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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

Who needs an angioplasty in 2008?Unstable Angina

Rob Henderson

Trent Cardiac Centre

Nottingham University Hospitals

slide2

I have NO CONFLICTS OF INTEREST TO DECLARE

but have received travel grants and/or honoraria from

Cordis, Boston Scientific, Medtronic

trials of revascularization strategies in non st elevation acs unstable angina nqmi
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
trials of invasive versus conservative strategies in non st elevation acs
Trials of invasive versus conservative strategies in non-ST-elevation ACS

*weighted means

rita 3 invasive vs conservative strategies in non st elevation acs
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

slide6

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

rita 3 invasive vs conservative strategies in non st elevation acs1

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

slide8

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

slide9

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

slide10

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

slide11

Interventional trials in non-ST elevation ACS

Stratified by revascularization rate in conservative arm

N=8114

Heterogeneity

Invasive better

Conservative better

rita 3 cumulative risk of death or mi by risk score
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

slide13

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

trials of invasive versus conservative strategies in non st elevation acs1
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
2007 acc aha esc guidelines indications for early invasive strategy
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