Invasive evaluation of NSTE-ACS Timing of Coronary Angiography+/RevascularizationDr Zhihua (Michael) Zhang Interventional fellow Wellington Hospital Dec 2011 1 Case ---Mr B 68 yr old History of HTN, hyperlipaedimia On regular aspirin Presented with NSTEMI to one of peripheral hospitals ST depression in lateral leads BP 141/80 and P 86 Trop T + Cr 125 2 Case ---Mr B TIMI score: 4---20% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia. GRACE score: 144---3% in hospital death or 17% IH death or MI. 3 4. 3. 2. In the day of admission Next day During the hospital admission Conservative Mx 4 .Case ---Mr B When should we refer/transfer this pt for coronary angiogram+/-revascularization? 1. ASAP in unstable pts – with major arrhythmias – haemodynamic instability – Post-MI unstable angina – or a history of prior bypass surgery 5 .ESC Management guideline of NSTEMI 2000 In high risk pts. coronary angiography should be performed during the initial hospitalization. Urgent coronary angiography is recommended in Unstable pts (I-C). 6 .ESC Management guideline of NSTEMI 2007 Early (<72 h) coronary angiography followed by revascularization (PCI or CABG) in pts with intermediate to high-risk features is recommended (I-A). RCTs ---Timing of invasive evaluation In Pts with NSTEMI Trial Yr of No of Pts Scoring enrolment Timing (hours) 1 2 3 ISARCOOL 2000-02 410 Positive enzyme or ST depression >1mm 2.4 Vs 86 ABOARD 2006-08 352 TIMI>3 1.2 Vs 21 TIMACS 2003-08 3031 GRACE 14 Vs 50 7 . September 24.4hr Vs 86hr JAMA. 2003—Vol 290.ISAR-COOL trial 2. 12 1593 Intracoronary Stenting With Antithrombotic Regimen Cooling-Off trial 8 . No. 2003—Vol 290. 12 1593 9 . September 24. No.ISAR-COOL trial JAMA. 2003—Vol 290.ISAR-COOL trial JAMA. No. 12 1593 10 . September 24. 2003—Vol 290. September 24. 12 1593 11 .ISAR-COOL trial JAMA. No. ABOARD trial 1. 2009—Vol 302. No.2hr Vs 21hr JAMA. 9 949 The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) Trial 12 . September 2. ABOARD trial JAMA. 9 949 13 . September 2. 2009—Vol 302. No. September 2. 2009—Vol 302. 9 949 14 .ABOARD trial JAMA. No. 2009—Vol 302. No. 9 949 15 . September 2.ABOARD trial JAMA. TIMACS trial 14 hr Vs 52 hr Early versus Delayed Invasive Intervention in Acute Coronary Syndromes 16 . or refractory ischemia at 6 m 17 . MI. Secondary outcome: death. Primary outcome: a composite of death.TIMACS trial N Engl J Med 2009. MI. or stroke at 6 m.360:2165-75. 3031 ACS patients Early (≤24 hours) Vs delayed intervention (≥36 hours). 18 . 19 . 360:2165-75.TIMACS trial May 2009 N Engl J Med 2009. 20 . 360:2165-75.TIMACS trial May 2009 N Engl J Med 2009. 21 . (ELISA.A meta-analysis of randomized trials addressing the optimal timing (early vs. delayed) of coronary angiography in NSTE-ACS. TIMACS) 22 . ISAR-COOL. ABOARD. 23 . 24 . From the meta-analysis 25 . ESC Management guideline of NSTEMI 2011 26 . 4. 3. 2.Case ---Mr B When should we refer/transfer this pt for coronary angiogram+/-revascularization? 1. In the day of admission Next day In the index admission Conservative Mx 27 . Can we practically follow the guideline recommendations? Bed lock in Wellington Weekend presentations Weather 28 . Thank you for your attention Questions and comments 29 . 30 . 31 . GRACE SCORE 32 . 2009—Vol 302. September 2.ABOARD trial JAMA. No. 9 949 33 . 34 . From 2000-2011 Trend of recommendations for invasive evaluation High risk pts 2000 During the hospital admission < 72 hrs < 24 hrs Unstable pts ASAP 2007 2010 <1hrs <2 hrs 35 . intermediate risk pt should have stress test to document ischaemia 36 .Take home message Unstable pts should have urgent cath lab study +/.revascularization High risk pts should ideally have cath study +/.revascularization in 24hrs Low . GRACE SCORE of Mr B Age HR 60-69 ST deviation 70-89 Cardiac enzyme+ Yes Yes SBP Cr 140 CHF No GRACE Score: 155 120-139 106- Cardiac arrest No In hospital death: 4% To 6 months: 9% 37 . 38 . 39 . but without undue urgency. or at least within hospitalization period. In most cases coronary angiography is performed within the 48 h.ESC Management guideline of NSTEMI 2002 Coronary angiography should be planned as soon as possible.