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Revascularization in Patientswith ACS without ST segment
elevation
Cardiovascular UpdateCardiovascular UpdateRotterdam, June 11Rotterdam, June 11thth, 2012, 2012
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Robbert J de Winter MD PhD FESC
Professor Clinical CardiologyAcademic Medical CenterUniversity of Amsterdam
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ACUTE CORONARY SYNDROMEACUTE CORONARY SYNDROME
No ST ElevationNo ST Elevation ST ElevationST Elevation
ACC/AHA guidelines ACC/AHA guidelines UA/NSTEMI 9/00
Acute Coronary SyndromeAcute Coronary Syndrome
Davies MJ Davies MJ
Heart 83:361, 2000Heart 83:361, 2000
Ischemic DiscomfortIschemic DiscomfortPresentationPresentation
Working DxWorking Dx
Hamm Lancet 358:1533,2001Hamm Lancet 358:1533,2001
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Unstable AnginaUnstable Angina NQMI QwMIMyocardial InfarctionNQMI QwMI
Myocardial Infarction
NSTEMINSTEMI
No ST ElevationNo ST Elevation ST ElevationST Elevation
Unstable AnginaUnstable Angina NQMINQMI QwQw MIMI
NSTEMINSTEMI
Myocardial InfarctionMyocardial Infarction
ECGECG
BiochemBiochem. .
MarkerMarker
Final DxFinal Dx
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Revascularization in STEMI / NSTEMI
♥ When there is a clinical diagnosis of
thrombotic coronary artery occlusion,
immediate angiography and mechanical
reperfusion therapy is recommended
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
reperfusion therapy is recommended
and has been shown to reduce
mortality
♥ For NSTEMI / UA this is less clear
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♥ Revascularization to improve prognosis
♥ Revascularization to relieve symptoms
Revascularization in nSTE-ACS 2012
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
♥ Revascularization as part of a
comprehensive strategy in nSTE-ACS
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Revascularization in nSTE-ACS
Patients with nSTE-ACS represent a very heterogeneous
population:
♥ 45-year old male, positive family history, new onset
chest pain early morning, symmetrical negative T-
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
waves anterior ECG leads, normal troponin
♥ 80-year old lady with hypertension, diabetes, mitral
regurgitation, paroxysmal atrial fibrillation, LBBB,
progressive chest pain on exertion, presenting with
elevated troponin
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Acute coronary syndromes
Non-ST-elevation ACS is often a combination of
hemodynamically significant lesion, plaque
rupture, thrombus formation, coronary spasm
and increased oxygen demand, but with
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
preserved flow
Medical treatment combination of anti-ischemic,
vaso-dilator, anti-platelet and anti-coagulant
drugs
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AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
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AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
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Risk of ischemic events according to the GRACE risk score
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
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AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
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Meta-analysis non-STE-ACS
Mehta et al. JAMA 2005;293:2908-17
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Meta-analysis non-STE-ACS
Mehta et al. JAMA 2005;293:2908-17
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FRISC II: 5-year mortality
RR 0.95 (95%CI: 0.75-1.21, p=0.693)
0 1 2 3 4 5
Selective invasive
Routine invasive(Minimal 5-Y FU)
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RITA-3: 5-year mortality
Selective invasive
OR 0.76 (95%CI: 0.58-1.00, p=0.054)
Routine invasive
(Median 5-Y FU)
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ICTUS: 5-year mortality
Routine invasive
HR 1.13 (95%CI: 0.80-1.60, p=0.52)
Selective invasive
Damman P. et al.
