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Management of Acute Myocardial Infarction miocardial infarction

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Management of Acute Myocardial Infarction miocardial infarction Powered By Docstoc
					Management of Acute Myocardial Infarction
       Minimal Acceptable vs Optimal Care




                              Hussien H. Rizk, MD
                                  Cairo University
                Background

• Suspicious chest pain: extremely common
  cause of ER visits
• Acute MI: the most costly cardiac cause of
  ER visits
• 5-10% of acute MI patients are missed
  because of errors in symptom interpretation
  or missed ECG diagnosis
• Many patients do not receive proven
  inexpensive effective therapy
       Clinical proceedings of a suspected MI
• Symptom evaluation          • Relief of symptoms
   – Pain characteristics        – Pain
   – Heart failure, syncope      – Nausea
   – Contraindication to SK      – Anxiety
• Physical examination        • Aspirin
• ECG                            – Saves as many lives as SK
   – Quick                    • ACE-I
   – Interpretation correct
                                 – Low dose [Captopril 6.25]
• Lab work-up                    – Not if SBP<100
   – Basic [Sugar. CRT. K.    • BB
     CK if no ST elevation]
   – CXR                      • Thrombolysis
   – Specific [Clinically        – SK
     guided]                     – TPA: SK sensitive or recent
• Disposal:                        use
   –   Discharge              • Primary PCI:
   –   Observation               – Who? Where?
   –   Admission
   –   Referral
Should everybody with acute MI have:

• Statin?
• Clopedogrel?
• Platelet GP II b/III a inhibitor?
• Primary PCI?
  Timing of Statin Therapy Initiation After
      ACS in Recent Clinical Studies
                                                    Atorvastatin
                                                    Pravastatin
                          MIRACL
                                                    Simvastatin
                                     PROVE IT       Fluvastatin

WOSCOPS                                                          4S
                                    FLORIDA
                                L-CAD           CARE
        ACS                                     LIPID

Primary          Secondary prevention
prevention

             0   6 12 18 24 2    4    6 8 10 12 3                 6
                  Hours               Days              Months
                  MIRACL
          Study Outcome Measures
Primary
   –Death, Non-fatal MI, Cardiac arrest
   –Worsening angina + evidence of
    myocardial ischemia.

Secondary
   –Stroke
   –Revascularization.
   –Worsening CHF
   –Worsening angina without evidence of ischemia



                             Schwartz GG et al. JAMA 2001;255:1711
                     MIRACL
    Worsening Angina with New Objective Evidence
        Ischemia Primary Efficacy Measure
     of MIRACL:Requiring Urgent Hospitalisation

                    Risk reduction = 16%     Placebo 17.4%
          15        P=0.048

Cumulative                                                Atorvastatin 14.8%
Incidence                                               95% CI = 0.701–0.999
   (%)     10
                                       Time to first occurrence of
                                       composite endpoint of:
                                              Placebo 8.4%
                                          Death (any cause)
                                          Non-fatal MI
           5                              ResuscitatedAtorvastatin 6.2%
                                                          cardiac arrest
                                          Worsening angina with new
                                                             Risk reduction = 26%
                                                             P=0.02
                                           objective evidence and urgent
                                           rehospitalisation

           0
                0            4            8           12                            16
                         Time Since Randomisation (Weeks)
                                               Schwartz GG et al. JAMA 2001;255:1711-8.
       MIRACL: COST-BENEFIT

• Absolute risk reduction for worsening angina:
  2.2%
• NNT = 100/2.2 = 45.5
• Cost of avoiding one worsening angina event
  = NNT x No of Days x Daily cost
  (Ignoring lab tests & treating complications)
  = 45.5 x 120 X 36 = 196,364 LE
  GP II b/III a inhibitors for medically
  treated acute coronary syndromes
• GUSTO 4-ACS: Abciximab, no acute
  revascularization. No benefit at 30D (Simoons.
  Lancet 2001;357:1915) or 1Y (Ottervanger et al. CIRCULATION
  2003;107:437)
• GRAPE pilot: abciximab for acute MI: TIMI 3
  flow in 20% (van der Merkhof et al. JACC 1999;33:1528)
• PRISM: Tirofiban reduced total mortality
  compared to heparin alone.
Tirofiban in ACS: 1.5% ARR of 30D mortality
         compared to heparin alone
            PRISM. NEJM 1998;338:1498
                                NNT = 67
                         Cost/event = LE 130,000
• PRISM PLUS: terminated prematurely
  for excess mortality with tirofiban (4.6%
  vs 1.1% for heparin alone)
                DANAMI-2
              COST-BENEFIT
•   6% Absolute risk reduction
•   NNT = 16.7
•   Procedure cost: LE 14,000
•   Cost of preventing ONE EVENT (MI) at 30D =
                 LE 233,800
MINIMAL ACCEPTABLE CARE FOR MI
• CLINICAL TRAINING COST-EFFECTIVE
• ROUTINE LAB:     FBS. BUN. K. CK. CXR
• ROUTINE Rx.      SYMPTOMS. ASA. SK.
                   BB. ACE-I
• NOT ROUTINE:
  –   TPA
  –   CLOPEDOGREL
  –   STATIN
  –   PLATELET GLYCOPROTEIN INHIBITORS
  –   PRIMARY PCI

				
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