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Who needs an angioplasty in 2008? Unstable Angina

Who needs an angioplasty in 2008? Unstable Angina. Rob Henderson Trent Cardiac Centre Nottingham University Hospitals. I have NO CONFLICTS OF INTEREST TO DECLARE but have received travel grants and/or honoraria from Cordis, Boston Scientific, Medtronic.

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Who needs an angioplasty in 2008? Unstable Angina

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  1. Who needs an angioplasty in 2008?Unstable Angina Rob Henderson Trent Cardiac Centre Nottingham University Hospitals

  2. I have NO CONFLICTS OF INTEREST TO DECLARE but have received travel grants and/or honoraria from Cordis, Boston Scientific, Medtronic

  3. Trials of revascularization strategies in non-ST-elevation ACS (Unstable Angina & NQMI) • Invasive strategy Early coronary arteriography and PCI or CABG as clinically indicated versus • Conservative strategy Medical management and coronary arteriography only for refractory ischaemia • No trials of PCI versus no PCI in Unstable Angina

  4. Trials of invasive versus conservative strategies in non-ST-elevation ACS *weighted means

  5. RITA-3: invasive vs conservative strategies in non-ST-elevation ACS RITA-3 Event rates at one year P<0.0001 P<0.0002 P=0.29 P=0.5 Lancet 2002;360:743

  6. Invasive strategy in non-ST elevation ACSRe-hospitalisation for unstable angina Odds Ratio ( 95%CI) OR 0.54 (95% CI 0.48-0.61) NNT 16 N=7966 P=0.00001 Heterogeneity p=0.01 Conservative better Invasive better Adapted from JACC 2006;48:1319

  7. RITA-3 25 25 20 20 15 15 Cumulative percentage 10 10 5 5 0 0 0 1 2 3 4 5 0 1 2 3 4 5 Conservative (n=915) Invasive (n=895) Follow-up time (years) Follow-up time (years) RITA-3: invasive vs conservative strategies in non-ST-elevation ACS Death or nonfatal MI Death OR 0.78 95% CI 0.61-0.99, p=0.044 OR 0.76 95% CI 0.58-1.00, p=0.054 20.0% 15.1% 16.6% 12.1% Lancet 2005;366:914

  8. Invasive strategy in non-ST elevation ACSIs there reduction in death or non-fatal MI? Odds Ratio ( 95%CI) OR 0.85 (95% CI 0.75-0.95) NNT 43 N=8114 P=0.005 Heterogeneity p<0.0001 Invasive better Conservative better

  9. Invasive strategy in non-ST elevation ACSIs there a mortality benefit? Odds Ratio ( 95%CI) OR 0.85 (95% CI 0.73-1.00) NNT 83 N=8375 P=0.05 Heterogeneity p=0.13 Invasive better Conservative better

  10. Trials of invasive strategy in non-ST-elevation ACSRates of revascularization in-hospital VINO - EHJ 2002;23:230 RITA 3 - Lancet 2002;360:743 FRISC - Lancet 1999;354:708 TACTICS - NEJM 2001;344:1879 TRUCS - EHJ 2000;21:1954 ICTUS - NEJM 2005;353:1095 ISAR COOL - JAMA 2003;290:1593

  11. Interventional trials in non-ST elevation ACS Stratified by revascularization rate in conservative arm N=8114 Heterogeneity Invasive better Conservative better

  12. RITA-3: cumulative risk of death or MIby risk score RITA-3 1 Low risk quartile 2 Medium risk quartile 3 Medium risk quartile 4a High risk quartile – lower 4b High risk quartile – upper Invasive group Conservative group 48.5% 50 50 35.4% 31.3% 40 40 30 30 29.2% Cumulative percentage 20 20 6.1% 6.6% 10 10 0 0 0 1 2 0 3 1 4 2 5 3 4 5 Follow-up time (years) Follow-up time (years) Risk score: age, diabetes, prev MI, smoking, pulse rate, ST depression, angina grade, gender, LBBB, randomised treatment Lancet 2005;366:914

  13. FRISC-2: cumulative risk of death or MIby risk score Conservative Invasive 41.6% 32.7% 20.4% Death or myocardial infarction (%) 14.6% 10.3% 8.2% 40 High risk (score 4-7) N=622 RR (95%CI) 0.79 (0.64-0.97) Δ8.9% 30 20 Medium risk (score 2-3) N=1092 RR (95%CI) 0.72 (0.55-1.13) Δ5.8% Low risk (score 0-1) N=369 RR (95%CI) 1.26 (0.66-2.40) 10 0 FRISC score (sum of): Age>65, male gender, diabetes, previous MI, ST-depression, elevated troponin / Il-6 / CRP 0 1 2 3 4 5 Years since randomisation Lancet 2006;368:998

  14. Trials of invasive versus conservative strategies in non-ST-elevation ACS • Interpretation confounded by high revascularization rates in ‘conservative’ arm & different definitions of myocardial infarction (benefit may be underestimated) • Nevertheless, good evidence to support early invasive strategy in non-ST-elevation ACS • Benefit greatest in high risk patients • (determined by risk scores: FRISC, RITA, TIMI, GRACE) • Optimal timing of invasive strategy uncertain

  15. 2007 ACC/AHA & ESC GuidelinesIndications for early invasive strategy *1 Should be done *2b May be done *3 Should not be done Circulation 2007;116:e148 Eur Heart J 2007;28:1598

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