Strive Teleconf Presentation Aug15 2007

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  • 1. ACS Critical Pathways 2007 Teleconferences August 15, 2007 This activity is co-provided by the Network for Continuing Medical Education and EduPro Resources LLC. This activity is supported by an educational grant from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.
  • 2. Faculty Christopher P. Cannon, MD Associate Professor of Medicine Harvard Medical School Senior Investigator, TIMI Study Group Associate Physician, Cardiovascular Division Brigham and Women’s Hospital Boston, Massachusetts
  • 3. The Network for Continuing Medical Education and EduPro Resources LLC require that CME/CNE faculty disclose, during the planning of an activity, the existence of any personal financial or other relationships they or their spouses/partners have with the commercial supporter of the activity or with the manufacturer of any commercial product or service discussed in the activity. Disclosure Statement
  • 4. Christopher P. Cannon, MD , has received research support from Accumetrics, AstraZeneca Pharmaceuticals LP, GlaxoSmithKline, Merck & Co., Inc., Merck/Schering-Plough Pharmaceuticals, sanofi-aventis, and Schering-Plough Corporation. The team from Doylestown Hospital reports it has no relationships to disclose. The NCME staff reports it has no relationships to disclose. Faculty Disclosure Statement
  • 5. Update of the ACC/AHA ACS Guidelines: UA/NSTEMI Christopher P. Cannon, MD
  • 6. Polling Question #1
    • Have you implemented a formal plan to incorporate the new UA/NSTEMI guidelines into your institution’s ACS pathways?
    • Updated ACS pathways plan has not been discussed
    • Updated ACS pathways plan discussed but not initiated
    • Updated ACS pathways plan initiated; full implementation expected ≤6 months
    • Updated ACS pathways plan initiated; full implementation expected >6 months
  • 7. What’s New Since 2002?
    • Background:
    • 1.57 million hospital admissions for ACS annually
    • 1.24 million UA/NSTEMI cases
    • As previously, risk scores guide serial clinical decision making
    Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com. 2007 ACC/AHA UA/NSTEMI Guideline Revision
  • 8. Risk Stratification
    • Integral prerequisite to decision making a) Intensive initial assessment b) Continuous clinical assessment c) Targeted ECG and marker data
    • Risk based on contingent probabilities a) Probability of obstructive CAD causing ischemia b) Risk given presence of obstructive CAD
    • Risk scores should be a routine part of assessment throughout the hospital course and periodically after discharge
    2007 ACC/AHA UA/NSTEMI Guideline Revision Anderson JL, et al. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 9. Risk Assessment Dependent on Contingent Probabilities
    • Likelihood of obstructive CAD as cause of symptoms
      • Dominated by acute findings
        • Examination
        • Symptoms
        • Markers
      • Traditional risk factors are of limited utility
    • Does this patient have symptoms due to acute ischemia from obstructive CAD?
    • Risk of bad outcome
      • Dominated by acute findings
        • Older age very important
        • Hemodynamic abnormalities critical
        • ECG, markers
    • What is the likelihood of death, MI, heart failure?
