Case study #1 Evolving Concepts in Non-ST Elevation ACS (NSTE-ACS)
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2 Case study #1 Evolving Concepts in Non-ST Elevation ACS (NSTE-ACS) Fernando Bátiz MD PGY-5 cardiology fellow Hospital Español Fernando Bátiz
3 Sex: Female Race: Caucasian Age: 79 years old CC: chest pain Fernando Bátiz
4 Family history None Social history 3 cigarettes per day for 30 years Fernando Bátiz fernando_batiz@me.com
5 Past medical & surgical history 1953 Appendectomy Unspecified chronic joint pain Meds: NSAIDs PRN for joint pain Fernando Bátiz
6 HPI 79 year old female patient that presented to our ED complaining of sudden onset of oppressive chest pain 7/10 in intensity that radiated to the left arm. It presented 3 hours before ED eval and lasted for 1 hour. It was not associated with exertion. Her discomfort was associated by nausea and profuse sweating. Asymptomatic in ED. When asked, she had a similar episode 1 week ago. Fernando Bátiz fernando_batiz@me.com
7 Physical examination BP: 140/80 mmhg HR: 70 BPM RR: 16 VPM TEMP: 36º C O 2 Sat: 94% Ø murmurs, S3, S4 or rubs. Neck: Ø JVD Heart: Chest: Unremarkable. Abdomen: Unremarkable. Extremities: Ø edema. Weight: 107 Kg Height: 178 cm BMI: 34 kg/m 2 Fernando Bátiz fernando_batiz@me.com
8 Fernando Bátiz
9 Posterior leads Right leads V7 V1R V4R V8 V2R V5R V9 V6R Fernando Bátiz
10 ER LABS CE BMP Troponin I 0.05 ng/dl Na 136mmol/L Myoglobin 47 mg/dl K 4mmol/L CK 84 mg/dl Cl 102mmol/L CKMB 2.5 mg/dl CO mmol/L CBC Mg 1.97mg/dL Leuk 6.4x103/uL Creatinine 0.7 mg/dl Hb 17.2g/dL BUN 24.02mg/dL PLT 243x103/uL Uric acid 3.88mg/dL Neut 4.85x103/uL Urea 24.6mg/dL Lymph 1.6x103/mL HbA1 c 5.8% Fernando Bátiz fernando_batiz@me.com
11
12 Fernando Bátiz
13 ARS Question:Which type of invasive strategy would you choose for this patient? Immediate <2hrs Early <24hrs Delayed 25-72hrs 1 2 3
14 She was admitted to the CCU and was eventually (4 hours later) taken to the cathlab. Ticagrelor 180mg Aspirin 250mg
15 Fernando Bátiz
16 Fernando Bátiz
17 Post PCI Fernando Bátiz
18 Early versus delayed invasive strategies Fernando Bátiz
19 TIMI IIIB VANQWISH 1 YEAR AVG FU 23MO Anderson HV, Cannon CP, Stone PH, et al. One-year results of the thrombolysis in myocardial infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-q wave Myocardial infarction. J Am Coll Cardiol. 1995;26(7): Boden WE, Oʼrourke R a., Crawford MH, et al. Outcomes in Patients with Acute Non-Q-Wave Myocardial Infarction Randomly Assigned to an Invasive as Compared with a Conservative Management Strategy. N Engl J Med 1998 Oct 8;339(15):1091. Fernando Bátiz fernando_batiz@me.com
![FRISC II (Risk ratio 0.78 [95% CI 0.62 0.98], p=0.031) 6MO Ragmin F.](/docs-images/88/115211603/images/20-2.jpg "Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomized multicentre study.")
