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British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in C

British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in Cardiology Associate Director of Wellcome Trust Clinical Research Facility. Case 1. 46 year old woman

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British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in C

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  1. British Cardiac Intervention Society Risk Assessment In Acute Coronary Syndromes Dr David Newby BHF Senior Lecturer in Cardiology Associate Director of Wellcome Trust Clinical Research Facility

  2. Case 1 • 46 year old woman • Family history of ischaemic heart disease, hypertension, smoker and hypercholesterolaemia • No prior history of angina • 3 episodes of chest pain 12 hours prior to admission • Already taking aspirin and statin on admission • ECG normal • Troponin I 1.2 µg/L

  3. Case 1 Commenced on medical therapy and settles Would you manage the patient with: (a). In-patient coronary angiography and revascularise (b). Conservative treatment and consider angiography/revascularisation if symptoms recur

  4. Case 2 • 79 year old man • Non-smoker, hypertension and no risk factors • Chronic stable angina for 15 years with known single vessel disease (angiogram 10 years ago) • One episode of rest pain prior to admission • Not taking aspirin • ECG - minor ST depression on admission • Troponin I <0.1 µg/L

  5. Case 2 Commenced on medical therapy and settles Would you manage the patient with: (a). In-patient coronary angiography and revascularise (b). Conservative treatment and consider angiography/revascularisation if symptoms recur

  6. TIMI Risk Score • Age ≥ 65 years • ≥3 Risk factors for coronary artery disease • Significant coronary stenosis • ST Segment deviation • Severe anginal symptoms (≥2 anginal events in last 24 hours) • Prior aspirin use (within last 7 days) • Elevated serum cardiac markers Antman et al. JAMA 2000;284:835-842

  7. Antman et al. JAMA 2000;284:835-842

  8. TIMI Risk Score and Benefit with LMW Heparin Antman et al. JAMA 2000;284:835-842

  9. TIMI Risk Score Case 1 Case 2 Age ≥65 0 1 ≥3 Risk factors for CAD 1 0 Significant CAD 0 1 ST Segment deviation 0 1 Angina ≥2 times within 24 hrs 1 0 Prior aspirin use 1 0 Elevated cardiac markers 1 0 Total TIMI Score 4 3 14 Day Event Rate 20% 13%

  10. Other Risk Factors and Scores

  11. GRACE Registry • Robust data on in-hospital & 6-month outcomes in over 12,000 patients in 14 different countries • In well-characterized patients with ACS: • In-hospital to 6 month rates of: • death: ST-MI 12%, Non-ST-MI 13%, UA 8% • Stroke: 1.5 to 3% • Recurrent hospitalization for cardiac event: 17 to 20% • Unselected patients reveal substantially higher event rates than those entered into recent trials • A major challenge exists in the application of proven therapies to the full spectrum of patients with ACS

  12. -2 –1 0 1 2 3 4 5 6 7 8 Multivariable Risk Model SBP (per 20 mmHg increase) 0.7 0.69-0.78 Initial serum creatinine 1.2 1.15-1.35 Heart rate 30bpm 1.3 1.16-1.48 Initial cardiac enzyme + 1.6 1.32-2.00 Age (per 10 yr) 1.7 1.55-1.85 Killip class 2.0 1.81-2.29 ST deviation 2.4 1.90-3.00 Pre-hosp arrest 4.3 2.80-6.72

  13. Comparison of TIMI Risk Scores for Death: Antman Data Vs. GRACE Data 7 Antman GRACE Death Rate (%) 6 5 4 3 2 1 0 0/1 2 3 4 5 '6/7 TIMI Risk Score

  14. Outcome of “low-risk” patients with ACS Presentation with UA in the absence of dynamic ECG changes, no troponin elevation, no arrhythmia nor hypotension 6 month outcome: • 16.6% readmission • 8.7% revascularised • 2.2% deaths • 0.2% MI “Low-risk” is not no risk

  15. FRISC II Study Wallentin et al. Lancet 2000;356:9-16.

  16. RITA-3 Study Fox etal. Lancet 2002;360:743-751

  17. Meta-analysis of Intervention Trials Fox etal. Lancet 2002;360:743-751

  18. Who Should We Target For Invasive Intervention?

  19. MEN • ≥65 YEARS • CHRONIC ANGINA • NON-SMOKERS • CHEST PAIN at REST • (TROPONIN +VE) • ST DEPRESSION FRISC II et al. Lancet 1999;354:708-715

  20. 6 Month Risk Reduction Based on FRISC Dataset Case 1 Case 2 Age 1.00 0.66 Sex 1.26 0.64 Smoking 1.34 0.66 Angina > 3 months 0.95 0.59 ST Segment deviation 0.94 0.66 Elevated cardiac markers 0.73 0.80 14 Day TIMI Event Rate 20% 13% Benefit from Intervention No Yes

  21. Risk Assessment In Acute Coronary Syndromes Evaluation of Treatment Benefit In Acute Coronary Syndromes

  22. Survival Benefits of Revascularisation Single Vessel Disease Two Vessel Disease Three Vessel Disease 75% Left Main Stem 95% Left Main Stem 0.0 0.5 1.0 1.5 2.0 2.5 Harzard Ratio

  23. Frequency Luminal Stenosis 14% >70% 18% 50-70% 68% <50% Severity of Underlying Luminal Stenosis in Patients with an Acute Myocardial Infarction Degree of Stenosis in the Culprit Lesion of Acute Myocardial Infarction Frequency (%) of 5 year Vessel Occlusion or Myocardial Infarction 25 20 15 10 5 0 0 5-49 50-85 >85 Severity of Luminal Stenosis (%)

  24. Conclusions • Risk scores need to be carefully applied • Risk scores may be population dependent and not reflect ‘true life’ populations • Low risk is not no risk • High risk does not equate to most benefit from intervention • Is the benefit of interventional strategies for acute coronary syndromes derived from revascularising patients with prior stable angina and prognostically significant disease?

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