    2007 ACC/AHA UA/NSTEMI Guideline Revision Anderson JL, et al. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 10. Selection of Strategy: Invasive Versus Conservative Strategy
    • An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is indicated with refractory angina or hemodynamic or electrical instability (Class I, Level of Evidence: B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 11. Selection of Strategy: Invasive Versus Conservative Strategy (cont)
    • An early invasive strategy is indicated in initially stabilized patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (I, A). Scores indicating elevated risk include combinations of the following:
      • Recurrent angina/ischemia at rest or during low-level activities
      • Elevated cardiac biomarkers
      • New/presumably new ST-segment depression
      • Signs or symptoms of HF or new/worsening mitral regurgitation
      • High-risk findings from noninvasive testing
      • Hemodynamic instability
      • Sustained ventricular tachycardia
      • PCI within 6 months
      • Prior CABG
      • High risk score
      • LVEF < 0.40
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 12. Selection of Strategy: Invasive Versus Conservative Strategy (cont)
    • In initially stabilized patients, an initially conservative (ie, a selectively invasive) strategy may be considered in patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events, including those who are troponin-positive (IIb, B). The decision to implement an initial conservative strategy may consider physician and patient preferences (IIb, C)
    • A conservative strategy is recommended in women with low-risk features (I, B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 13. Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy Proceed to Diagnostic Angiography ASA (Class I, A) Clopidogrel if ASA intolerant (Class I, A) Diagnosis of UA/NSTEMI Is Likely or Definite Invasive Strategy Initiate A/C Rx (Class I, A) Acceptable options: enoxaparin or UFH (Class I, A) bivalirudin or fondaparinux (Class I, B) Select Management Strategy Proceed With an Initial Conservative Strategy Prior to Angiography Initiate at least one (Class I, A) or both (Class IIa, B) of the following: Clopidogrel IV GP IIb/IIIa inhibitor Factors favoring administration of both clopidogrel and GP IIb/IIIa inhibitor include: Delay to angiography High risk features Early recurrent ischemic discomfort Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision
  • 14. Initiate clopidogrel (Class I, A) Consider adding IV eptifibatide or tirofiban (Class IIb, B) Conservative Strategy Initiate A/C Rx (Class I, A): Acceptable options: enoxaparin or UFH (Class I, A) or fondaparinux (Class I, B), but enoxaparin or fondaparinux are preferable (Class IIA, B) Select Management Strategy ASA (Class I, A) Clopidogrel if ASA intolerant (Class I, A) Diagnosis of UA/NSTEMI Is Likely or Definite Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy Proceed With Invasive Strategy (Continued on slide 18) Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision
  • 15. Initial Conservative Strategy: Early Hospital Care
    • ASA; clopidogrel if intolerant (I, A)
    • Anticoagulant therapy should be added to antiplatelet therapy as soon as possible after presentation (I, A)
      • Enoxaparin or UFH (I, A)
      • Fondaparinux (I, B)
      • Enoxaparin or fondaparinux preferable (IIa, B)
    • Initiate clopidogrel, loading dose + maintenance dose (I, A)
      • Consider IV eptifibatide or tirofiban (IIb, B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 16. Initial Conservative Strategy: Early Hospital Care (cont)
    • Beta-blocker therapy
      • Initiate oral therapy within first 24 h unless HF, low-output state, increased risk for cardiogenic shock, or relative contraindications (I, B)
      • IV therapy for high blood pressure without contraindications (IIa, B)
      • IV therapy may be harmful with contraindications to beta blockade, signs of HF or low-output state, or other risk factors for cardiogenic shock (III, A)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 17. Initial Conservative Strategy: Early Hospital Care (cont)
    • Lipid management
      • Fasting lipid profile within 24 h (I, C)
      • Statin (in absence of contraindications) should be given regardless of baseline LDL-C predischarge (I, A)
    • ACE inhibitor (oral)
      • Within 24 h with pulmonary congestion or LVEF  40, in absence of hypotension (systolic blood pressure <100 mm Hg or <30 mm Hg below baseline) or known contraindications (I, A)
      • ARB if ACE intolerant (I, A)
      • Can be useful without pulmonary congestion or LVEF < 0.40 (IIa, B)
      • No IV ACE inhibitor in first 24 h because of increased risk of hypotension (III, B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 18. Any subsequent events necessitating angiography? EF >0.40 Evaluate LVEF Low Risk Continue ASA indefinitely (Class I, A) Continue clopidogrel for at least 1 month (Class I, A) and ideally up to 1 y (Class I, B) Discontinue IV GP IIb/IIIa if started previously (Class I, A) Discontinue A/C Rx (Class I, A) (Class I, B) Proceed to Dx Angiography Yes EF ≤ 0.40 Stress Test (Class I, A) No Not Low Risk (Class IIa, B) Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy (Continued from slide 14) (Class I, A) (Class IIa, B) (Class I, B) Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision
  • 19. Initial Conservative Strategy: Early Hospital Care (cont)
    • If LVEF is < 0.40, it is reasonable to perform diagnostic angiography (IIa, B)
    • A stress test should be performed for assessment of ischemia (I, B)
      • If the patient is classified as not low risk, diagnostic angiography should be performed (I, A)
    • Measurement of BNP or NT-pro-BNP may be considered to supplement assessment of global risk in patients with suspected ACS (IIb, B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 20.
