1 / 42

Published in JACC and Circulation September, 2000 Revisions Released in March, 2002

ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation MI. Published in JACC and Circulation September, 2000 Revisions Released in March, 2002. Guidelines Issues for Emergency Medicine: Pollack CV, Gibler WB. Ann Emerg Med 2001.

donaldbjones
Download Presentation

Published in JACC and Circulation September, 2000 Revisions Released in March, 2002

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation MI Published in JACC and Circulation September, 2000 Revisions Released in March, 2002 Guidelines Issues for Emergency Medicine: Pollack CV, Gibler WB. Ann Emerg Med 2001

  2. Evidence-Based Medicine:What’s the Problem? “There is an unsettling truth about the practice of medicine. …study after study shows that few physicians systematically apply to everyday treatment the scientific evidence about what works best.” Millenson, ML. Demanding Medical Excellence: Doctors and Accountability in the Information Age. 1997

  3. Ischemic Heart DiseaseUnstable Angina and Acute MI • 12,200,000 people in the US have had an MI, angina pectoris, or both • 5,315,000 Americans visited Emergency Departments for chest pain in 1997 • 1,433,000 Americans hospitalized for IHD in 1996 • 225,000 died before hospital • 1,100,000 Americans will have a new or repeat IHD event this year WHO – 2000, NCHS 2000 AHA - 2000 Heart and Stroke Statistical Update

  4. Spectrum of Acute Coronary Syndromes Presentation Ischemic Discomfort at Rest No ST-Segment Elevation ST-Segment Elevation Emergency Department + + + + In-Hospital Unstable Angina Non-Q-wave MI Q-wave MI ( : positive cardiac biomarker)

  5. Participants in Updated Guidelines

  6. Updated GuidelinesReview Process Original Guidelines Reviewers • 3 AHA • 1 ACP-ASIM • 3 ACC • 1 ESC • 3 ACEP • 1 STS • 1 AAFP • 29 Others Literature searches Committee Evidence tables Revise Guidelines draft Final Approval by ACC and AHA

  7. Updated GuidelinesWeighing the Evidence • 1994 version was starting point; literature searches added more current reports • Weight of evidence grades: = Data from many large, randomized trials = Data from fewer, smaller randomized trials, careful analyses of nonrandomized studies, observational registries = Expert consensus

  8. I IIa IIb III Updated GuidelinesClasses of Recommendations Intervention is useful and effective Evidence conflicts/opinions differ but leans towards efficacy Evidence conflicts/opinions differ but leans against efficacy Intervention is not useful/effective and may be harmful

  9. Prognosis in Unstable Angina / NSTEMI PURSUIT trial data

  10. 30 60 90 120 150 180 Mortality in Non-ST  ACS Patients WithMyocardial Infarction During Hospitalization 20 Patients with MI within 72 hours (n=593) % Mortality 18.3% 15 12.8% (P= 0.0001) 10 Patients without MI within 72 hours (n=8,868) 5.5% 5 Days following randomization Fintel D, ACC, 2000

  11. Initial Chest PainEvaluation Symptoms Suggestive of ACS Possible ACS Definite ACS (–) ECG; Normal biomarkers No ST  ST  ST-T ’s, chest pain,  markers Use MI Guidelines Observe; repeat ECG, markers at 4-8 hrs No recurrent pain; (–) follow-up studies Recurrent pain; (+) follow-up studies Stress test;  LV function if ischemia (+) test Admit, Use Acute Ischemia Pathway (–) test: outpt follow-up

  12. I IIa IIb III Hospital CareAnti-Thrombotic Therapy Immediate aspirin Clopidogrel, if aspirin contraindicated Aspirin + clopidogrel for up to 1 month, if medical therapy or PCI is planned Heparin (IV unfractionated, LMW) with antiplatelet agents listed above Enoxaparin preferred over UFH unless CABG is planned within 24 hours

  13. Acute Coronary Syndromes Without ST Evidence for Aspirin Cairns Lewis Theroux Wallentin Pooled 0 1.0 2.0 Favors Aspirin Favors Placebo Relative Risk — Death or MI

  14. Acute Coronary Syndromes without ST Evidence for Heparin Use (UFH + ASA versus ASA) Relative Risk of Death or MI Theroux (n = 243) RISC (n = 399) Cohen (n = 69) Cohen (n = 214) Holdright (n = 185) Gurfinkel (n = 143) Overall (n = 1353) 2.66 6.87 P = 0.06 0 0.5 1 1.5 2 ASA + UFH Better ASA Better Oler A, JAMA 1996

  15. LMWH vs. UFH in Non-ST ACS:Effect on Death, MI, Recurrent Ischemia Trial: FRIC (Dalteparin; n = 1,482) FRAXIS (nadroparin; n = 2,357) ESSENCE (enoxaparin; n = 3,171) TIMI 11B (enoxaparin; n = 3,910)   (p= 0.032)  (p= 0.029)  .75 1.0 1.5 LMWH Better UFH Better Braunwald E, Circulation 2000

