ACS guidelines Pre-program

To understand the ACS guidelines it is necessary to know mortality risk if you do nothing and bleeding risk for different kinds of treatment.

We make therefore use of the GRACE score (mortality)CRUSADE score (bleeding)

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GRACE score best score for ACS at the moment

050212 6Eduard van den Berg, cardio.nl

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Mortality after Acute Coronary Syndromes

0

1

2

3

4

5

6

7

8

0 - 10days

11 - 30days

31 - 90days

90 - 180days

>180days

STE MITrop 0 - 0.25Trop 0.25 - 1.0

Cumulative:13.6% Blue10.6% Green11.6% Red

Do we need risk scoring ?

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Risk scoring leeds to lower mortality

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Evolving ACS Guidelines

• Revised diagnosis– IAP to NSTEMI– Troponin and HS-Troponin– Increasing awareness of prognosis NSTEMI

• Take account of new data– Improved risk scoring

• Allow for improved hospital facilities– cath lab facilites; functional imaging

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Why another risk scoring ?

• Commonest reason for non-referral– Patients “not at high enough risk”

• Analysis of records of those not referred– 59.1% at intermediate or high risk according to

baseline TIMI risk score

• Over reliance on one or two key risk factors– ECG and Tn – Under use of other variables : age, CCF, renal function

• Decrease of bed capacity

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ACS Risk Scoring

• TIMI– Age - Use of aspirin– Risk Factors - Known CAD– > 1 episode rest pain - ST segment deviation– Cardiac risk markers

• PURSUIT– Age, Sex - CCS class in last 6/52– Signs of CCF - ST depression on ECG

• GRACE– Age - Heart rate and systolic BP– Creatinine - CCF (Killip class)– Cardiac arrest at admission– Elevated cardiac markers - ST segment deviation

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ACS Risk Scoring

• TIMI– Age - Use of aspirin– Risk Factors - Known CAD– > 1 episode rest pain - ST segment deviation– Cardiac risk markers

• PURSUIT– Age, Sex - CCS class in last 6/52– Signs of CCF - ST depression on ECG

• GRACE– Age - Heart rate and systolic BP– Creatinine - CCF (Killip class)– Cardiac arrest at admission– Elevated cardiac markers - ST segment deviation

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ACS Risk Scores

• Balance between complexity and utility• Score that include continuous variables more

powerful but more complex to compute– Simple PC/PDA programmes now available

• Objective data more robust

•GRACE most powerful and has most objective data

How was GRACE introduced ?

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Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)Kim A. Eagle, Shaun G. Goodman, Álvaro Avezum, Andrzej Budaj, Cynthia M. Sullivan, José López-Sendón, for the GRACE Investigators

Lancet 2002;359:373-77

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Missed Opportunities for Reperfusion

ST ↑ or LBBB, <12 hrs from onset, no contraindications

ANC (%) US (%) AB (%) EUR (%) n 269 327 339 739 PCI alone 1.1 17.7 13.9 16.2 Lytic alone 66.9 30.6 53.1 49.4 Both 2.2 18.7 5.0 4.9 Neither 29.7 33.0 28.0 29.5

AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States

Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..

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Independent Predictors of No Reperfusion

Variable OR (95% CI)

Prior CABG 2.28 (1.35 - 3.87) History of diabetes 1.46 (1.11 -1.94) History of congestive heart failure 2.92 (1.84 - 4.67) Presentation without chest pain 2.23 (2.13 - 4.89) *Age 75 years 2.37 (1.82 - 3.08)

*As compared to the <55 years age group

Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..

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80 78

61

82

20 22

39

18

0

20

40

60

80

100

USA Europe ANC AB

Pa

tie

nts

(%

)

Cath lab No cath lab

ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil

Geographical Variation: Admission to Hospitals

with/without Access to Cath Lab

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Global patterns of use of antithrombotic and antiplatelet therapies in patients with acute coronary syndromes: Insights from the Global Registry of Acute Coronary Events (GRACE)Andrzej Budaj, David Brieger, Ph Gabriel Steg, Shaun G. Goodman, Omar H. Dabbous, Keith A. A. Fox, Álvaro Avezum, Christopher P. Cannon, Tomasz Mazurek, Marcus D. Flather, and Frans Van De Werf, for the GRACE Investigators

Am Heart J 2003;146:999-1006.

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3733

13

92

178

58

92

30

15

65

91

24

9

39

95

0

20

40

60

80

100

PCI GP IIb/IIIa LMWH ASA

Pat

ien

ts (

%)

United States

Australia/New Zealand/Canada

Europe

Argentina/Brazil

Geographic Practice Variation

Budaj A et al. Am Heart J 2003;146:999-1006.Budaj A et al. Am Heart J 2003;146:999-1006.

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Incidence of Major Bleeding

3.9

2.4

8.3

2.9

0

3

6

9

Major bleed

Pat

ien

ts (

%)

UFH

LMWH

UFH + IIb/IIIa

LMWH + IIb/IIIa

Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.

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5.13.0

5.3 7.0

18.616.1 15.3

22.8

0

10

20

30

40

50

Overall Unstable Angina NSTEMI STEMI

Pa

tie

nts

(%

)

No Major Bleed

Major Bleed

** ****

**P<0.001

In-Hospital Mortality Rates

**

Moscucci MMoscucci M et al.et al.Eur Heart J 2003;24:1815-23.Eur Heart J 2003;24:1815-23.

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Hospital Outcomes of ACS Patients Stratified by Statin Use

Outcome Prior statins Prior & Hospital Hospital Statins Only Statin Only

Death 1.39 (0.91,2.14) 0.20 (0.16,0.25) 0.38 (0.30,0.48)

Recurrent MI 0.69 (0.43,1.11) 0.90 (0.75,1.07) 1.22 (1.08,1.37)

Stroke 1.08 (0.43,2.73) 0.68 (0.42, 1.12) 0.80 (0.57, 1.14)

Composite 1.02 (0.74,1.41) 0.66 (0.56,0.77) 0.87 (0.78,0.97)

*Compared to patients never receiving statins

Ann. Intern Med. 2004;140:856-866.Ann. Intern Med. 2004;140:856-866.

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At Admission Risk Model

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At Discharge Risk Model

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GRACE PDA Software

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Manuscript Status

16

8

7

12

66

0 20 40 60 80

Unprioritized

Top priorityindependent

Edit/write assistance

Submitted/beingrevised

Published/in press

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Unique Features of GRACE

• Multi-national perspective• Full spectrum of coronary syndromes• Increased data on demographics,

presentation, management and outcome• Regular audits of data quality• Feedback to participating sites• Long follow-up

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http://www.outcomes-umassmed.org/grace/guide_to_grace_manuscripts.aspx

Guide to GRACE manuscripts (1999 to 2006)

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Bleeding Risk Score

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Can Rapid risk stratification of Unstable angina patients Suppress

ADverse outcomes with Earl implementation of the American College of Cardiology/American Heart Association guidelines

(CRUSADE)

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http://www.crusadebleedingscore.org

http://www.ahjonline.com/article/S0002-8703(08)00384-0/abstract

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