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Mace

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Mace

  1. 1. ACUTE CORONARY SYNDROME ACUTE CORONARY SYNDROME (ACS), including those associated with or without ST- segment elevation, share in common pathophysiology mediated by activated platelets and thrombin superimposed on a culprit plaque
  2. 2. ACS • No ST elevation Unstable angina NSTEMI NQMI* QMI • ST elevation QMI* NQMI
  3. 3. ClassificationA. Secondary B. Primary C. Postinfarction (< 2 weeks) Braunwald classification of unstable angina I New onset, severe or accelerated angina IA IB IC II Subacute rest angina (> 48 hours ago) IIA IIB IIC III Acute rest angina (within 48 hours) IIIA IIIB IIIC
  4. 4. MI: ST elevation New bundle branch block ECG changes of posterior MI Evolution of Q waves 2 × upper limit of CK-MB, CK  Troponins T > 0.2 ng/dl Troponin I > 1.0-1.5 ng/dl Minimal injury Aborted ST elevation MI Transient ST elevation ST depression T inversion Minor non-specific ECG changes < 2 × elevation CK-MB, CK Troponins T 0.01-0.2 ng/dl Troponin I 0.1 or 0.4 ng/dl to 1.0-1.5 ng/dl UA: Transient ST elevation ST depression T inversion Minor non-specific ECG changes Normal ECG CK-MB, CK below upper limit Troponins T < 0.01 ng/dl Troponin I < 0.1 or 0.4 ng/dl
  5. 5. Prior risk - older age (> 65 years) - prior myocardial infarction or heart failure - co morbidity: diabetes, hypertension - impaired renal function
  6. 6. Acute ischemic risk - refractory or recurrent ischemic pain - ECG: ST segment depression or transient ST elevation during pain - ECG: T wave inversion (lower risk than ST segment depression or transient ST elevation) - impaired left ventricular function with ischemia - release of cardiac enzymes: CK, CK-MB, troponin T or troponin I - raised C reactive protein (high sensitivity assay)
  7. 7. Management of AMI • ASA or other anti platelets • O2 • Analgesics • Anticoagulants • GP IIb/IIIa inhibitors • Nitrate • B blocker • ACEi • Thrombolytic • Mechanical reperfusion
  8. 8. PCI in AMI • Primary • Rescue • Early < 4 days • Deferred > 4 days
  9. 9. Complication of AMI Mechanical: • Pump failure>>shock • Free wall rupture • Interventricular rupture • Papillary muscle rupture>>MR • pseudo aneurysm Arrhythmia: *Tachyarrhythmia's supraventricular ventricular *Brady arrhythmias *Bundle branch block
  10. 10. Other complications of AMI • Recurrent chest pain • Recurrent MI • Pericarditis • Deep vein thrombosis>>Pulmonary emboli • Lv aneurysm • Lv thrombosis>>Arterial embolism
  11. 11. ADMIRAL abciximab before direct angioplasty and stenting in myocardial infarction regarding acute and long-term follow 300 pt, GP IIb/IIIa inhibitor • Composite end point at 30 days: 6% abciximab and 14.6% in the placebo • Mortality at 30-day: 3.4% abciximab group and 6.6% in the placebo • Urgent revascularization : 1.3% abciximab and 6.6% in placebo • Mortality at 6 months: 3.4% abciximab group and 7.3% in the placebo • Composite end point at 6 months: 7.4% abciximab and 15.9% in the placebo NEJM 2001;344
  12. 12. CADILLAC controlled abciximab and device investigation to lower late angioplasty complications 2081 pt: effect of IIb/IIIa inhibitor • Primary out come at 6 m: MI, death, TVR, CVA • Hospital mortality: 1-1.6% • Strokes: 0.4% • Re-infarction: 0.6% PTCA 0% PCTA + abciximab 0.8% stent 0.2% stent+ abciximab TVR: 2.3% PTCA 0.2% PCTA + abciximab 0.8% stent 0.2% stent+ abciximab AHA 1999
  13. 13. CADILLAC controlled abciximab and device investigation to lower late angioplasty complications • Recurrent ischemia: • 4.9% PTCA 1.4% PTCA+ abciximab 3.9% stent 1.2% stent+ abciximab AHA 1999
  14. 14. GUSTO V global use of strategies to open occluded coronary arteries 16588 pt; fibrinolytic+/- GP IIb/IIIa inhibitor • Mortality at 24-h: 2.3% with reteplase and 2.2% in reteplase+ abciximab • Mortality at 7-d: 4,5% with reteplase and 4.3% in reteplase+ abciximab • Mortality at 30-d: 5.9% in reteplase and 5.6% in the reteplase+ abciximab • Stroke: 0.3% in reteplase and 0.2% in the reteplase+ abciximab • Re-infarction: 3.5% in reteplase and 2.3% in the reteplase+ abciximab • MACE: at 7-d: 20.6% in reteplase and 16.2% in reteplase+ abciximab • More non-intracranial bleeding complications in the combination group • The rates of intracranial hemorrhage and non-fatal disabling stroke were similar in patients< 75 years Lancet 2001
