Download ppt - Challenging cases and risk assessment in clinical practice

Challenging cases and risk assessment in clinical practice

Christian Spaulding MD, PhD, FESC, FACCCardiology DepartmentCochin HospitalParis Descartes UniversityParis, France

Trends in ACS

Inci

den

ce r

ate

(per

100

,000

)

Q-wave Non Q-wave

1975–1978

1981–1984

1986–1988

1990–1991

1993–1995

1997

ACS = acute coronary syndrome Reprinted with permission: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80

180

160

140

120

100

80

60

40

20

0

STEMI versus NSTEMI in-hospital versus 1-year-mortality

Mo

rtal

ity

(%)

9.3

7.1

5.7

10.8p<0.01

p<0.01

STEMI = ST segment elevation myocardial infarctionNSTEMI = non-ST segment elevation myocardial infarction

Adapted from: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80

STEMI

NSTEMI

14

12

10

8

6

4

2

0In-hospital mortality 1-year mortality

Months after discharge

Su

rviv

al (

MI

pat

ien

ts

dis

char

ged

ali

ve)

STEMI versus NSTEMI mortality after discharge

0 1 2 3 4 5 6 7 8 9 10 11 12

1.0

0.98

0.96

0.94

0.92

0.90

STEMI

NSTEMI

Adapted from: Furman MI, et al. J Am Coll Cardiol 2001;37:1571–80MI = myocardial infarction

OASIS-5: mortality at days 30/180 in patients with major bleeds

Adapted from: Yusuf S. N Engl J Med 2006;354:1464–76

Major bleed 9 days

No major bleed 9 days

Days

Cu

mu

lati

ve h

azar

d

0.2

0.15

0.1

0.05

0 0 30 60 90 120 150 180

Treatment of NSTEMI: a balancing act

Clinical benefit of drugintervention

Bleeding complications

Single antiplatelet therapy

Dual antiplatelettherapy

Higher IPA

+ 60% + 38% + 32%

Relative reduction in

ischaemicevents

Relative increase

in major bleeding

The progression of antiplatelet therapy

100

80

60

40

20

0Placebo APTC1 CURE2 TRITON-TIMI 383

Aspirin–25%

Aspirin +clopidrogrel

–20% Aspirin +prasugrel

–19%

1Antiplatelet Trialists’ Collaboration. BMJ 1994;308:81–1062Yusuf S, et al. N Engl J Med 2001;345:494–502

3Wiviott SD, et al. N Engl J Med 2007;357:2001–15

A new concept was born

Bleeding carries a high risk of death, MI and stroke

Rate of major bleeding is as high as the rate of death at the acute phase of NSTE-ACS

Prevention of bleeding is equally as important as prevention of ischaemic events and results in a significant risk reduction for death, MI and stroke

Risk stratification for bleeding should be part of thedecision-making process

Bassand, JP et al. Eur Heart J 2007;28:1598–660

Risk factors for bleeding: the GRACE registry

Adjusted OR 95% CI P-value

Age (per 10-year increase) 1.28 1.21–1.37 <0.0001

Female 1.43 1.23–1.66 <0.0001

History of renal insufficiency 1.48 1.19–1.84 0.0004

History of bleeding 2.83 1.94–4.13 <0.0001

Mean arterial pressure 1.11 1.04–1.19 0.0016

Thrombolytics only 1.43 1.14–1.78 0.0017

GP IIb/IIIa blockers only 1.93 1.59–2.35 <0.0001

Thrombolytics and GP IIb/IIIa blockers 2.38 1.69–3.35 <0.0001

PCI 1.63 1.36–1.94 <0.0001

Right heart catheterisation 2.48 1.98–3.11 <0.0001

OR = odds ratio; CI = confidence interval GP = glycoprotein; PCI = percutaneous coronary intervention

Moscussi M, et al.Eur Heart J 2003;24:1815–23

Non-CABG TIMI major bleeding: in selected subgroups of the TRITON TIMI 38 study

Prasugrel better Clopidogrel better

Kaplan-Meier event estimates for patients receiving 1 dose, within 7 days of discontinuation, or as determined locally to be related; †Tests hazard ratio = 1.0 within subgroups; ‡Tests equality of hazard ratio between subgroups; TIA = transit ischaemic attack

History of stroke or TIA Yes

No

At least one of: age 75 years, body weight <60kg, or history stroke/TIA

Yes

No

p† value

p‡

interaction

0.06 –

0.08 0.22

0.10 –

0.17 0.64

Adapted from: Wiviott S, et al. NEJM 2007;357:2001–15

Hazard ratio (95% CI)0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5

Any cause death, non-fatal MI, non-fatal stroke, non-CABG TIMI major bleeding in selected subgroups of the TRITON TIMI 38 study

Prasugrel better Clopidogrel better

History of stroke or TIA Yes

No

Yes

No

0.04 –

<0.001 0.006

0.43 –

<0.001 0.006

Hazard ratio (95% CI)0.5 0.8 1.0 1.3 1.5 1.8 2.0 2.3 2.6

Kaplan-Meier estimates intention-to-treat cohort†Tests hazard ratio = 1.0 within subgroups‡Tests equality of hazard ratio between subgroups

Adapted from: Wiviott S, et al. NEJM 2007;357:2001–15

p† value

p‡

interaction

At least one of: age 75 years, body weight <60kg, or history stroke/TIA

A difficult decision on a rainy Sunday afternoon in Paris

Male, 78 years of age

Past history– diabetes treated by insulin– haemorrhagic stroke with no sequellae 2 years ago – medical treatment: clopidogrel 75mg, atorvastatin 10mg

Chest pain on exertion for 2 weeks and at rest for 48 hours, lasting 20 minutes– last chest pain 2 hours before admission

Physical examination: 1.58m, 48kg (BMI: 19.2kg/m2)

ECG: ST segment depression in leads V1–V6

Troponin: 0.5 (normal <0.004)

Normal creatinine levelBMI = body mass index; ECG = electrocardiogram

Is this patient at low, moderate or high risk for ischaemic events?

Is this patient at low, moderate or high risk for bleeding complications?


High-risk for ischaemic events

– age

– diabetes

– ST segment depression in anterior leads

– elevated troponin

High risk for bleeding complications

– age

– past history of haemorrhagic stroke

– BMI: 19.2kg/m2


Treatment

– aspirin: 160mg followed by 100mg daily

– clopidogrel: reloading dose of 600mg, 75mg daily

– LMWH: fondaparinux 2.5mg daily

– atenolol: 100mg daily

– atorvastatin: 80mg

LMWH = low molecular weight heparin

Coronary angiogram

Coronary angiogram

Bare metal stent (2.75 x 15)

Two days later . . .

Would you initiate a GP IIb/IIIa inhibitor?


Because of the high risk profile for ischaemic events and bleeding complications, GP IIb/IIIa inhibitors were not administered and a coronary angiogram was performed 4 hours after admission via the radial artery

What would you do?

IVUS

Undersized stent (2.8mm; RVD 3.5mm)

Balloon inflation (3.5 X 12 at 22 atm)

Balloon 3.5 X 12 at 22atm

Stent thrombosis

Technical issues

Undersized stentUncovered dissection

Patient selection

Heavily calcified lesionsSmall vesselsLong lesions

Platelet aggregation

New therapeutic approaches

Treatment of NSTEMI: a balancing act

Careful patient selection– age, gender, past history of

bleeding, low weight, renal insufficiency

Clinical benefit of a drug– reduces mortality

Bleeding complications– increases mortality