1 / 18

Cooling Off? Early Intervention? Very Early Intervention?

Cooling Off? Early Intervention? Very Early Intervention?. Steve Holmberg Sussex Cardiac Centre. NO CONFLICT OF INTEREST TO DECLARE. Invasive Strategy in ACS - is there still a debate?. ICTUS No benefit of invasive strategy out to 5 years

portia-dennis
Download Presentation

Cooling Off? Early Intervention? Very Early Intervention?

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. Cooling Off? Early Intervention? Very Early Intervention? Steve Holmberg Sussex Cardiac Centre

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. Invasive Strategy in ACS- is there still a debate? • ICTUS • No benefit of invasive strategy out to 5 years • Intervention rates high in the ‘conservative’ arm • No penalty for early intervention • Invasive strategy may facilitate early discharge and obviate readmission

  4. The Evidence for Intervention • 3 Landmark Trials • FRISC II (2457) • RITA-3 (1810) • TACTICS-TIMI 18 (2220)

  5. FRISC II • Death/MI 6/12 INV CON (PCI at 96 hrs) • Revasc 71% 9% • Endpoint 9.4% 12.1% • Death 1.9% 2.9% • MI 7.5% 9.2%

  6. RITA-3 • Death/MI/Refractory Angina 4/12 INV CON (PCI at 72hrs) • Endpoint 9.6% 14.5% (Driven by refractory angina) But: • Death/MI at 5 years 16.6% 20.0%

  7. TACTICS-TIMI 18 Death/MI/Re-Hospitalisation at 6/12 INV CON (PCI at 24 hrs) • Endpoint 15.9% 19.4% • Death 3.3% 3.5% • MI 4.8% 6.9% • Rehosp 11.0% 13.7% • Revasc 60% 36% • TIMI Risk 5-7 19.5% 30.6% 3-4 16.1% 20.3% 0-2 12.8% 11.8%

  8. TIMI Risk Score • History • Age 65 or older • Risk Factors 3 or more • Known CAD 50%+ stenosis • Aspirin use Within 7 days • Presentation • Recent severe angina within 24hrs • Raised cardiac markers • ST depression 0.5mm or more

  9. The Dilemma • Delayed • Benefit: • Plaque passification with medical treatment followed by intervention on more stable plaque • Risk: • Events that may occur while waiting • Early • Benefit: • Prevention of early events that may have occurred while waiting • Rapid diagnosis and early discharge • Risk: • Potential for early hazard because of intervention on unstable plaque with fresh thrombus

  10. ISAR-COOL • Death/MI (CK-MB >5 x ULN) at 30 days (410) (Clopidogrel 600mg + Heparin + Tirofiban) • Raised Troponin 67% • ST Depression 65% IMMEDIATE DELAYED CATH 2.4hr 86hr ENDPOINT 5.9% 11.6%

  11. ABOARD • Peak Troponin I (352) • TIMI RISK > 2 IMMEDIATE DELAYED CATH 1.2hr 20.5hr ENDPOINT 2.0 1.7 (Death/MI/Revasc at 1/12 - No different)

  12. OPTIMA • Death/MI/Urgent Revasc at 30 days (241) • Raised Troponin 32% • ST Depression 37% IMMEDIATE DELAYED CATH 25 mins! 25 hrs ENDPOINT 60% 39%

  13. OPTIMA • End-point driven by ‘small’ MIs • CK 1-2 x ULN • Loading with 300mg Clopidogrel • Considering average times to PCI • Extravagant conclusion regarding optimal timing of intervention

  14. TIMACS • 3000+ • Troponin Positive IMMEDIATE DELAYED CATH 14hr 50hr ENDPOINT 6/12 HR Death/MI/Stroke 0.85 (p=0.15 NS) +Ref Isch 0.72 (p=0.002)

  15. TIMACS • Death/MI/Stroke at 6/12 (3000+) • Troponin Positive EARLY DELAYED CATH 14hr 50hr GRACE Score 140 Low Risk 7.7 6.7 (p=0.43 NS) High Risk 14.1 21.6 (p=0.005)

  16. SUMMARY OF KEY TRIALS

  17. CONCLUSIONS • Immediate intervention may be beneficial for some • Posterior MIs • On-going pain • Haemodynamic instability • It may be possible to intervene too early • Optimal medical therapy is essential • Out-of-hours procedures may have inferior outcomes • High risk patients (particularly) should have intervention at the earliest reasonable opportunity

  18. CONCLUSIONS • Get out of bed rarely (for NSTEMI) • Next day is probably fine • The weekend may be too long

More Related