  16. I IIa IIb III Hospital CareClopidogrel Therapy Aspirin + clopidogrel, for up to 1 month* Aspirin + clopidogrel, for up to 9 months* Withhold clopidogrel for 5-7 days for CABG * For patients managed with an early conservative strategy, and those who are planned to undergo early PCI Guidelines do not specify initial approach to using clopidogrel when coronary anatomy is unknown

  17. CURE Primary Results % 14 11.4% Placebo + ASA 12 9.3% 10 8 Clopidogrel + ASA Death, MI, or Stroke 20% RRR P < 0.001 N = 12,562 6 4 2 0 0 3 6 9 12 Months of Follow-Up N Engl J Med. 2001

  18. Major bleeding 2.7% 3.7% 0.001 Life-threatening bleeding 1.8% 2.2% NS Non-life-threatening bleeding 0.9% 1.5% 0.002 Minor bleeding 2.4% 5.1% < 0.001 CURE - Bleeding Complications Placebo + ASA(N = 6303) Clopidogrel + ASA(N = 6259) P-Value N Engl J Med, 2001

  19. CURE PCI Sub-StudyUpstream Clopidogrel Before PCI * % 15 12.6% Placebo + ASA 8.8% 10 Clopidogrel + ASA Death or Nonfatal MI 5 31% RRR P = 0.002N = 2658 0 0 100 200 300 400 Mehta S, Lancet 2001 Days of follow-up * Median Time to PCI = 6 Days

  20. I IIa IIb III Hospital CareAnti-Ischemic Therapy (1) -blocker (IVoral) if not contraindicated Non-dihydropyridine Ca2+ antagonist if -blocker contraindicated and no LV dysfunction, for recurrent ischemia ACE inhibitor if  BP persists with NTG+ -blocker, for pts with CHF or diabetes

  21. I IIa IIb III Hospital CareAnti-Ischemic Therapy (2) ACE inhibitor for all ACS pts Extended-release Ca2+ blocker instead of -blocker Immediate-release Ca2+ blocker with -blocker Long-acting Ca2+ blocker for recurrent ischemia, if no contraindications and NTG + -blocker used fully

  22. I IIa IIb III Hospital CarePlatelet GP IIb/IIIa Inhibitors (1) Any GP IIb/IIIa inhibitor + ASA/Heparin for all patients, if cath/PCI planned Eptifibatide or tirofiban + ASA/Heparin for high-risk* patients in whom early cath/PCI is not planned Any GP IIb/IIIa inhibitor for patients already on ASA + Heparin + clopidogrel, if cath/PCI is planned * High-risk: Age > 75; prolonged, ongoing CP; hemodynamic instability; rest CP w/ ST ; VT; positive cardiac markers

  23. Platelet GP IIb/IIIa Inhibition for Non-ST  ACSPrimary Endpoint Results from the 5 Major RCTs 20 Placebo 17.9 GP IIb/IIIa 15.7 14.2 15 12.9 12.8 11.8 11.7 10.3 Primary Endpoint % 10 5.6 5 3.8 P = 0.04 P = 0.01 P = 0.004 P = 0.48 P = 0.33 0 PURSUIT30 days PRISM48 hrs PRISM PLUS7 days PARAGON A30 days PARAGON B30 days

  24. Platelet GP IIb/IIIa Inhibition for Non ST  ACS:Enhanced Benefit in Patients Undergoing Early PCI Placebo GP IIb/IIIa 18.5 20 16.7 11.6 11.6 10.2 % 30-Day Death or MI 10 5.9 0 PRISM-PLUS PURSUIT PARAGON-B

  25. GP IIb/IIIa Blockade Before and After PCI: CAPTURE, PURSUIT, PRISM-PLUS Before PCI Post-PCI 10% Placebo GP IIb/IIIa inhibitor 8.0% 8% 6% N=12,296 P=0.001 Death or MI 4.9% 4.3% 4% 2.9% N=2754 P=0.001 2% 0% +24 h +48 h +72 h +24 h +48 h 0 PCI Boersma, Circulation, 1999

  26. Platelet GP IIb/IIIa Blockade for Non-ST  ACS: Pre-Treatment Before CABG in PURSUIT 40 32.7% 30 27.6% p = 0.02 20 Death or MI (%) 10 Eptifibatide Placebo 0 0 30 60 90 120 150 180 Days After Randomization Marso, Circulation 2000

  27. I IIa IIb III Hospital CarePlatelet GP IIb/IIIa Inhibitors (2) Eptifibatide or tirofiban + ASA/Heparin for patients without continuing ischemia in whom PCI is not planned Abciximab for patients in whom PCI is not planned

  28. Medically refractory unstable angina Culprit lesion identified during angiography Mandatory treatment period (18-24h) pre- PCI Infusion stopped 1 hr after PCI completed Short duration of chest pain ( 10 mins) ST  ( 0.5 mm) or elevated TnI / TnT No angiography expected for 48 hrs Medical management anticipated Prolonged Infusions of Abciximab for Non-ST  ACS CAPTURE GUSTO-IV ACS