(Minimal 5-Y FU)
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LongLong--Term Outcome of a Routine versus Term Outcome of a Routine versus Selective Invasive Strategy in Patients with Selective Invasive Strategy in Patients with
nonnon--ST elevation ACS ST elevation ACS
Keith AA Fox, Tim C Clayton, Peter Damman, Keith AA Fox, Tim C Clayton, Peter Damman, Stuart J Pocock, Robbert J de Winter, Jan GP Tijssen, Stuart J Pocock, Robbert J de Winter, Jan GP Tijssen, Stuart J Pocock, Robbert J de Winter, Jan GP Tijssen, Stuart J Pocock, Robbert J de Winter, Jan GP Tijssen,
Bo Lagerqvist, Lars WallentinBo Lagerqvist, Lars Wallentin
FIRFIR collaboration: collaboration: FFRISC RISC IICTUS CTUS RRITAITA
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FIR patientFIR patient--pooled databasepooled database
• Core variables:• Demographics• Clinical history• Risk factors for CAD• Baseline ECG characteristics• Baseline laboratory results• Baseline laboratory results• 5-year clinical outcomes
• 5467 patients with nSTE-ACS included
FIRFIR collaboration: collaboration: FFRISC RISC IICTUS CTUS RRITAITA
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Timing of first coronary revascularizationTiming of first coronary revascularization
60
80
100C
um
ula
tive p
erc
enta
ge
Selective invasive
Routine invasive
64.1%64.1% 71.8%71.8% 73.3%73.3%
17.6%17.6% 41.6%41.6% 47.8%47.8%
0
20
40
Cum
ula
tive p
erc
enta
ge
0 1 2 3 4 5
Follow-up time (years)
17.6%17.6% 41.6%41.6% 47.8%47.8%
Revasc at 1yr % Routine invasiveRoutine invasive Selective invasiveSelective invasive
ICTUS 7979 5454
FRISC II 7878 4444
RITA-3 5757 2828
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Table 2: Outcomes by study and treatment
Combined dataset Hazard ratio p-value
Selective Selective invasive invasive n = 2746n = 2746
Routine Routine invasive invasive n = 2721n = 2721
(95% CI)
MI 338 338 260 260 0.77 0.001
Primary outcomes at 5 yearsPrimary outcomes at 5 years
MI 338 338 12.9%12.9%
260 260 10.0%10.0%
0.77 (0.65 - 0.90)
0.001
CV death 218 218 8.1%8.1%
181 181 6.8%6.8%
0.83 (0.68 - 1.01)
0.068
CV death/MI
475 475 17.9%17.9%
389 389 14.7%14.7%
0.81 (0.71 -0.93)
0.002
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Table 2: Outcomes by study and treatment
Combined dataset Hazard ratio p-value
Selective Selective invasiveinvasive
Routine Routine invasiveinvasive
(95% CI)
All-cause 321 321 288 288 0.90 0.19
Outcomes at 5 yearsOutcomes at 5 years
All-cause death
321 321 11.7%11.7%
288 288 10.6%10.6%
0.90 (0.77 -1.05)
0.19
All-cause death/MI
560 560 20.9%20.9%
480 480 18.1%18.1%
0.85 (0.75 - 0.96)
0.008
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Cumulative risk of CV death or MICumulative risk of CV death or MI
10
15
20
25C
um
ula
tive p
erc
enta
ge
Selective invasive
Routine invasive 17.9%17.9%
14.7%14.7%
0
5
Cum
ula
tive p
erc
enta
ge
2721 2485 2410 2235 2166 1952RI
2746 2452 2351 2178 2077 1880SI
0 1 2 3 4 5
Follow-up time (years)
HR 0.81 95% CI 0.71HR 0.81 95% CI 0.71--0.930.93p = 0.002p = 0.002
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Are the results influenced by the baseline risk of Are the results influenced by the baseline risk of
the patients?the patients?
• Univariable and multivariable predictors
of outcome derived (Cox regression).
