1 / 38

STEP BY STEP APPROACH TO NSTEACS

José F. Díaz Juan R Jimenez University Hospital Huelva. Spain. STEP BY STEP APPROACH TO NSTEACS. Invasive vs conservative Timing of intervention Antithrombotic drugs Type of revascularization. Invasive vs Conservative. Death/MI from randomization to the end of follow-up.

alpha
Download Presentation

STEP BY STEP APPROACH TO NSTEACS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. José F. Díaz Juan R Jimenez University Hospital Huelva. Spain STEP BY STEP APPROACH TO NSTEACS

  2. Invasive vs conservative • Timing of intervention • Antithrombotic drugs • Type of revascularization

  3. Invasive vs Conservative Death/MI from randomization to the end of follow-up Conservative better Invasive better TIMI IIIB VANQWISH MATE FRISC II TACTICS VINO RITA 3 TOTAL OR 0.82 95% CI, 0.72-0.93 P<0.01 0.1 10 OR (95% CI) Mehta. JAMA 2005; 293: 2908-17

  4. Invasive vs Conservative N=1810 Fox. Lancet 2007; 366: 914-20

  5. Invasive vs Conservative N=1200 Hirsch. Lancet 2007; 369: 827-35

  6. Revascularization gradient Eur Heart J 2004: 25: 1471-2

  7. ICTUS: revascularization rates Hirsch. Lancet 2007: 369: 827-35

  8. ICTUS: revascularization vs no revascularization Hirsch. EHJ 2008; sept 29 ahead pub

  9. Invasive vs Conservative O’Donaghue. JAMA 2008: 300: 71-80

  10. Invasive vs Conservative Bavry. JACC 2006; 48: 1319

  11. InvasivevsConservative All-cause mortality as a function of time Bavry. JACC 2006; 48: 1319

  12. Timing of intervention • Early intervention better: ISAR-COOL • Delayed intervention better: • ICTUS • Mehta meta-analysis • TIMACS, OPTIMA, ABROAD • GRACE and CRUSADE registries

  13. Early intervention

  14. ISAR-COOL Death or MI at 30 days 15% Prolonged antothrombotic treatment 10% p=0.04 5% Early intervention 0 5 10 15 20 25 30 Days after randomization Neuman. JAMA 2003: 290: 1593-9

  15. ICTUS: MI(%) at 1 year p<0.01 p NS Timingdependingonthe basis ofriskstratificaton Hirsch. Lancet 2007: 369: 827-35

  16. TIMACS Mehta. NEJM 2009: 360: 2165-75

  17. TIMACS Mehta. NEJM 2009: 360: 2165-75

  18. Drugs in PCI

  19. ISAR-REACT 2 N=2022 JAMA 2006: 295: 1531

  20. PRISM PLUS n=1915 NEJM 1998; 338: 1488-97

  21. IIbIIIa inhibitors • Intermediate to high risk patients (IIa-A) • Eptifibatide • Tirofiban • When epti/tirofiban prior to angiography, should be mantained during/after PCI (IIa-B) • Not IIbIIIa-pretreated patients should be treated with abciximab (I-A) • Bivalirudin might be an alternative to IIbIIIa plus heparin/enoxaparin (IIa-B)

  22. TRITON: Prasugrel p=0.0004 p=0.03 Wiviott, NEJM 2007; 357: 2001-15

  23. TRITON: Prasugrel Wiviott, Lancet 2008; 371: 1353-63

  24. PLATO: Ticagrelor CV death, MI or stroke

  25. PLATO: Ticagrelor

  26. PLATO: Ticagrelor Major bleeding

  27. Management strategy NSTEACS EARLY (< 72 h) URGENT (< 120 ‘) ELECTIVE

  28. Urgent (<120’) Abciximab/bivalirudin

  29. Early (<72h) Tirofiban/eptifibatide

  30. Elective

  31. Type of revascularization Invasive arm

  32. PCI: considerations • Treatment of non-significant lesions not recommended (III-C) • Complete vs “culprit vessel” not adressed • BMS or DES depending on (I-C): • Benefit ratio • Comorbidities • Need for surgery in the short medium follow-up

  33. Complete vs incomplete revascularization Complete Incomplete Hannan. JACC-CI 2009; 2: 17-25

  34. ACS only patients Incidence of Death, MI or revascularization p<0.05 Shishehbor. JACC 2007; 49: 849-57

  35. DES vs BMS: GRACE registry All cause mortality (n=6447)

  36. DES vs BMS for ACS: 2 years follow-up Death n=2456 TVR MI Mauri. NEJM 2008; 359: 1330-42

  37. GRACE registry (n=15088) -21% -15% Heart 2007; 93:177-82

  38. “If you know what you have to do and you do not do it then you are worse than before” Confucius

More Related