  29. 10 placebo placebo placebo 8 PTCA Cath PTCA 6 p = 0.029 p = 0.009 p = 0.029 p = 0.009 4 abciximab abciximab abciximab 2 0 12 24 36 0 12 24 36 0 12 24 36 CAPTURE Results % 10 8 6 4 2 0 12 24 36 Hours

  30. Study Design 7800 Patients with Non-ST-Elevation ACS ( 0.5 mm ST , + Troponin T or I) Aspirin + Unfractionated Heparin/Dalteparin No cath expected for 48 hours Placebo (n = 2598) Abciximab x 24 hrs (n = 2590) Abciximab x 48 hrs (n = 2612)

  31. Death Placebo Abciximab Placebo Abciximab Abciximab 24 hour 24 hour Primary Endpoint Death or MI at 30 Days % 12 12 Death or MI 10 10 9.1 9.1 8 8 8.2 8.2 8.0 8.0 6 6 4 4 4.2 4.2 3.9 3.9 3.4 3.4 2 2 n = 2598 n = 2590 n = 2612 n = 2598 n = 2590 n = 2612 0 0 Abciximab 48 hour 48 hour

  32. GP IIb/IIIa Inhibition for Non-ST-Elevation ACS 30-Day Death or Nonfatal MI n Trial Risk Ratio & 95% CI Placebo GP IIb/IIIa 7.1% 5.8% PRISM 3,232 PRISM PLUS 11.9% 10.2% 1,915 PARAGON A 11.7% 11.3% 2,282 PURSUIT 15.7% 14.2% 9,461 PARAGON B 11.4% 10.5% 5,165 GUSTO-IV ACS 8.0% 8.7% 7,800 0.92 (0.86, 0.995) p = 0.037 11.5% 10.7% Pooled 29,855 0.5 1.0 1.5 GP IIb/IIIa Better Placebo Better Boersma, Lancet 2002

  33. I IIa IIb III Hospital CareConservative vs. Invasive Strategies (1) Early invasive strategy in high-risk patients with any of the following: - Recurrent ischemia, despite meds - Elevated Troponin I or T - New ST-segment depression - New CHF symptoms - High-risk stress test findings - LV dysfunction (EF < 40%) - Hemodynamic instability, sustained VT - PCI within 6 months, prior CABG

  34. I IIa IIb III Hospital CareConservative vs. Invasive Strategies (2) Either strategy in low- to moderate-risk patients without contraindications to revascularization Early invasive strategy for patients with repeated ACS presentations, without high-risk features or ongoing ischemia

  35. FRISC-II Mortality at One-Year Invasive Vs. Conservative Management Strategies .04 Non-Invasive (n = 1235) .03 Probability of Death .02 Invasive (n = 1222) .01 Invasive Noninvasive RR (95 % CI) 2.2 % 4.0 % 0.56 (0.35 - 0.89) p = 0.018 0 0 30 90 180 360 Wallentin, Lancet 2000

  36. TACTICS-TIMI-18: Primary Endpoint: Death, MI, Rehospitalization for ACS at 6 Months 19.4% 15.9% 20 16 12 O.R 0.78 95% CI (0.62, 0.97) p=0.025 % Patients 8 4 CONS INV 0 0 1 2 3 4 5 6 Time (months) Cannon C, AHA 2000

  37. Early Invasive Management and Enhanced Anti-Platelet Therapy FRISC II TACTICS-TIMI 18 Low Molecular Weight Heparin GP IIb/IIIa Inhibitor 0.14 CONS 0.12 0.10 CONS 0.08 INV Probability of MI 0.06 INV 0.04 0.02 0.00 0 30 60 90 120 150 180 Time (days) FRISC-II Investigators, Lancet, 1999 Cannon, AHA 2000

  38. I IIa IIb III Discharge/Post-Discharge Medications ASA, if not contraindicated Clopidogrel, when ASA contraindicated Aspirin + Clopidogrel, for up to 9 months -blocker, if not contraindicated Lipid  agents + diet, if LDL >130 mg/dL ACE Inhibitor: CHF, EF < 40%, DM, or HTN

  39. LIPID Trial - Statin Therapy for Patients with Recent ACS 15% • P = 0.00002 • 23% reduction • 31 deaths avoided • per 1000 patients Placebo 10% Cumulative Mortality 5% Pravastatin 0% 0 1 2 3 4 5 6 7 Years Since Randomization LIPID Study Group, NEJM, 1998

  40. HOPE Primary Results Broad Benefits of ACE Inhibitors 0.2 Ramipril Placebo 0.15 % Death, MI, or Stroke 0.1 p<0.001 0.05 0 0 500 1000 1500 Days of Follow-up

  41. I IIa IIb III Risk Factor Modification Smoking Cessation Counseling Dietary Counseling and Modification Cardiac Rehabilitation Referral HTN Control (BP < 130/85 mm Hg) Tight Glycemic Control in Diabetics

More Related