p<0.01 for inclusion in multivariable
model (Wald test)
• Simplified integer score derived:• Simplified integer score derived:
• Age, diabetes, prior MI, ST depression, hypertension, BMI
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Cumulative risk of CV death or MI by risk groupCumulative risk of CV death or MI by risk group
20
30
40
50C
um
ula
tive
pe
rce
nta
ge
Selective invasive
Routine invasive
Intermediate
0
10
20
Cu
mu
lative
pe
rce
nta
ge
2721 2485 2410 2235 2166 1952RI 2746 2452 2351 2178 2077 1880SI
0 1 2 3 4 5
Follow-up time (years)
Intermediate
Low
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Cumulative risk of CV death or MI by risk groupCumulative risk of CV death or MI by risk group
20
30
40
50C
um
ula
tive
pe
rce
nta
ge
Selective invasive
Routine invasiveHigh
Intermediate
0
10
20
Cu
mu
lative
pe
rce
nta
ge
2721 2485 2410 2235 2166 1952RI
2746 2452 2351 2178 2077 1880SI
0 1 2 3 4 5
Follow-up time (years)
Intermediate
Low
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Summary
• The routine invasive strategy reduced
cardiovascular death or MI at long-term follow-up
• 3.2% absolute risk reduction in CV death/MI
• 19% relative risk reduction
• No statistically significant reduction in mortality• No statistically significant reduction in mortality
• Risk stratification identifies the patient group with
the greatest absolute benefits
• 11.1% absolute risk reduction in highest risk patients
KAA Fox, TC Clayton, P Damman, SJ Pocock, RJ de Winter, JGP Tijssen,
B Lagerqvist, L Wallentin (FIR collaboration) JACC 2010;55:2435-45
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AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
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< 72 hrs
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
< 24 hrs
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< 24 hrs
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
< 72 hrs
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An International Randomized Trial of Early
TIMACSTiming of Interventionin patients with Acute Coronary Syndromes
An International Randomized Trial of Early
Versus Delayed Invasive Strategies in
Patients with Non-ST Segment Elevation
Acute Coronary Syndromes
Funded by Canadian Institutes of Health ResearchFunded by Canadian Institutes of Health Research
Additional support from GSK and SanofiAdditional support from GSK and Sanofi--AventisAventis
Preliminary Results
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TIMACSTIMACSTIMACSTIMACS Interventions and TimingInterventions and Timing
EarlyEarly
N=1,593N=1,593
DelayedDelayed
N=1,438N=1,438
Coronary Angiography (%)Coronary Angiography (%) 97.697.6 95.595.5
Median time (h Median time (h ±± iqriqr)) 14 (314 (3--21)21) 50 (4150 (41--81)81)
Preliminary Results as of Nov 7, 2008
Median time (h Median time (h ±± iqriqr)) 14 (314 (3--21)21) 50 (4150 (41--81)81)
PCI (%)PCI (%) 59.659.6 55.055.0
Median time (h Median time (h ±± iqriqr)) 16 (316 (3--23)23) 52 (4152 (41--101)101)
CABG (%)CABG (%) 14.714.7 13.613.6
Median time (d Median time (d ±± iqriqr)) 7.7 (4.77.7 (4.7--17.4)17.4) 10.8 (6.710.8 (6.7--19.8)19.8)
iqr=interquartile range
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TIMACSTIMACSTIMACSTIMACS
Primary OutcomePrimary OutcomeDeath, MI, or StrokeDeath, MI, or Stroke
Cu
mu
lative
Ha
za
rd
0.0
60
.10
Death/MI/Stroke at 180 days
Early
Delayed
HR 0.85
Preliminary Results as of Nov 7, 2008
Days
Cu
mu
lative
Ha
za
rd
0.0
0.0
2
0 30 60 90 120 150 180
No. at Risk
Delayed
Early
1438 1328 1269 1254 1234 1229 1211
1593 1484 1413 1398 1391 1382 1363
HR 0.8595% CI 0.68-1.06
P= 0.15
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TIMACSTIMACSTIMACSTIMACS
Secondary OutcomeSecondary OutcomeDeath, MI, or Refractory IschemiaDeath, MI, or Refractory Ischemia
Cum
ula
tive H
azard
0.0
80.1
2
Death/MI/RI at 180 days
Delayed
Early
Preliminary Results as of Nov 7, 2008
Days
Cum
ula
tive H
azard
0.0
0.0
4
0 30 60 90 120 150 180
No. at Risk
Delayed
Early
1438 1303 1243 1230 1209 1205 1187
1593 1485 1417 1402 1394 1386 1366
HR 0.7295% CI 0.58-0.79
P=0.002
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TIMACSTIMACSTIMACSTIMACSPrePre--specified Subgroupsspecified Subgroups
Overall
Age < 65
>=65
FemaleMale
3031
1293
1736
10521976
9.7
6.5
12.3
9.79.8
0.463
0.540
0.85 ( 0.68 - 1.06 )
0.98 ( 0.64 - 1.52 )
0.83 ( 0.64 - 1.07 )
0.77 ( 0.54 - 1.12 )
0.89 ( 0.68 - 1.18 )
NCharacteristic HR (95% CI) Interaction p-Value
Early%
11.4
6.5
14.8
12.310.9
Delayed%
Male
No ST deviationST deviation
No elevated marker
Elevated marker
GRACE 0-140
GRACE >=141
1976
15231508
668
2363
2070
961
9.8
7.611.7
10.5
9.5
7.7
14.1
0.540
0.722
0.423
0.0097
0.89 ( 0.68 - 1.18 )
0.88 ( 0.62 - 1.26 )
0.81 ( 0.61 - 1.07 )
1.00 ( 0.62 - 1.60 )
0.81 ( 0.63 - 1.04 )
1.14 ( 0.82 - 1.58 )
0.65 ( 0.48 - 0.88 )
0.33 0.5 0.7 1.00 1.52.0 3.0
Early better Delayed better Hazard Ratio (95% CI)
10.9
8.714.3
10.5
11.7
6.7
21.6
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TIMACSTIMACSTIMACSTIMACSConclusionsConclusions
1. Overall, we found no significant difference between an early and a delayed invasive strategy for prevention of death, MI or stroke (primary outcome).
