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The NICE ACS Guidelines: variation on an ESC theme? PowerPoint PPT Presentation


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The NICE ACS Guidelines: variation on an ESC theme? . Rob Henderson Consultant Cardiologist Trent Cardiac Centre Nottingham University Hospitals. MY CONFLICTS OF INTEREST ARE Member, NICE ACS Guideline Development Group Advisory Boards and Speaker Honoraria

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The NICE ACS Guidelines: variation on an ESC theme?

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The nice acs guidelines variation on an esc theme l.jpg

The NICE ACS Guidelines: variation on an ESC theme?

Rob Henderson

Consultant Cardiologist

Trent Cardiac Centre

Nottingham University Hospitals


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MY CONFLICTS

OF INTEREST ARE

Member, NICE ACS Guideline Development Group

Advisory Boards and Speaker Honoraria

(Pfizer, Lilly UK, Daiichi-Sankyo UK Ltd, Boston Scientific, Cordis UK, Abbott Vascular)


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UA/NSTEMI Guidance fromESC and NICE


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NICE UA/NSTEMI Guideline

Development Group 2008-2009

John Camm, chair

Huon Gray, clinical advisor, NCGC

Sotiris Antoniou, pharmacist

Lina Bakhshi, information scientist

Jenny Cadman, nurse

Emily Crowe, research fellow

Mark de Belder, cardiologist

Jose Diaz, research fellow

David H. Geldard, patient rep

Rob Henderson, cardiologist

Marjan Jahangiri, cardiac surgeon

Taryn Krause, project manager

Kate Lovibond, health economist

Gavin Maxwell, patient rep

Francis Morris, A&E physician

Alun Roebuck, nurse consultant

Nicola Sloan, research fellow

Claire Turner, project manager

Richard Underwood, cardiac imaging

Mark Whitbread, paramedic


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NICE UA/NSTEMI Guideline

Development Group2008-2009

John Camm, chair

Huon Gray, clinical advisor, NCGC

Sotiris Antoniou, pharmacist

Lina Bakhshi, information scientist

Jenny Cadman, nurse

Emily Crowe, research fellow

Mark de Belder, cardiologist

Jose Diaz, research fellow

David H. Geldard, patient rep

Rob Henderson, cardiologist

Marjan Jahangiri, cardiac surgeon

Taryn Krause, project manager

Kate Lovibond, health economist

Gavin Maxwell, patient rep

Francis Morris, A&E physician

Alun Roebuck, nurse consultant

Nicola Sloan, research fellow

Claire Turner, project manager

Richard Underwood, cardiac imaging

Mark Whitbread, paramedic

359 pages

36 recommendations


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NICE Guideline - Risk Assessment

R1Formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (e.g. GRACE)

(Observational studies)


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Troponin status and in-hospital mortalityas function of GRACE risk score

3500

40%

Troponin positive (red bars)

Troponin negative (yellow bars)

In-hosp mortality (blue line)

3000

30%

2500

2000

Number of patients

20%

In-hospital mortality (%)

1500

1000

10%

500

0

0%

>226

<51

56

66

76

85

95

105

115

125

135

145

155

165

175

185

195

205

215

225

GRACE risk score (Granger algorithm)

N=27406 non-ST-elevation ACS

Steg et al, Am J Med 2009;122:107


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NICE Guideline - Risk Categories

R5Use predicted 6-month mortality to categorise the risk of future adverse cardiovascular events:

*estimated from MINAP registry


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NICE Guideline - Clopidogrel

R9Offer 300mg loading dose of clopidogrel in addition to aspirin to patients with no contra-indications and predicted 6-month mortality >1.5%

(CURE, CREDO, Cuisset, PRACTICAL)

Emerging evidence for use of 600mg in PCI patients

In CURRENT double dose prevented 6 MI’s and 7 stent thromboses with excess of 3 extra major bleeds per 1000 PCI patients


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NICE Guideline - Fondaparinux

R17Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission

(OASIS-5, cost effective with high certainty)


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OASIS 5 - Fondaparinux vs Enoxaparin in

Non-ST-elevation Acute Coronary Syndromes

Events at 9 days

UFH/LMWH but not Fonda inhibits contact activation pathway (FXII, XI)

P<0.001

Non-inferiority

P=0.007

P<0.001

P<0. 001

Fondarinux 2.5mg sc od

Enoxaparin 1mg/kg sc bd

OASIS 5 investigators NEJM 2006;354:1464


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OASIS 5 - Fondaparinux vs Enoxaparin in

Non-ST-elevation Acute Coronary Syndromes

0.06

0.04

0.02

0.00

0

60

90

120

150

180

30

Fondarinux n=10,021

Enoxaparin n=10,057

Cumulative mortality

6.5%

5.8%

Cumulative mortality

Hazard ratio 0.89 (95% CI 0.80–1.00) P=0.05

OASIS 5 Investigators, NEJM 2006;354:1464


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NICE Guideline - Glycoprotein Inhibitors

R14Consider iv eptifibatide or tirofiban as part of the early management of patients with predicted 6-month mortality >3%, and who are scheduled to undergo angiography within 96 hours of hospital admission

R15Consider abciximab as an adjunct to PCI for patients at intermediate or higher risk who are not already receiving a GPI or bivalirudin

(Meta-analyses: Boersma, Roffi. New RCTs: ISAR-REACT-2, ELISA-2, ACUITY-TIMING, Early-ACS, high uncertainty in cost effectiveness modeling)


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Upstream GPI in non-ST-elevation ACS

Meta-analysis of ACUITY-TIMING & Early-ACS

Odds Ratio (95% CI)

Favours early GPI

Favours delayed GPI

N=14009

Thienopyridine use 64% in ACUITY, 75% in Early-ACS

Draft NICE guideline document


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NICE Guideline - Bivalirudin

R22Consider switching to bivalirudin, rather than adding a GPI to an alternative antithrombin, for patients:

  • with predicted 6-month mortality >3% and

  • are not already receiving a GPI or fondaparinux and

  • are scheduled to undergo angiography within 24 hrs

    (ACUITY, REPLACE-2, cost effective with high uncertainty)


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ACUITY – bivalirudin vs heparin & IIb/IIIa blocker in non-ST elevation ACS patients scheduled for invasive strategy

30 d outcomes

P<0.001

P=0.015

NS

All patients scheduled for coronary arteriography/PCI <72h

Bivalirudin 0.1mk/kg bolus, 0.25mg/kg/hr infusion

*Death, MI, revasc for ischaemia

Stone, NEJM 2006;355:2203


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NICE Guideline - Invasive strategy

R24Offer coronary angiography (and follow-on PCI) within 96 hrs of admission to patients with predicted 6-month mortality >3.0% if they have no contraindications (active bleeding, comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk

R25Offer coronary angiography to patients with low risk if ischaemia is subsequently experienced or demonstrated

(High Quality RCTs, meta-analyses)


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Conclusions

  • NICE Guideline provides clinical guidance for effective & cost-effective treatment of UA/NSTEMI

  • Potentially important differences between ESC and NICE Guidance

  • NICE Guidance will change our approach to

    • risk stratification

    • anticoagulation

    • early invasive strategy

  • Due for final publication March 2010


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