DGH management of acute coronary syndromes

1. DGH management of acute coronary syndromes Who can be discharged without angiography ? Dr Conrad Murphy St Richard’s Hospital Chichester

2. 6 weeks Prognosis of ACS Terkelsen EHJ 2005

4. Incomplete MI Non-Q infarct Completed Infarction ‘Q wave MI’ Marked ST change On going angina Heamodynamic instability Major Arrhythmia Stable Patient Fully Ambulant But Trop +ve Angiogram Not Necessary Angiogram Mandatory In-patient Angiogram Desirable Who is likely to benefit from pre-discharge angiography ? Risk of Early Ischaemic Event Low Moderate High

5. Invasive vs Conservative Strategy for UA/NSTEMI ISAR-COOL RITA-3 VANQWISH ICTUS VINO MATE TRUCS TIMI IIIB TACTICS-TIMI 18 FRISC II Conservative Invasive UA indicates unstable angina, NSTEMI, non–ST-segment myocardial infarction; ISAR, Intracoronary Stenting and Antithrombic Regimen Trial; RITA, Randomized Intervention Treatment of Angina; VANQWISH, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital study; MATE, Medicine vs Angioplasty for Thrombolytic Exclusions trial; TACTICS-TIMI18, Treat Angina with Aggrastat® and Determine Cost of Therapy with Invasive or Conservative Strategy; and FRISC, Fragmin during InStability in Coronary artery disease.

6. The benefits of pre-discharge angiography & intervention • The trial evidence • Readmissions • Non-fatal MI • Mortality • QOL • Other benefits • Investigation ‘upfront’ • Simplify follow up • Back to work • Happy patient • ‘On-Guideline’

7. Non-STEMI Audit 25% >80yrs old For under 80’s Mean age 69yrs Transfer rate=24% (urgent PCI slots available) Readmission rate= 8% Mortality 3% at 3/12 The downside of pre-discharge angiography & intervention (UK) • May destabilise otherwise stable patient • Other procedural and therapy complications • Bed blocking while waiting for transfer Beds Blocked Each Day 2003 2004

8. Completed Infarction ‘Q wave MI’ Marked ST change On going angina Heamodynamic instability Major Arrhythmia Multiple ACS Risk Factors Incomplete MI Non-Q infarct Stable Patient Fully Ambulant But Trop +ve Further Risk Stratification ? Who is likely to benefit from pre-discharge angiography ? Risk of Early Ischaemic Event Low Moderate High Angiography Most cases ‘ESC 2002’

9. 85 male Non-STEMI Prev MI, CRF 45 male Non- STEMI ST depression BP ok Who to transfer; Grace data Age 0-100 CCF 24 Previous MI 14 Heart Rate 0-43 BP 0-24 ST depression 11 CRF 1-20 Enzymes up 15 No in-hosp PCI 14 Eagle et al JAMA 2004

10. Who to transfer; TIMI score (Non-STEMI) % of MI population Event rate at 14 days Event Rate Post MI % TIMI scoring Age CAD risk Factors Known CAD Aspirin use Recent severe AP Elevated Markers ST deviation Score 0-7 TIMI score

11. Exercise testing in risk stratification

13. Who does not need pre-discharge angiography after ACS ? • Not candidate for intervention • Completed MI • Lower risk non-Q MI • Stable • No high risk features • Good Ex Test; other risk stratification • Not disadvantaged by delayed investigation • Regional centre lead

14. Conclusion • The move to angiogram based risk stratification and treatment is irresistible and preferable • Cost effectiveness will be lost if long transfer times persist • limitations of a ‘lesion based’ approach

15. Occlusion & Infarct Occlusion Stable severe stenosis Resolution What to do next