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Stanford ACS Guidelines 2003

Stanford ACS Guidelines 2003. David P. Lee, M.D. John S. Schroeder, M.D. *Donald Schreiber, M.D. Division of Cardiovascular Medicine and *Department of Emergency Medicine. Acute Coronary Syndromes. Within the guidelines, ACS is defined as: Unstable angina Non-ST-elevation MI

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Stanford ACS Guidelines 2003

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  1. Stanford ACS Guidelines 2003 David P. Lee, M.D. John S. Schroeder, M.D. *Donald Schreiber, M.D. Division of Cardiovascular Medicine and *Department of Emergency Medicine

  2. Acute Coronary Syndromes • Within the guidelines, ACS is defined as: • Unstable angina • Non-ST-elevation MI • These guidelines do NOT apply to acute ST-elevation MI Stanford

  3. Acute Coronary Syndromes • Based upon recent clinical data, these guidelines reflect new management strategies in ACS • Any questions or comments may be directed to any of the authors Stanford

  4. Heparin Enoxaparin ESSENCE Time to First Triple Endpoint (Death/MI/RA) 40 35 30 25 20 Cumulative event rate (%) 15 10 5 0 0 2 4 6 8 10 12 14 Months Stanford

  5. Cardiac Events at 6 Months CONS (%) INV (%) RR P value No. Pts 1o Endpoint Death/MI Death MI Rehosp ACS 1106 19.4 9.5 3.5 6.9 13.7 1114 15.9 7.3 3.3 4.8 11.0 0.78 0.74 0.93 0.67 0.78 0.025 <0.05 0.74 0.029 0.054 Stanford

  6. 19.4% 15.9% RR 0.78 95% CI (0.62, 0.97) p=0.025 CONS INV Primary Endpoint Death, MI, Rehosp for ACS at 6 Months 20 16 % Patients 12 8 4 0 0 1 2 3 4 5 6 Time (months) Stanford

  7. TIMI Risk Score: 6 month results RR=0.55 CI (0.33, 0.91) CONS INV RR=0.75 CI (0.57, 1.00) Death/MI/ACS Rehosp (%) TIMI Risk Score % of Pts: 25% 60% 15% Stanford

  8. CURE Outcomes Stanford

  9. CURE Cumulative Hazard Rates for CV Death/MI/Stroke Placebo Clopidogrel Cumulative Hazard Rates P < 0.001 0 3 6 9 12 Months of Follow-up N Plac Clop 6303 6259 5780 5866 4664 4779 3600 3644 2388 2418 Stanford

  10. Stanford

  11. Acute Coronary Syndromes • Data from several recent trials suggest: • Unfractionated heparin should be replaced by low • molecular weight heparin (enoxaparin) [ESSENCE] • In higher-risk patients, early (“upstream”) use of a platelet glycoprotein IIb/IIIa receptor inhibitor should be strongly considered as well as early angiography (within 24 hours of hospitalization) [TACTICS/TIMI-18] • Clopidogrel should be considered for early therapy [CURE/OASIS-4] • An HMG-co-A-reductase inhibitor (statin) should be initiated during hospitalization [MIRACL] Stanford

  12. TIMI Risk Score for UA / NSTEMI HISTORICAL POINTS RISK OF CARDIAC EVENTS (%) BY 14 DAYS IN TIMI 11B* Age  65 1 RISK SCORE DEATH OR MI DEATH, MI OR URGENT REVASC  3 CAD risk factors (FHx, HTN,  chol, DM, active smoker) 1 0/1 2 3 4 5 6/7 3 3 5 7 12 19 5 8 13 20 26 41 Known CAD (stenosis  50%) 1 ASA use in past 7 days 1 PRESENTATION Recent (24H) severe angina 1  cardiac markers 1 ST deviation  0.5 mm 1 RISK SCORE = Total Points (0 - 7) *Entry criteria:UA or NSTEMI defined as ischemic pain at rest within past 24H, with evidence of CAD (ST segment deviation or +marker) Stanford Antman et al JAMA 2000; 284: 835 - 842

  13. ACS ALGORITHM in ED Chest pain Suspicious for cardiac? Yes No Risk *High Low OPT f/u ASA Clopidogrel Enoxaparin Tirofiban EARLY CATH (<24h) ASA Clopidogrel +/- Enoxaparin Fxn test If +, CATH Stanford * = TIMI risk score> 2, active ECG changes, refractory pain, + marker

  14. Acute Coronary Syndromes Notes about the ACS algorithm • IV NTG and beta-blocker encouraged • OK to give enoxaparin before catheterization • If surgery is anticipated, hold clopidogrel • Early catheterization encouraged in higher-risk patients 5. If IIb/IIIa used on the floor, may use either tirofiban or eptifibatide Stanford

  15. Acute Coronary Syndromes Notes about the ACS algorithm 7. If IIb/IIIa used, reduce enoxaparin dose to 0.75 mg/kg SQ BID • For patients with CrCl<30 or creatinine >2.0, give unfractionated heparin and adjust to ½ dose IIb/IIIa • No dosing adjustment necessary for obesity • Statin use should be started on day 1 Stanford

  16. Acute Coronary SyndromesDosing ASA 325 mg chewable 81 mg if already on ACE-inhibitor Clopidogrel 300 mg po load, then 75 mg QD Enoxaparin 1 mg/kg SQ BID 0.75 mg/kg SQ BID if IIb/IIIa used Tirofiban 0.40 mcg/kg/min IV x 30 minutes, then 0.10 mcg/kg/min (*In Acute MI’s use 10mcg/kg IVB over 3 minutes, then 0.15mcg/kg/min*) Eptifibatide 180 mcg IV bolus, then 2.0 mcg/kg/min Stanford

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