Final ACS Risk Stratification Management for 12th VN

Final ACS Risk Stratification Management for 12th VN tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án, bài tập lớ...

Acute Coronary Syndromes

Risk Stratification & Management

USA

Hospitalizations in the U.S due to

ACS

Acute Coronary Syndromes*

UA/NSTEMI† STEMI

1.24 million

Admissions per year

0.33 million

Admissions per year

*Primary and secondary diagnoses †About 0.57 million NSTEMI and 0.67 million UA.

Heart Disease and Stroke Statistics – 2007 Update Circulation 2007; 115:69–171.

Age- and Sex-Adjusted Incidence Rates of Acute

Myocardial Infarction, 1999 to 2008

•Yeh RW et al N Engl J Med 2010;362:2155-2165

Adjusted Odds Ratio for 30-Day Mortality, According to Year

•Yeh RW et al N Engl J Med 2010;362:2155-2165

Standard treatment for ACS

Antianginal drugs

Beta-blocker Nitroglycerin Diltiazem

Lipid-lowering drugs Statins

Antiplatelet drugs

Aspirin Clopidogrel Prasugrel

Antithrombotic drugs

Heparin Enoxaparin Fondaparinux Bivalirudin

Invasive management Angiogram ± revascularization

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Risk Stratification

• Clinical factors

– Age, history of coronary disease, LV function, diabetes mellitus

– Prolonged/recurrent resting CP or CP with dyspnea

– Presence or absence of heart failure, hypotension,

tachycardia, cardiac arrest

TIMI risk score

Points Age ≥ 65 years 1

≥ 3 CAD risk factors 1

Prior CAD stenosis ≥ 50% 1

≥ 2 anginal events within last 24 h 1

ASA use during 7 days prior to hosp 1

Elevated cardiac markers 1

ST segment change ≥ 0.05 mV 1

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High risk: Total ≥ 5

30-day and 1-year endpoint rates by risk group for the TIMI score

de Araújo Gonçalves P et al Eur Heart J 2005;26:865-872

PURSUIT risk score

30-day and 1-year endpoint rates by risk group for the PURSUIT score

de Araújo Gonçalves P et al Eur Heart J 2005;26:865-872

Global Registry of Acute Coronary Events

(GRACE) risk score

Points

Heart rate 0-46 Systolic BP 0-63 Creatinine 2-31 Killip class 0-64 Cardiac arrest at admission 43 Elevated cardiac markers 15 ST-segment deviation 30

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High risk: Total ≥ 140

Eagle KA, et al JAMA 2004;291:2727-33 11

Admission Risk Calculator

www.outcomes.org/grace

Discharge Risk Calculator

www.outcomes.org/grace

30-day and 1-year endpoint rates by risk group for the GRACE score

de Araújo Gonçalves P et al Eur Heart J 2005;26:865-872

GRACE and PURSUIT superior to TIMI

Receiver-operating characteristic curves for predicting in-hospital and 1-year mortality

•Yan A T et al Eur Heart J 2007;28:1072-1078

Why are GRACE and PURSUIT

superior?

• Age as a continuous variable

– Only included as a categorical variable in TIMI

• Heart failure on admission

– Not in TIMI

• Baseline serum creatinine (only in GRACE)

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Admission risk score correlates with

benefit from revascularization

de Araújo Gonçalves P et al

Eur Heart J 2005;26:865-872

Fox, K A A et al J Am Coll Cardiol 2010;55:2435-2445

Meta-analysis of FRISC-II, ICTUS, RITA-3

Routine versus selective invasive in ACS

Risk of CV Death or MI

•Copyright ©2010 American College of Cardiology Foundation Restrictions may apply.

Fox, K A A et al J Am Coll Cardiol 2010;55:2435-2445

Meta-analysis of FRISC-II, ICTUS, RITA-3

Routine versus selective invasive in ACS

Early versus Delayed Invasive Intervention in Acute

Coronary Syndromes The TIMACS Study

• 3031 patients with ACS

randomized to early

(median 14 h) or delayed

(median 50 h) angiography

• Primary outcome: Death,

MI, stroke at 6 mos

Kaplan-Meier Cumulative Risk of the Primary Outcome, Stratified

According to GRACE Risk Score at Baseline

Mehta SR et al N Engl J Med 2009;360:2165-2175

TIMACS: High-risk patients benefit from early

intervention

Major bleeding and 30 day mortality

34 146 ACS patients from OASIS, OASIS-2, CURE

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Eikelboom, J W et al Circulation 2006;114:774-782

5-fold ↑ mortality

Prior vascular disease defined as h/o stroke or peripheral arterial disease

Heart rate is truncated @ <70 bpm

CrCl: Cockcroft-Gault is truncated @ >90 mL/min

CRUSADE: Multivariable Predictors of Bleeding

Variable 2 Derivation Cohort

OR 95% CI

Validation Cohort

OR 95% CI

Baseline HCT <36% (vs ≥ 36%) 434.6 2.28 2.11-2.46 2.17 1.92-2.44 CrCl (per 10 mL/min decrease) 433.2 1.12 1.10-1.13 1.11 1.09-1.13

Heart rate (per 10 bpm increase) 159.2 1.08 1.07-1.10 1.09 1.07-1.12

Female 77.8 1.31 1.23-1.39 1.33 1.19-1.50

Signs of heart failure 37.7 1.23 1.15-1.31 1.13 1.01-1.28

Prior vascular disease 30.4 1.19 1.12-1.27 1.10 0.98-1.24

Diabetes mellitus 26.6 1.16 1.10-1.23 1.25 1.12-1.40

SBP ≤ 110 mm Hg (vs 110-180) 12.6 1.26 1.16-1.36 1.27 1.10-1.47 SBP ≥ 180 mm Hg (vs 110-180) 1.24 1.14-1.35 1.18 1.02-1.37

c-Statistic 0.72 0.71

www.crusadebleedingscore.org

Risk Stratification:

Tailoring therapy

quickly at the bedside or on-line using

readily available information

and invasive treatments should be dictated

by the individual patient’s risk of ischemic and bleeding events.

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Recommendations (1/2)

1 Determine the patient’s risk of an ischemic event

(death, MI, recurrent ischemia) using the TIMI,

PURSUIT, and/or GRACE risk scores.

2 Assess the patient’s risk of bleeding using the

CRUSADE algorithm

3 Start antiplatelet (aspirin, clopidogrel/prasugrel),

antianginal, and statin medications.

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Recommendations (2/2)

4 Low risk patients may be treated with heparin or

fondaparinux and undergo further diagnostic

testing (serial ECGs, enzymes/markers, echo,

stress testing, etc).

5 High risk patients should undergo early

angiography (<24 h) These patients may receive bivalirudin or heparin Provisional GP IIb/IIIa may

be given in the cath lab.

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