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NSTEMI INVASIVE TREATMENT-RATIONALE AND TIMING
DEV PAHLAJANI MD,FACC,FSCAIHOD INTERVENTIONAL CARDIOLOGY BREACH CANDY HOSPITAL MUMBAI
4.78.3
13.2
19.9
26.2
40.9
0
10
20
30
40
50
60
0/1 2 3 4 5
TIMI Risk Score for UA/NSTEMI
D/M
I/UR
by
14 D
ays
(%)
Antman RM et al JAMA 2000, 284, 835% Population 4.3 17.3 32.0 29.3 13.0 3.4
6-7
SABATINE AND ANTMAN TIMI RISK SCORE FOR UA/NSTEMI
Meta-analysis for CV death or MI
Overall
FRISC-II (N=2457)
ICTUS (N=1200)
RITA-3 (N=1810)
Study
0.81 (0.71, 0.93)
0.79 (0.66, 0.95)
0.99 (0.72, 1.35)
0.75 (0.58, 0.96)
0.81 (0.71, 0.93)
0.79 (0.66, 0.95)
0.99 (0.72, 1.35)
0.75 (0.58, 0.96)
Hazard ratio (95% CI)
0.5 0.75 1 1.33 2
Favors routine invasive Favors selective invasiveHazard ratio
0.1 1 10
Odds Ratio (95%CI)
Invasive strategy in non-ST elevation ACSRe-hospitalisation for unstable angina
Invasive better Conservative betterN=7966P=0.00001Heterogeneity p=0.01
OR 0.54(95% CI 0.48-0.61)
NNT 16
Adapted from JACC 2006;48:1319
Inv Con
17.1% 28.2%
17.1% 23.6%
11.0% 13.7%
6.5% 11.6%
9.4% 17.9%
7.2% 10.7%
11.4% 17.5%
Trial FUmonths
FRISC2 24
TRUCS 12
TACTICS 6
RITA 3 12
VINO 6
ICTUS 12
TOTAL
0.1 1 10
Odds Ratio (95%CI)
Invasive strategy in non-ST elevation ACSIs there a mortality benefit?
Invasive better Conservative better
Trial FU months
FRISC2 60
TRUCS 12
TACTICS 6
RITA 3 60
VINO 6
ISAR COOL 1
ICTUS 32
TOTAL 38
N=8375P=0.05Heterogeneity p=0.13
OR 0.85(95% CI 0.73-1.00)
NNT 83
Inv Con
9.6% 10.0%
3.9% 12.5%
3.3% 3.5%
11.4% 14.4%
3.1% 13.4%
0.0% 1.4%
7.5% 6.7%
7.3% 8.5%
FRISC score (sum of): Age>65, male gender, diabetes, previous MI, ST-depression, elevated troponin / Il-6 / CRP
Lancet 2006;368:998
High risk (score 4-7) N=622RR (95%CI) 0.79 (0.64-0.97)
Medium risk (score 2-3) N=1092RR (95%CI) 0.72 (0.55-1.13)
Low risk (score 0-1) N=369RR (95%CI) 1.26 (0.66-2.40)
Years since randomisation
Dea
th o
r myo
card
ial i
nfar
ctio
n (%
)
41 5320
10
20
30
40
0
32.7%
41.6%
14.6%
20.4%
10.3%8.2%
ConservativeInvasive
FRISC-2: cumulative risk of death or MIby risk score
Δ8.9%
Δ5.8%
RITA 3 -10 YRS GRACE SCORE
PROGNOSTIC VALUE OF TN&ECG INACS
Invasive vs. Conservative
• Invasive strategy is favoured over conservative management
• Unresolved Issues –
–Optimal timing– need to balance the risks of intervention for
unstable plaque – risk of new ischemic events while waiting to
perform an invasive procedure
Milosevic A, et al. J Am Coll Cardiol Intv 2016
ELISA 3 TRIAL
• 542 HIGH RISK NSTEMI• RANDOMIZED TO IMMEDIATE-<12 HRS
INVASIVE AND DELAYED >48 HRS • COMPOSITE OF DEATH,MI,AND RECURRENT
ISCH AT 30 DAYS• IMMEDIATE 9.9%,DELAYED 14% P=0.35• SAFE TO PERFORM IMMEDIATE
Cumulative incidence of primary endpoint of death or MI at 30 days for immediate versus delayed. Dashed black line intersecting the X axis denotes
the median time to angiography (61h) in patients undergoing delayed invasive intervention Milosevic A, et al. J Am Coll Cardiol Intv 2016
Variable ImmediateIntervention (n = 162)
DelayedIntervention (n = 161)*
HR (95% CI) p Value
30 daysDeath or MI 4.3 13.0 0.32 (0.13–0.74) 0.008Death, MI, or recurrent ischemia)
6.8 26.7 0.23 (0.12–0.45 <0.001
Death 3.1 3.1 0.98 (0.28–3.37) 0.97MI 2.5 9.9 0.24 (0.08–0.70) 0.01Recurrent ischemia 3.7 15.5 0.24 (0.10–0.57) 0.001Major bleeding 0.6 0.6 0.99 (0.06–15.89) 0.99 31 days to 1 yrDeath or MI 2.6 6.5 0.39 (0.12–1.27) 0.12Death, MI, or recurrent ischemia 9.3 9.3 0.99 (0.45–2.19) 0.71
Death§ 1.9 2.6 0.74 (0.17–3.31) 0.69MI 0.6 4.3 0.15 (0.02–1.22) 0.07Recurrent ischemia 6.5 2.2 2.99 (0.82–10.85) 0.06Major bleeding 0.0 2.5 0.01 (0.01–46.38) 0.301 yrDeath or MI 6.8 18.8 0.34 (0.17–0.67) 0.002Death, MI, or recurrent ischemia
15.4 33.1 0.28 (0.15–0.51) <0.001
Death 4.9 5.6 0.87 (0.34–2.26) 0.78MI 3.1 13.8 0.21 (0.08–0.55) 0.002Recurrent ischemia 9.9 16.9 0.28 (0.12–0.63) 0.002Major bleeding 0.6 3.1 0.20 (0.02–1.68) 0.14
Clinical Outcomes Up to 1 Year
Cumulative incidence of the combined primary endpoint of death or new myocardial infarction at 30 days and thereafter for patients undergoing
immediate versus delayed invasive intervention.Milosevic A, et al. J Am Coll Cardiol Intv 2016
2015 ESC Guidelines for the management of acute coronary
syndromes in patients presenting without persistent ST-segment
elevation
Risk criteria mandating invasive strategy in NSTE-ACS2015 ESC Guidelines
NSTEMI NSTEMI 2015
NSTEMI ESC 2015
NSTEMI ESC 2015
Summary
• The routine invasive strategy reduces cardiovascular death or MI at long-term follow-up• 3.2% absolute risk reduction in CV death/MI • 19% relative risk reduction
• Risk stratification identifies the patient group with the greatest absolute benefits• 11.1% absolute risk reduction in highest risk patients
• The absolute risk reductions in CV death/MI in low (2.0%) and Intermediate groups (3.8%) exceed those seen in many trials of pharmacological agents
CONCLUSIONS• INVASIVE TREATMENT SUPERIOR TO
CONSERVATIVE• IN HIGH SCORE IMMEDIATE APPROACH
WITHIN 2 HOURS• BIOMARKERS,RECURRENT ISCHEMIA,ECG AND
HEMODYNAMIC CHANGES DETERMINE THE APPROACH
• LONG TERM OUTCOMES BETTER IN HIGH RISK