  15. 15. STENT-PAMI primary angioplasty in myocardial infarction PCI+/- stent in ACS 900 pt • angina at 6 months occurred in 11.3% patients in the stent and 16.9% in angioplasty • TVR: 7.7 % vs. 17.0% in stent and angioplasty • The primary end point: 12.6% and 20.1% • 6-month mortality: 4.2% and 2.7% NEJM 1999
  16. 16. STENT-PAMI primary angioplasty in myocardial infarction Long term effect of PCI as compared to streptokinase for AMI 395 pt • Mortality over 5 ys was 13 % in the angioplasty, 24 % in the streptokinase • TVR <30 ds in PCI: 12.4% and in thrombolytic: 42.8% • TVR >30 ds in PCI: 34.1% and in thrombolytic: 28.3% • Re-MI in first 30 days: 0.5 % in angioplasty and 9 % in streptokinase. • Re-MI After 30 days: 6% in the angioplasty vs. 12% in streptokinase • • NEJM 1999
  17. 17. STENTIM-2 Comparison of PTCA and Stenting in AMI-2 in 211 pt • Re-infarction: 4% in PTCA and 3.6% in stent • Repeat revascularization: 5.4% in PTCA and 5% in stent • In-hospital event free survival: 94.6% in PTCA and 95% in stent • Six-month event free survival: 72.7% in PTCA and 82% in stent • Six-month revascularization: 26.4% in PTCA and 16.8% in stent • One year revascularization: 28.2% in PTCA and 17.8% in stent • Restenosis: 39.6% in PTCA and 25.3% in stent JACC 2000
  18. 18. GUSTO IV ACS effect of GP IIb/IIIa inhibitor in7800 pt • primary endpoint death or myocardial infarction at 30 days. • FINDINGS: 30- day death and MI: 8.0% patients on placebo 8.2% abciximab on 24 h 9.1% on 48 h abciximab died • This study indicates that abciximab is not beneficial as first-line medical treatment in patients admitted with acute coronary syndromes. Lancet. 2001 Jun
  19. 19. GUSTO-IV Pilot Early PCI after reteplase+/- abciximab 30-day composite end point in early PCI (death, re-infarction, urgent revascularization): (5.6%) Death 3.4%, Re-vascularization 1.6% Re-infarction 1.2% 30-day composite end point in no early PCI (death, re-infarction, urgent revascularization): (16%) Re-vascularization 9.3% Re-infarction 4.9% JACC 2000;36
  20. 20. STAT Stenting vs. Thrombolysis in AMI Trial in123 pt • Primary end point at 6-month : 24.2% in stent vs. 55.7% in t-PA • Re-infarction: 6.5% in stent and 16.4% in t-PA • Stroke: 1.6% in stent and 4.9% in t-PA • TVR: 14.5% in stent and 49.5% in t-PA • Recurrent UA: 9.7% in stent and 26.2% in t-PA JACC 2001
  21. 21. IMPACT-AMI t-PA +/- IIb/IIIa integrin receptor blockade • The primary end point was TIMI grade 3 flow at 90-minute angiography. Secondary end points were time to ST-segment recovery, an in-hospital composite (death, reinfarction, stroke, revascularization procedures, new heart failure, or pulmonary edema), and bleeding variables • The highest Integrilin dose groups had more complete reperfusion (TIMI grade 3 flow, 66% versus 39% for placebo-treated patients; P=.006) • Shorter median time to ST-segment recovery (65 versus 116 minutes for placebo; P=.05). • Mortality: 5.6% in integrin treated and 3.6% in placebo treated group • Death and re-infarction: 8% in integrin treated and 7.3% in placebo treated • The groups had similar rates of the composite end point (43% versus 42% for placebo-treated patients) Circulation 1997;95
  22. 22. RAPPORT ReoPro and Primary PTCA Organization and Randomization Trial • The primary end point was death, reinfarction, or any (urgent or elective) target vessel revascularization (TVR) at 6 months • abciximab significantly reduced the incidence of death, reinfarction, or urgent TVR at all time points assessed: 9.9% versus 3.3%, at 7 days; 11.2% versus 5.8%, at 30 days; and 17.8% versus 11.6%, at 6 months The effect of abciximab with respect to death or reinfarction: 4.7% versus 1.4%, at 7 days; 5.8% versus 3.2%, at 30 days; and 12.0% versus 6.9%, at 6 months Circulation 1998;98
  23. 23. TIMI-14 (Substudy) Thrombolysis in Myocardial Infarction-14 (alteplase, abciximab) alone or abciximab+ reduced dose of lytics • ST segment resolution: 59% in combination of tPA+ abciximab vs. 37% in full dose tPA alone • 30-day mortality: 1.1% with complete ST resolution 4.7% with incomplete ST resolution 7.1% with no ST resolution Circulation 2000;101
  24. 24. ISAR-2 Intracoronary Stenting and Antithrombotic Regimen-2 coronary stenting +/- abciximab • 30-day MACE: 5% in abciximab and 10.5% in heparin groups • 30-day death: 2% in abciximab and 4.5% in heparin groups • 30-day MI: 0.5% in abciximab and 1.5% in heparin groups • 30-day TVR: 3% in abciximab and 5% in heparin groups • At one year there was 5.7% absolute reduction in cardiac events • At six-month restenosis: 31.1% in abciximab and 30.6% in heparin groups JACC 2000;35

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