular ammation and ACS

35 - MPO serum levels in patients with TE-ACS were associated with increased risk sequent death. independent of other risk factors & other iac markers. -Elevations of MPO have been seen ughout the coronary vasculature in patients UA/NSTEMI.

36 Serum Creatinine : evated creatinine was found to be ociated with an adverse prognosis, dependent of other standard risk ctors.

37 LUCOSE : -Adverse outcomes have been seen among betic patients with acute MI with elevated mission glucose values compared with patients thout hyperglycemia. -This association was found even among tients without a prior diagnosis of diabetes. -Adverse oucome also with poor glycemic ntrol, as measured by hemoglobin A 1c has

38 aunwald Classification of Risk or Patients with NSTE-ACS

39 INCAL INDICATORS OF INCREASED ISK IN PATIENTS WITH NSTE-ACS; istory ; ge more than 70 y M ost MI angina VD erebrovascular disease

40 LINICAL PRESENTATION; raunwald class II or III (acute,subacute est pain) raunwald class B (secondary UA) F ypotension entricular arrhythmias

41 CG ; T deviation 0.05 Mv BBB wave inversion 0.03 Mv

42 ardiac markers n T or Tn I NP K-MB D40 LIGAND LUCOSE REATININE

43 NGIOGRAM ; hrombus VD EDUCED EF

44 COMBINED RISK ASSESSMENT SCORES. - Comprehensive risk scores that use clinical iables, findings from ECG, & findings from serum diac markers. - the most important baseline determinants of higher rtality were: -increasing age. -increasing heart rate. -lower systolic BP. -ST segment depression. -signs of heart failure.

45 TIMI Risk Score edicts risk of death, new/recurrent MI, need for urgent revascularization within 14 days >65 years AD Risk Factors Coronary Stenosis >50 % eviation nginal events <24 hours in last 7 days ated Cardiac Markers (CK-MB or troponin)

46 s scoring system was used to atify the risk for patients across a 10 s gradient of risk m 4.7 % to 40.9 % (p<0.001)

47 The TIMI Risk Score and Incidence of dverse Ischemic Events in Patients with NSTE-ACS Death, MI, or Urgent Revascularization (%) / /7 Number of Risk Factors

48 Risk Stratification

49 e strongest prognostic markers RP ; marker of inflammation initiator of therosclerosis NP; reflect impaired LV function n ;the most sensitive and specific marker f myocyte necrosis

50 ients with higher TIMI risk scores ; significant reductions in events when ated with ; noxaparine compared with ufh (heparin) ith a GPII B/III A inhibitor compared with acebo. ith an invasive vs conservative strategy.

An update on the management of UA / NSTEMI. Michael H. Crawford, MD

An update on the management of UA / NSTEMI Michael H. Crawford, MD New ACC/AHA Guidelines 2007 What s s new in the last 5 years CT imaging advances Ascendancy of troponin and BNP Clarification of ACEI/ARB