Impact of Delay to Angioplasty in Acute Coronary Syndromes ,nicvd

7/27/2019 Impact of Delay to Angioplasty in Acute Coronary Syndromes ,nicvd

1/24


2/24

Presenter:

DR. BINOY GUHAMD 3rd part student

Moderator:

DR. BADRUL ALAM

Assistant professor, Cardiology

NICVD


3/24

Impact of Delay to Ang iop lasty in Pat ients With

Acute Coronary Syndrom es Undergo ing InvasiveManagement

Analysis From the ACUITY (Acute Catheterization and Urgent

Intervention Triage) Trial strategY

Paul Sorajja, MD,Bernard J. Gersh, MB, CHB, DPHIL, David A. Cox, MD,Michael G.McLaughlin, MD, Peter Zimetbaum, MD,Costantino Costantini, MD,ThomasStuckey, MD,James E. Tcheng, MD, Roxana Mehran, MD,Alexandra J. Lansky,MD,Cindy L. Grines, MD,Gregg W. Stone, MD

Rochester, Minnesota; Boston, Massachusetts; Charlotte, Greensboro, and Durham,North Carolina Royal Oak, Michigan; and New York, New York

Reference:

Journal of the American College of Cardiology Vol. 55, No. 14, 2010 2010 by the American College of Cardiology Foundation, ISSN 0735-1097/10/$36.00Published by Elsevier Inc.


4/24

INTRODUCTION

Early invasive strategy leads to improved clinical outcomes inmoderate- and high-risk patients with nonST-segmentelevation acute coronary syndromes (NSTE-ACS) .

Randomized clinical trials have demonstrated that the benefitsof an early invasive strategy in these patients occur early,persist inlong-term follow-up, and are particularly evident inhighrisk patients.Early invasive strategy in the management of many patientswith NSTE-ACS, with angiography typically performed within 48to 72 h of hospital admission .


5/24

INTRODUCTION(CONT.)

Angiography and revascularization might hasten

definitive management reduce the need for

prolonged antithrombotic therapy.

One modest-sized randomized trial of immediate

versus delayed cardiac catheterizationin patients

with NSTE-ACS found a significant reduction in

death and myocardial infarction (MI) among patients

who underwent angiography >6 h after hospitaladmission versus several days later .


6/24

METHODS

Study population (n=13819)

The ACUITY trial was a prospective, open-label, randomized,

multicenter trial in which patients with NSTE-ACSundergoing an early invasive management strategy wererandomized to receive 1 of 3 antithrombotic regimens:

1) unfractionated or low molecular weight heparin plus aglycoprotein IIb/IIIa inhibitor

2) bivalirudin plus a glycoprotein IIb/IIIa inhibitor

3) bivalirudin alone.


7/24

Inclusion criteria

Patients were eligible for study participation

1. Age >18 years

2. Symptoms of NSTE-ACS within the preceding 24h

3. 1 or more of the following criteria were met:

new ST-segment depression

transient elevation of 1 mm

elevations in the troponin I, troponin T, or creatinekinase-MB levels

known coronary artery disease all 4 other variables for predicting Thrombolysis

In Myocardial Infarction (TIMI) risk scores forunstable angina .

METHODS(cont.)


8/24

EXCLUSION CRITERIA

ST-segment elevation MI or cardiogenic shock

Bleeding diathesis or major bleeding episode within 2weeks; thrombocytopenia

A calculated creatinine clearance rate of 30ml/min

Recent administration of abciximab, warfarin,

fondaparinux, fibrinolytic agents, bivalirudin, or 2 ormoredoses of low-molecular-weight heparin

Allergy to anyof the study drugs or to iodinated contrastmedium that could not be controlled in advance withmedication.


9/24

Data analysis

Patients were stratified by time from hospitalpresentation to revascularization with PCI into 3approximately equal-size groups: 8 h, 8 to 24h,and24h.

To analyze the acute risk of the patient as apotential confounder, the TIMI risk score for NSTE-ACS was calculated for each patient (0 to 2 low-risk;3 to 4 intermediate-risk; 5 to 7 high-risk) .


10/24

RESULTS

Baseline characteristics

Clinical, and angiographic characteristics of the overallstudy cohort, stratified according to time from hospitalpresentation to revascularization with PCI.

Median time to PCI was 19.5 h in all patients and 3.5 h,18.1 h, and 39.2 h in those undergoing PCI in 8 h, 8 to 24h, and 24 h, respectively, after hospital presentation.


11/24


12/24


13/24

30-day and 1-year clinical outcomes

Clinical follow-up was available in 7,627 patients (98%)at 30 days. There were no significant differences in the30-day or 1-year rates of death or the combined endpoint of death or MI in patients who underwent PCI 8 h

versus those who had PCI 8 to 24 h after clinicalpresentation.

In contrast, patients who underwent PCI 24 h afterclinical presentation had higher rates of death, MI,

composite ischemia, and net adverse clinical events at30 days in comparison with those who underwentearlier PCI.


14/24


15/24

30dayincidence

%

Timing of PCI After clinical presentation & 30

day outcome

aemia


16/24

TIMI risk score, PCI timing, and outcome

Delay to PCI 24 h after clinical presentation was associatedwith significant increases in the rates of 30-day death anddeath or MI among both intermediate and high-riskpatients.

In comparison with patients who had earlier PCI, high-riskpatients(TIMI score 5 to 7) who had PCI delay 24 h also

demonstrated an approximately 2-fold increase in 30-daymortality.

The relation between PCI delay 24 h and risk

of death at 1-year follow-up persisted irrespective of the

baseline TIMI risk score, although the greatest difference.


17/24


18/24


19/24

TIMI risk score


20/24

TIMI risk score

30day

composite

ischaem

ia%


21/24

TIMI risk score

30-daynetclinical

outcome%


22/24

DISSCUSION

The principal findings of this investigation are:

Delay to PCI 24 h after clinical presentation in patientswith NSTE-ACS is a strong, independent predictor ofincreased 30- day and 1-year mortality and combineddeath or MI

The hazard of PCI delay is greatest in the highest-riskpatients and is independent of antithrombinrandomization

The benefits of bivalirudin monotherapy in reducinghemorrhagic complications while affording similar

suppression of ischemic complications compared with aglycoprotein IIb/IIIa inhibitor based-regimen isindependent of time from presentation to PCI.


23/24

DISSCUSION(CONT.)

In the present large-scale, multicenter, randomized trial,there was a strong, independent association of PCI delay

24 h after clinical presentation with NSTE-ACS and

subsequent mortality and adverse clinical outcomes.

An increase in mortality was observed early with PCI delayand persisted throughout the 1-year follow-up period andwas particularly evident among high-risk patients. Therealso was an increased risk of MI and composite ischemiaamong patients with PCI delay 24 h.


24/24

Conclusions

In this large-scale study, delaying revascularization withPCI 24 h in patients with NSTE-ACS was an independent

predictor of early and late mortality and adverse ischemic

outcomes.

These findings suggest that urgent angiography and triageto revascularization should be a priority in NSTE-ACSpatients.

Documents

Impact of Delay to Angioplasty in Acute Coronary Syndromes ,nicvd