20 FRISC II (Risk ratio 0.78 [95% CI ], p=0.031) 6MO Ragmin F. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomized multicentre study. Lancet. 1999;354(9180): Fernando Bátiz
21 TACTICS TIMI 18 Primary endopoint: Death, Nonfatal Myocardial Infarction, or Rehospitalization for an Acute Coronary Syndrome during the Six- Month Follow-up Period. 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(25): Fernando Bátiz fernando_batiz@me.com
22 Amsterdam EA, Wenger NK, Brindis RG, et al AHA/ACC guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014
23 Timing
24 Amsterdam EA, Wenger NK, Brindis RG, et al AHA/ACC guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Fernando Bátiz fernando_batiz@me.com
25 Amsterdam EA, Wenger NK, Brindis RG, et al AHA/ACC guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Fernando Bátiz fernando_batiz@me.com
26 Amsterdam EA, Wenger NK, Brindis RG, et al AHA/ACC guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Fernando Bátiz fernando_batiz@me.com
27 Amsterdam EA, Wenger NK, Brindis RG, et al AHA/ACC guideline for the management of patients with Non-ST-Elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol Fernando Bátiz fernando_batiz@me.com
28 Roffi M, Patrono C, Collet J-P, et al ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent STsegment elevation. Eur Heart J Fernando Bátiz
29 Roffi M, Patrono C, Collet J-P, et al ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent STsegment elevation. Eur Heart J Fernando Bátiz
30 TIMACS Composite of death, myocardial infarction, or stroke at 6 months Early intervention did not differ greatly from delayed intervention in preventing the primary outcome. Mehta SR, Granger CB, Boden WE, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes. N Engl J Med. 2009;360(21):
31 TIMACS Grace >140 Mehta SR, Granger CB, Boden WE, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes. N Engl J Med. 2009;360(21):
32 TIMACS Secondary outcome Secondary outcome Mehta SR, Granger CB, Boden WE, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes. N Engl J Med. 2009;360(21):
33 Security
34 ISAR COOL Neumann F, Kastrati A, Pogatsa-Murray G, al et. Evaluation of prolonged antithrombotic pretreatment ( cooling-off strategy) before intervention in patients with unstable coronary syndromes: A randomized controlled trial. JAMA. 2003;290(12):
35 ABOARD Median troponin I value N = 352 Immediate Delayed 2.1 [ ] ng/ml VS 1.7 [ ] ng/ml p=0.70 Montalescot G, Cayla G, Collet JP, et al. Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA 2009;302: Fernando Bátiz fernando_batiz@me.com
36 N: 4 RCT N: Katritsis DG, Siontis GCM, Kastrati A, et al. Optimal timing of coronary angiography and potential intervention in non-st-elevation acute coronary syndromes. Eur Heart J. 2011;32(1):32-40.
37 Katritsis DG, Siontis GCM, Kastrati A, et al. Optimal timing of coronary angiography and potential intervention in non-st-elevation acute coronary syndromes. Eur Heart J. 2011;32(1):32-40.
38 N: 7 RCT 4 Observational studies N: Navarese EP, Gurbel PA, Andreotti F, et al. Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158(4):
39 Navarese EP, Gurbel PA, Andreotti F, et al. Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158(4):
40 Navarese EP, Gurbel PA, Andreotti F, et al. Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158(4):
41 Navarese EP, Gurbel PA, Andreotti F, et al. Optimal Timing of Coronary Invasive Strategy in Non ST-Segment Elevation Acute Coronary Syndromes A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158(4):
42 Costs
43 Katritsis DG, Siontis GCM, Kastrati A, et al. Optimal timing of coronary angiography and potential intervention in non-st-elevation acute coronary syndromes. Eur Heart J. 2011;32(1):32-40.
44 Lamy A, Tong WR, Bainey K, Gafni A, Rao-Melacini P, Mehta SR. Cost Implication of an Early Invasive Strategy on Weekdays and Weekends in Patients With Acute Coronary Syndromes. Can J Cardiol. 2015;31(3):
45 Ischemia & CV outcomes
46 TIMACS Grace >140 Mehta SR, Granger CB, Boden WE, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes. N Engl J Med. 2009;360(21):
47 TIMACS Secondary outcome Secondary outcome Mehta SR, Granger CB, Boden WE, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes. N Engl J Med. 2009;360(21):
48 Katritsis DG, Siontis GCM, Kastrati A, et al. Optimal timing of coronary angiography and potential intervention in non-st-elevation acute coronary syndromes. Eur Heart J. 2011;32(1):32-40.
49 Milosevic A, Vasiljevic-Pokrajcic Z, Milasinovic D, et al. Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients: The RIDDLE-NSTEMI Study. JACC Cardiovasc Interv. 2016;9(6):
50 There is a tendency that earlier is better. Early invasive therapy is safe. Early invasive therapy reduces costs. Early invasive therapy reduces ischemia and other CV outcomes. Fernando Bátiz fernando_batiz@me.com
51 There are specific scenarios for each strategy. Patients should be assessed individually to select the best strategy for them. Fernando Bátiz
52 Thank you!
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