Optimal Management of ACS Invasive vs Conservative Strategy

1. Optimal Management ofACSInvasive vs Conservative Strategy Layth Mimish Consultant Cardiologist The Cardiovascular Consultant Group Jeddah KSA

6. Approach To ACS • Risk stratification • Appropriate acute medical management • Identify coronary anatomy in higher risk patients, otherwise exercise imaging • PCI vs CABG based on extent of coronary disease, LV function, and co morbid factors • Long term medical management ; risk factors modification

7. TIMI Risk Score for ACSUnfractionated Heparin Cohort TIMI 11B (n=1957) • Age > 65 years • > 3 CAD risk factors • Prior CAD Stenosis > 50% • ST segment changes on presentation • > 2 anginal events in last 24 Hrs • ASA use < 7years • Increased serum cardiac markers

10. FRISC Score • Age>70 years • Diabetes Mellitus • Previous MI • Angina > 30 days • ST depression • Elevated Troponin • Elevated Fibrinogen • Elevated II-6 (2P)

11. 2 Yr Mortality and MI Mortality Death or MI

15. Culprit Lesion Morphology & Troponin Levels in UAP

18. Antithrombotic approaches in ACS Acute Medical Management • ASA & LMWH ( FRIC, FRISC I&II, ESSENCE, TIMI 11B) • Direct Thrombin Inhibitors (GUSTO IIB, OASIS-2) • GP IIb/IIIa Inhibitors (4P Trials, Oral trials, GUSTO-IV ACS, TIMI-18) • ASA & Clopidogril (CURE) Coronary Interventions • Direct Thrombin Inhibitors (HELVETICA, Hirulog Trials) • GIIbIIa Inhibitors (EPIC, EPILOG, CAPTURE, EPISTENT, IMPACT-2, RESTORE, ESPIRIT, TARGET) • LMWH & GPIIb/IIIa Inhibitors(NICE Registry) • ASA & Clopidogril (CREDO)

33. Overview of GP IIb/IIIa Trials by Pooled Analysis

38. Conservative X Invasive Trials in ACS

39. Conservative X Invasive Trials in ACS

40. TIMI - IIIB

44. Study Limitations of VANQUISH • High surgical mortality (7.7%) & 12% in invasive arm • PTCA performed prior to era of stents and GPIIb/Iia blockers • No PTCA for multivessel disease • Results not necessarily applicable to females