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					        STEP BY STEP
       APPROACH TO
          NSTEACS
José F. Díaz
Juan R Jimenez University Hospital
Huelva. Spain
 Invasive vs conservative

 Timing of intervention

 Antithrombotic drugs

 Type of revascularization
Invasive vs Conservative
  Death/MI from randomization to the end of follow-up

                 Invasive better   Conservative better

 TIMI IIIB
 VANQWISH
 MATE
 FRISC II
 TACTICS
 VINO
 RITA 3
 TOTAL                             OR 0.82
                                   95% CI, 0.72-0.93
                                   P<0.01
               0.1                                     10
                          OR (95% CI)

                               Mehta. JAMA 2005; 293: 2908-17
Invasive vs Conservative
                                   N=1810




            Fox. Lancet 2007; 366: 914-20
Invasive vs Conservative
                                    N=1200




             Hirsch. Lancet 2007; 369: 827-35
Revascularization gradient




              Eur Heart J 2004: 25: 1471-2
ICTUS: revascularization rates




                Hirsch. Lancet 2007: 369: 827-35
ICTUS: revascularization vs no
      revascularization




               Hirsch. EHJ 2008; sept 29 ahead pub
Invasive vs Conservative




           O’Donaghue. JAMA 2008: 300: 71-80
Invasive vs Conservative




              Bavry. JACC 2006; 48: 1319
Invasive vs Conservative
All-cause mortality as a function of time




                         Bavry. JACC 2006; 48: 1319
 Timing of intervention

 Early intervention better: ISAR-COOL


 Delayed intervention better:
   ICTUS
   Mehta meta-analysis
   TIMACS, OPTIMA, ABROAD
   GRACE and CRUSADE registries
Early intervention
               ISAR-COOL
Death or MI at 30 days

     15%
                         Prolonged antothrombotic treatment

     10%
                                                 p=0.04

     5%
                                          Early intervention




           0     5       10      15      20      25       30

                                  Days after randomization


                                        Neuman. JAMA 2003: 290: 1593-9
 ICTUS: MI(%) at 1 year

                           p<0.01
         p NS




                          Hirsch. risk stratificaton
Timing depending on the basis of Lancet 2007: 369: 827-35
TIMACS




    Mehta. NEJM 2009: 360: 2165-75
TIMACS




    Mehta. NEJM 2009: 360: 2165-75
Drugs in PCI
ISAR-REACT 2
                     N=2022




        JAMA 2006: 295: 1531
PRISM PLUS

           n=1915




        NEJM 1998; 338: 1488-97
          IIbIIIa inhibitors
 Intermediate to high risk patients (IIa-A)
   Eptifibatide
   Tirofiban
 When epti/tirofiban prior to angiography,
  should be mantained during/after PCI (IIa-B)
 Not IIbIIIa-pretreated patients should be
  treated with abciximab (I-A)
 Bivalirudin might be an alternative to IIbIIIa
  plus heparin/enoxaparin (IIa-B)
TRITON: Prasugrel


        p=0.0004




          p=0.03




         Wiviott, NEJM 2007; 357: 2001-15
TRITON: Prasugrel




         Wiviott, Lancet 2008; 371: 1353-63
PLATO: Ticagrelor
  CV death, MI or stroke
PLATO: Ticagrelor
PLATO: Ticagrelor
   Major bleeding
Management strategy

            NSTEACS




URGENT       EARLY      ELECTIVE
(< 120 ‘)    (< 72 h)
Urgent (<120’)




 Abciximab/bivalirudin
Early (<72h)




      Tirofiban/eptifibatide
Elective
Type of revascularization
       Invasive arm
    PCI: considerations
 Treatment of non-significant lesions not
  recommended (III-C)
 Complete vs “culprit vessel” not
  adressed
 BMS or DES depending on (I-C):
   Benefit ratio
   Comorbidities
   Need for surgery in the short medium
   follow-up
Complete vs incomplete
  revascularization
        Complete


        Incomplete




                Hannan. JACC-CI 2009; 2: 17-25
     ACS only patients
Incidence of Death, MI or revascularization



                              p<0.05




                    Shishehbor. JACC 2007; 49: 849-57
DES vs BMS: GRACE registry
    All cause mortality (n=6447)
DES vs BMS for ACS: 2 years follow-up
                 Death


 n=2456




          MI                        TVR




                    Mauri. NEJM 2008; 359: 1330-42
GRACE registry (n=15088)


           -21%




           -15%




                  Heart 2007; 93:177-82
“If you know what you have
to do and you do not do it
then you are worse than
before”
                   Confucius

				
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posted:3/20/2013
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