Nstemi invasive treatment rationale and timing

1. NSTEMI INVASIVE TREATMENT-
RATIONALE AND TIMING
DEV PAHLAJANI MD,FACC,FSCAI
HOD INTERVENTIONAL CARDIOLOGY
BREACH CANDY HOSPITAL MUMBAI

6. 4.7
8.3
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/MI/URby14Days(%)
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

7. 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 invasive
Hazard ratio

8. 0.1 1 10
Odds Ratio (95%CI)
Invasive strategy in non-ST elevation ACS
Re-hospitalisation for unstable angina
Invasive better Conservative better
N=7966
P=0.00001
Heterogeneity 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
FU
months
FRISC2 24
TRUCS 12
TACTICS 6
RITA 3 12
VINO 6
ICTUS 12
TOTAL

9. 0.1 1 10
Odds Ratio (95%CI)
Invasive strategy in non-ST elevation ACS
Is 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=8375
P=0.05
Heterogeneity 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%

10. 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=622
RR (95%CI) 0.79 (0.64-0.97)
Medium risk (score 2-3) N=1092
RR (95%CI) 0.72 (0.55-1.13)
Low risk (score 0-1) N=369
RR (95%CI) 1.26 (0.66-2.40)
Years since randomisation
Deathormyocardialinfarction(%)
41 5320
10
20
30
40
0
32.7%
41.6%
14.6%
20.4%
10.3%
8.2%
Conservative
Invasive
FRISC-2: cumulative risk of death or MI
by risk score
Δ8.9%
Δ5.8%

11. RITA 3 -10 YRS GRACE
SCORE

14. PROGNOSTIC VALUE OF
TN&ECG INACS

17. 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

18. 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

21. 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

22. Variable Immediate
Intervention
(n = 162)
Delayed
Intervention
(n = 161)*
HR (95% CI) p Value
30 days
Death or MI 4.3 13.0 0.32 (0.13–0.74) 0.008
Death, 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) 0.97
MI 2.5 9.9 0.24 (0.08–0.70) 0.01
Recurrent ischemia 3.7 15.5 0.24 (0.10–0.57) 0.001
Major bleeding 0.6 0.6 0.99 (0.06–15.89) 0.99
31 days to 1 yr
Death or MI 2.6 6.5 0.39 (0.12–1.27) 0.12
Death, 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) 0.69
MI 0.6 4.3 0.15 (0.02–1.22) 0.07
Recurrent ischemia 6.5 2.2 2.99 (0.82–10.85) 0.06
Major bleeding 0.0 2.5 0.01 (0.01–46.38) 0.30
1 yr
Death or MI 6.8 18.8 0.34 (0.17–0.67) 0.002
Death, 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) 0.78
MI 3.1 13.8 0.21 (0.08–0.55) 0.002
Recurrent ischemia 9.9 16.9 0.28 (0.12–0.63) 0.002
Major bleeding 0.6 3.1 0.20 (0.02–1.68) 0.14
Clinical Outcomes Up to 1 Year

23. 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

24. 2015 ESC Guidelines for the
management of acute coronary
syndromes in patients presenting
without persistent ST-segment
elevation

25. Risk criteria mandating invasive strategy in NSTE-ACS
2015 ESC Guidelines

26. NSTEMI NSTEMI 2015

27. NSTEMI ESC 2015

28. NSTEMI ESC 2015

29. 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

30. 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