2. In the subgroup at highest risk (GRACE score > 140), an early invasive strategy appears to be superior to a
Preliminary Results as of Nov 7, 2008
an early invasive strategy appears to be superior to a delayed invasive strategy for prevention of death, MI or stroke.
3. The early invasive strategy had a large impact on reducing the rate of refractory ischemia by 70%.
4. There were no significant differences in major bleeding or other safety concerns between the two strategies.
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ABOARD study designABOARD study designABOARD study designABOARD study design
NSTENSTE--ACS ACS 2 of 3 Criteria: Ischemic symptom, ST2 of 3 Criteria: Ischemic symptom, ST--T change, troponin riseT change, troponin rise
with TIMI score with TIMI score >> 33
IVRS RANDOMIZATIONIVRS RANDOMIZATION
Preliminary Results
Immediate cathImmediate cath Next day cathNext day cath
All PCIs on abciximabAll PCIs on abciximab
11--month Followmonth Follow--upup
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OutcomesOutcomesOutcomesOutcomes
•• Primary Primary
−− MI: defined as the peak of troponin I during MI: defined as the peak of troponin I during hospitalizationhospitalization
•• SecondarySecondary
Preliminary Results
•• SecondarySecondary
1.1. Death (any), new MI (CKDeath (any), new MI (CK--MB) or urgent MB) or urgent revascularization (PCI or CABG)revascularization (PCI or CABG)
2.2. Death, new MI, urgent revascularization or Death, new MI, urgent revascularization or recurrent ischemia recurrent ischemia
3.3. Individual parametersIndividual parameters
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Index ACS eventIndex ACS eventIndex ACS eventIndex ACS event
Entry criteria, (%) Immediate(N=175)
Delayed(N=177)
Ischemic symptom 98.2 97.7
ST-T segment changes 69.7 76.8
Preliminary Results
ST-T segment changes 69.7 76.8
Elevated Troponin I 75.4 72.9
TIMI score, (%)
> 3 95.4 95.5
> 5 22.9 30.5
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InIn--hospital medicationshospital medicationsInIn--hospital medicationshospital medications
Immediate(N=175)
Delayed(N=177)
Aspirin, (%) 99.4 100
Clopidogrel, (%) 96.6 98.9
Loading dose, mean ± sd, mg 660 ± 268 663 ± 267
Maintenance dose, mean ± sd, mg 111 ± 40 111 ± 39
Abciximab, (%) 65.1 57.4
Preliminary Results
Abciximab, (%) 65.1 57.4
Unfractionated heparin only, (%) 5.1 3.4
Low Molecular Weight Heparin only, (%) 68.6 67.2
Both UFH and LMWH, (%) 22.9 28.8
Neither UFH nor LMWH, (%) 2.9 0.6
Beta-blocker, (%) 87.4 85.3
Statin, (%) 94.3 95.5
ACE inhibitor or ARB, (%) 84.5 80.2
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Time to catheterization (hrs)Time to catheterization (hrs)Time to catheterization (hrs)Time to catheterization (hrs)
IMMEDIATEIMMEDIATE DELAYEDDELAYED
FRISC 2 (1999) 96 408
TRUCS (2000) 48 120
TIMI-18 (2001) 22 79
VINO (2002) 6 1464
Preliminary Results
VINO (2002) 6 1464
RITA 3 (2002) 48 1020
ELISA (2003) 6 50
ISAR-COOL (2003) 3 86
ICTUS (2005) 23 283
TIME-ACS (2008) 14 50
ABOARD (2009)
median (IQR), hr.min1.10
(0.51-2.03)20.48
(17.30-24.36)
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InterventionsInterventionsInterventionsInterventions
IMMEDIATEIMMEDIATE DELAYEDDELAYED
Radial access (%) 87.487.4 81.881.8
Culprit artery
Left main trunk, (%) 4.1 7.3
Left anterior descending artery, (%) 48.6 45.0
Circumflex artery, (%) 24.7 29.1
Preliminary Results
Circumflex artery, (%) 24.7 29.1
Right coronary artery, (%) 24.7 25.2
Coronary bypass graft, (%) 2.1 2.0
Percutaneous Coronary Intervention, (%) 80.1 69.5
Stent (at least one), (% of PCI) 94.0 96.2
DES (at least one), (% of PCI) 47.9 55.2
Number of stents/patient, mean±sd 1.2 ± 0.9 1.2 ± 1.0
CABG surgery, (%) 11.0 11.3
