Final ACS Risk Stratification Management for 12th VN tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án, bài tập lớ...
Acute Coronary Syndromes Risk Stratification & Management Matching Treatment to Risk Khôi M Lê, MD Desert Cardiology Center Eisenhower Medical Center Rancho Mirage, California USA Hospitalizations in the U.S due to ACS Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI† STEMI 1.24 million 0.33 million Admissions per year Admissions per year *Primary and secondary diagnoses †About 0.57 million NSTEMI and 0.67 million UA Heart Disease and Stroke Statistics – 2007 Update Circulation 2007; 115:69–171 Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to 2008 •Yeh RW et al N Engl J Med 2010;362:2155-2165 Adjusted Odds Ratio for 30-Day Mortality, According to Year •Yeh RW et al N Engl J Med 2010;362:2155-2165 Standard treatment for ACS Beta-blocker Antianginal drugs Nitroglycerin Diltiazem Lipid-lowering drugs Statins Aspirin Antiplatelet drugs Clopidogrel Prasugrel Heparin Enoxaparin Antithrombotic drugs Fondaparinux Bivalirudin Invasive management Angiogram ± revascularization Risk Stratification • Clinical factors – Age, history of coronary disease, LV function, diabetes mellitus – Prolonged/recurrent resting CP or CP with dyspnea – Presence or absence of heart failure, hypotension, tachycardia, cardiac arrest • ECG – ST segment shifts – T wave changes • Laboratory data – Cardiac markers/enzymes – Serum creatinine TIMI risk score Points Age ≥ 65 years ≥ CAD risk factors Prior CAD stenosis ≥ 50% ≥ anginal events within last 24 h ASA use during days prior to hosp Elevated cardiac markers ST segment change ≥ 0.05 mV High risk: Total ≥ 30-day and 1-year endpoint rates by risk group for the TIMI score de Araỳjo Gonỗalves P et al Eur Heart J 2005;26:865-872 PURSUIT risk score Points Age 0-14 Male CCS-class in previous weeks 0-2 Heart failure ST-segment depression High risk: Total ≥ 14 30-day and 1-year endpoint rates by risk group for the PURSUIT score de Araỳjo Gonỗalves P et al Eur Heart J 2005;26:865-872 In-hospital and year outcomes Physicians’ assessment PURSUIT TIMI GRACE 15 •Yan A T et al Eur Heart J 2007;28:1072-1078 GRACE and PURSUIT superior to TIMI Receiver-operating characteristic curves for predicting in-hospital and 1-year mortality In-hospital mortality •Yan A T et al Eur Heart J 2007;28:1072-1078 1-year mortality Why are GRACE and PURSUIT superior? • Age as a continuous variable – Only included as a categorical variable in TIMI • Heart failure on admission – Not in TIMI • Baseline serum creatinine (only in GRACE) 17 Admission risk score correlates with benefit from revascularization de Araỳjo Gonỗalves P et al Eur Heart J 2005;26:865-872 Meta-analysis of FRISC-II, ICTUS, RITA-3 Routine versus selective invasive in ACS Risk of CV Death or MI Fox, K A A et al J Am Coll Cardiol 2010;55:2435-2445 Meta-analysis of FRISC-II, ICTUS, RITA-3 Routine versus selective invasive in ACS •Sustained advantage of routine invasive approach •Degree of benefit corresponds to clinical risk Fox, K A A et al J Am Coll Cardiol 2010;55:2435-2445 Copyright â2010 American College of Cardiology Foundation Restrictions may apply Early versus Delayed Invasive Intervention in Acute Coronary Syndromes The TIMACS Study • 3031 patients with ACS randomized to early (median 14 h) or delayed (median 50 h) angiography • Primary outcome: Death, MI, stroke at mos • Secondary outcomes: Death, MI, refractory ischemia Mehta SR et al N Engl J Med 2009;360:2165-2175 21 TIMACS: High-risk patients benefit from early intervention Kaplan-Meier Cumulative Risk of the Primary Outcome, Stratified According to GRACE Risk Score at Baseline Mehta SR et al N Engl J Med 2009;360:2165-2175 Major bleeding and 30 day mortality 34 146 ACS patients from OASIS, OASIS-2, CURE 5-fold ↑ mortality 23 Eikelboom, J W et al Circulation 2006;114:774-782 CRUSADE: Multivariable Predictors of Bleeding Variable Derivation Cohort OR 95% CI Validation Cohort OR 95% CI Baseline HCT