    • Continue ASA (Class I, A)
    • Loading dose of clopidogrel if not given preangiography (Class I, A)
    • Discontinue IV GP IIb/IIIa after at least 12 h if started preangiography (Class I, B)
    • Continue IV UFH for at least 48 h (Class I, A) or enoxaparin or fondaparinux for duration of hospitalization (A); either discontinue bivalirudin or continue at a dose of 0.25 mg/kg/h for up to 72 h at physician‘s discretion (Class I, B)
    • Continue ASA (Class I, A)
    • Discontinue clopidogrel 5-7 d prior to elective CABG (Class I, B)
    • Discontinue IV GP IIb/IIIa 4 h prior to CABG (Class I, B)
    • Continue UFH (Class I, B); discontinue enoxaparin 12-24 h prior to CABG; discontinue fondaparinux 24 h prior to CABG; discontinue bivalirudin 3 h prior to CABG. Dose with UFH per institutional practice (Class I, B)
    • Continue ASA (Class I, A)
    • Loading dose of clopidogrel if not given preangiography (Class I, A)
    • and
    • IV GP IIb/IIIa if not started preangiography (Class I, A)
    • Discontinue A/C Rx after PCI for uncomplicated cases (Class I, B)
    Antiplatelet and A/C Rx at physician’s discretion (Class I, C) No significant obstructive CAD on angiography CAD on angiography PCI CABG Management After Diagnostic Angiography in Patients With UA/NSTEMI Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. Select Post Angiography Management Strategy 2007 ACC/AHA UA/NSTEMI Guideline Revision Medical Therapy
  • 21. Long-term Antithrombotic Therapy at Hospital Discharge After UA/NSTEMI Medical Tx Without Stent Bare Metal Stent Drug-Eluting Stent ASA 162-325 mg/d for at least 1 mo, then 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 mo (Class 1, A) and ideally up to 1 y (Class I, B) Add: Warfarin (INR 2.0- 2.5) (Class IIb, B) Continue with dual antiplatelet tx as above Indication for Anticoagulation? ASA 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 mo (Class I, A) and up to 1 y (Class I, B) ASA 162-325 mg/d for at least 3-6 months, then 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 y (Class I, B) UA/NSTEMI Patient Groups at Discharge Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision
  • 22.
    • Medical therapy without stenting
      • ASA 75-162 mg/d indefinitely (I, A)
      • and
      • Clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 y (I, B)
    • Bare metal stent
      • ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely (I, A)
      • and
      • Clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 y (I, B)
    • Drug-eluting stent
      • ASA 162-325 mg/d at least 3 (sirolimus) to 6 (paclitaxel) mo, 75-162 mg/d indefinitely (I, A)
      • and
      • Clopidogrel 75 mg/d at least 1 y (I, B)
    More Aggressive Long-term Antiplatelet Therapy 2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 23. Discharge Planning: Secondary Prevention
    • Clopidogrel, initial conservative strategy
      • Continue at least 1 mo (I, A)
      • Continue ideally up to 1 y (I, A)
    • ACE inhibitor
      • Continue indefinitely with HF, LV dysfunction with LVEF < 0.40, hypertension, or diabetes (I, A)
      • Reasonable in absence of LV dysfunction, hypertension, or diabetes (IIa, A)
      • Reasonable with HF and LVEF >0.40 (IIa, A)
      • Consider ACE/ARB combination with persistent HF and LVEF <0.40 despite conventional therapy including ACE or ARB (IIb, B)
    • ARB should be administered at discharge (I, A) and long-term (IIa, B) with ACE inhibitor intolerance and signs of HF with LVEF < 0.40 (I, A)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 24. Discharge Planning: Secondary Prevention (cont)
    • Aldosterone receptor blockade should be prescribed long term if without significant renal dysfunction or hyperkalemia, already on ACE inhibitor, with LVEF < 0.40, and either symptomatic HF or diabetes (I, A)
    • Lipid management
      • Statin regardless of baseline LDL-C (I, A) initiated prior to discharge (I, A)
      • Goal LDL-C <100 mg/dL (I, A), with <70 mg/dL reasonable (IIa, A)