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Primary EP (peak of troponin I)Primary EP (peak of troponin I)Primary EP (peak of troponin I)Primary EP (peak of troponin I)
0.0
80.1
00.1
20.1
4
Density
Distribution curves of the peaks values of troponin in the immediate and delayed groups
immediate groupdelayed group
Median, IQR
2.1 (0.3-7.1)1.7 (0.3-7.2)
Peak values of troponin I in the 2 groups
p = 0.70
Preliminary Results
0 20 40 60 80 100
0.0
00.0
20.0
40.0
60.0
8
Troponin I (ng/mL)
Density
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Composite Ischemic Endpoints at 1 monthComposite Ischemic Endpoints at 1 month
%%
15
20
25
Immediate
Delayed
P=0.31
P=0.94
Preliminary Results
0
5
10
Death / MI / UR Death / MI / UR / RIKey secondary EP
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Individual Ischemic Endpoints at 1 monthIndividual Ischemic Endpoints at 1 month
8
10
12
14
16
18
20
ImmediateDelayed
%%
P=0.09
P=0.32
P=0.08
Preliminary Results
0
2
4
6
8
Dea
th
MI
Urg
Rev
asc
Urg
PC
IU
rg C
AB
GR
ec Is
ch
P=0.28
P=0.32
P=0.57
P=0.62
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Safety outcomes at 1 monthSafety outcomes at 1 monthSafety outcomes at 1 monthSafety outcomes at 1 month
Immediate Delayed PP
Major bleeding at 1 month, (%)Major bleeding at 1 month, (%) 4.0 6.8 0.250.25
NonNon--CABG related major bleeding, CABG related major bleeding, 2.3 5.1 0.260.26
CABGCABG--related major bleedingrelated major bleeding 1.7 1.7 1.001.00
Preliminary Results
Transfusion Transfusion >> 2 units2 units 3.4 5.6 0.320.32
Transfusion Transfusion >> 5 units5 units 1.1 1.1 1.001.00
Thrombocytopenia at 1 month, (%)Thrombocytopenia at 1 month, (%) 2.9 4.5 0.410.41
NonNon--CABG CABG thrombocytopenia,thrombocytopenia, (%)(%) 2.3 4.0 0.540.54
PostPost--CABG CABG thrombocytopenia,thrombocytopenia, (%)(%) 0.6 0.6 1.001.00
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Sites of Major BleedingsSites of Major BleedingsSites of Major BleedingsSites of Major Bleedings
11-- GastroGastro--IntestinalIntestinal 44
22-- PuncturePuncture--relatedrelated 44
33-- HemopericardiumHemopericardium 22
n
Preliminary Results
33-- HemopericardiumHemopericardium 22
44-- IntracranialIntracranial 11
55-- EpistaxisEpistaxis 11
66-- Hematoma (not punctureHematoma (not puncture--related)related) 11
unknownunknown 77
One patient had 2 bleeding events
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Subgroup analysis (primary EP)Subgroup analysis (primary EP)Subgroup analysis (primary EP)Subgroup analysis (primary EP)
Median differences and Hodges-Lehmann CI for the primary end point (peak of troponin)
Preliminary Results
Immediate better Delayed better
Page 47
Hospital stayHospital stayHospital stayHospital stay
ImmediateImmediate
Median, IQR, hrsMedian, IQR, hrs
55( 30; 98)
Preliminary Results
Median, IQR, hrsMedian, IQR, hrs ( 30; 98)
DelayedDelayed
Median, IQR, hrsMedian, IQR, hrs
77( 49; 145)
P<0.001
Page 48
ConclusionsConclusionsConclusionsConclusions
A « A « primaryprimary PCI PCI strategystrategy » in NSTE» in NSTE--ACS ACS
((comparedcompared withwith a a rapidrapid intervention on the intervention on the nextnext
dayday):):
−− isis feasiblefeasible, but , but doesdoes not not reducereduce the the riskrisk of MI (of MI (primaryprimary
Preliminary Results
−− isis feasiblefeasible, but , but doesdoes not not reducereduce the the riskrisk of MI (of MI (primaryprimary
outcomeoutcome))
−− isis not not associatedassociated withwith significantsignificant differencesdifferences in in otherother
efficacyefficacy or or safetysafety outcomesoutcomes
−− doesdoes not not benefitbenefit to a to a particularparticular subgroupsubgroup of patientsof patients
−− shortensshortens significantlysignificantly hospitalhospital staystay