      • Treatment of triglycerides and non – HDL-C useful
        • If TG 200-499 mg/dL, non – HDL-C should be <130 mg/dL (I, B)
        • TG  500 mg/dL, fibrate, or niacin before LDL-C lowering to prevent pancreatitis (I, C)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 25. Discharge Planning: Secondary Prevention (cont)
    • Blood pressure control
      • <140/90 mm Hg (I, A)
      • <130/80 mm Hg with diabetes mellitus or chronic kidney disease (I, A)
    • Smoking cessation and avoidance of exposure to environmental tobacco is recommended (I, B)
      • Education, referral to programs, and pharmacotherapy is useful (I, B)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 26. Discharge Planning: Secondary Prevention (cont)
    • NSAIDS
      • Discontinue at UA/NSTEMI presentation (I, C)
      • No NSAID, nonselective or COX-2 selective (except ASA), during hospitalization for patients at high risk of mortality, reinfarction,  BP, HF, or myocardial rupture (II, C)
      • At discharge, chronic musculoskeletal pain relief with acetaminophen, small dose narcotics, nonacetylated salicylates (I, A)
      • Nonselective NSAID (eg, naproxen) reasonable if above strategies are insufficient (IIa, C)
      • For intolerable discomfort, increasing COX-2 selectivity, lowest dose for shortest time (IIb, C)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 27. Discharge Planning: Secondary Prevention (cont)
    • Discharge education/referral
      • Medications, diet, exercise, smoking cessation, cardiac rehabilitation (I, C)
      • Return appointment
        • 2-6 wk low-risk medically treated or revascularized patients (I, C)
        • Within 14 days for higher-risk patients (I, C)
    • Menopausal hormone therapy (estrogen plus progestin or estrogen alone) should not be given de novo for secondary prevention of coronary events (III, A)
    • Antioxidant vitamin supplements (C, E, or beta carotene) and folic acid (with or without B6 and B12) should not be used for secondary prevention (III, A)
    2007 ACC/AHA UA/NSTEMI Guideline Revision Wenger NK. Available at: http://cardiosource.com/guidelinefocus/gfc_acs.asp. Accessed August 8, 2007. Reprinted with permission from Cardiosource.com.
  • 28. Coming in the Fall 2007: New ACS Critical Pathways Workshops
    • Implementing Updated ACC/AHA Guidelines for ACS: Achieving New Standards of Care
    For more information and to register for a program near you, visit www.strivecme.com and click on “Regional Programs” (on the left side of the page)
  • 29. Featured Institution Doylestown Hospital Doylestown, Pennsylvania
  • 30. Polling Question #2
    • 1) We are currently on the same item
    • 2) We have since moved to the next item on the checklist
    • 3) We have progressed by more than 1 item on the checklist
    • 4) ACS pathways are up-to-date and regularly followed
    If you participated in a previous teleconference, how much progress have you made since then? (Please refer to the checklists on the next 3 slides.)
  • 31. Progress Checklist: Immediate Goals Circulate discharge plan and other tools to all cardiology, ED, and CV nursing staff for comments  Circulate pathways to all cardiology, ED, and CV nursing staff for comments  Develop draft pathways  Assemble team and set up meeting of working group 
  • 32. Progress Checklist: Short-term Goals/Activities Grand rounds/conference: Cardiology/IM  Grand rounds/conference: Emergency Dept.  Grand rounds/conference: Nursing  Circulate memo  Launch critical pathways  Finalize critical pathways 
  • 33. Progress Checklist: Long-term Goals/Activities  NRMI  AHA Get With The Guidelines  ACC National Cardiovascular Data Registry  CRUSADE  GRACE  REACH  Other Monitor data: which registry? 
  • 34. Question-and-Answer Session
  • 35. Concluding Remarks Christopher P. Cannon, MD Next Program Gregg C. Fonarow, MD Wednesday, September 12, 2007 12:00 Noon Eastern Time (9:00 AM Pacific Time) Report From the European Society of Cardiology (ESC) Congress 2007