Page 49
A Death B Myocardial infarction
C Major bleeding D Recurrent Ischemia
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional CardiologyKatritsis et al. EurHJ 2011;32:32-40
C Major bleeding D Recurrent Ischemia
Page 50
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
Page 51
Medical management vs Revascularization
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional CardiologyChan et al. JACC Int 2008;1:369-78
Page 52
Medical management vs Revascularization
SYNERGY
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional CardiologyChan et al. JACC Int 2008;1:369-78
Page 53
Predictors of early invasive management
CRUSADE
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional CardiologyBhat DL et al. JAMA 2004;292:2096
Page 54
♥ Post hoc analyses SYNERGY / CRUSADE
♥ Patients magaged medically after angiography constitute a particularly high risk group of patients
Medical management vs Revascularization
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
♥ We need better strategies to improve
outcome in these patients
Page 55
nSTE-ACS
What’sComing?
"The secret to creativity is knowing how to hide your sources."
Page 56
ASA ASA + Clopidogrel
ASA + Prasugrel
-22%Ischaemic
Antiplatelet therapy in ACSThe risk of bleeding
-20%
-19%
+60% +38% +32%
Ischaemic events
Bleeding??!!
Page 59
hsTnT
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Mills et al, JAMA 2011Mills et al, JAMA 2011
Page 60
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
TwerenboldTwerenbold et al, et al, EurEur H J 2012H J 2012
Page 61
< 24 hrs
?
AMCAMC--UVA Amsterdam Interventional CardiologyUVA Amsterdam Interventional Cardiology
< 72 hrs
Page 62
Prasugrel / TicagrelorRivaroxaban / Vorapaxar
Darapladip
hs-troponinNew DES
Radial approachRadial approach
"The only thing that interferes with my learning is my education."
Page 63
Conclusion
Repeat allRCTs
"The only thing that interferes with my learning is my education."
Page 64
25
30
35
40
25000
30000
35000
40000
45000
PCI ‘s / year # PCI Centers
Number of PCI’s procedures and PCI-centers in the Netherlands
28
+ 13.000 procedures
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Source: BHN Nederland
0
5
10
15
20
0
5000
10000
15000
20000
25000
2002 2003 2004 2005 2006 2007 2008 2009 2010
14
Page 65
♥ Invasive strategy after risk stratification
√ most patients
♥ Reduction in death or MI
√ mortality reduction modest
Revascularization in nSTE-ACS 2012
♥ Reduction length of stay
♥ Improvements in pharmacology & stents &
hs-Troponins
√ has not been tested
Page 66
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Thank YouThank You
Page 67
Gender and revascularization in nSTE-ACS
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional CardiologyO’Donoghue et al. JAMA. 2008 Jul 2;300(1):71-80
Page 68
Gender and revascularization in nSTE-ACS
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional CardiologyO’Donoghue et al. JAMA. 2008 Jul 2;300(1):71-80
Page 69
Prognosis after procedure related MI
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Damman et al. Circulation. 2012;125:568-576
Page 70
Prognosis after procedure related MI
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Damman et al. Circulation. 2012;125:568-576
Page 71
Age and revascularization in nSTE-ACS
CV death or MI
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Damman et al. Heart 2012;98:207-213
Page 72
Age and revascularization in nSTE-ACS
CV death
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Damman et al. Heart 2012;98:207-213
Page 73
Age and revascularization in nSTE-ACS
Myocardial infarction
AMC Amsterdam Interventional CardiologyAMC Amsterdam Interventional Cardiology
Damman et al. Heart 2012;98:207-213