Current and Future Perspectives on Current and Future Perspectives on Acute Coronary SyndromesAcute Coronary Syndromes
Paul W. Armstrong MDPaul W. Armstrong MD
AMI QuebecAMI Quebec
Montreal Montreal October 1, 2010October 1, 2010
Pivotal Role of TimePivotal Role of Time
Timing of Symptom OnsetTiming of Symptom Onset Time to 1Time to 1stst Medical Contact Medical Contact Time to ReperfusionTime to Reperfusion Time as Modulator of Rx EffectTime as Modulator of Rx Effect Time as Modulator of Rx ChoiceTime as Modulator of Rx Choice Time Interaction & Risk Assessment Time Interaction & Risk Assessment
Strategic Alignment: Paramedical Program, IT & ECG, Molecular Chemistry Coronary Intervention
Symptom Recognition
Call to Medical System
ED Cath LabPreHospital
Delay in Initiation of Pharmacologic Reperfusion
CCU
Increasing Loss of Myocytes
Treatment Delayed is Treatment Denied
Armstrong Collen Antman Circulation 2003Armstrong Collen Antman Circulation 2003
2.4hrs2.4hrs
Reperfusion Options for STEMI PtsStep One: Assess Time and Risk
Time Since Symptoms
Time Required to
Initiate Invasive Strategy
Risk of STEMI
Risk of Lysis
5.04.03.02.01.0<1.0
100.0
80.0
60.0
40.0
20.0
0.0
% S
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Duration of occlusion/ Treatment delay (h)Duration of occlusion/ Treatment delay (h)
35.0
30.0
25.0
20.0
15.0
10.0
% R
ate Ab
orted
MI
Reperfusion Relationships: Time & Myocardial Salvage, Lives Saved & Frequency Aborted MI
Armstrong ,Westerhout, Welsh, Armstrong ,Westerhout, Welsh, Circulation 2009Circulation 2009
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Efficacy vs Effectiveness …..Efficacy vs Effectiveness …..Isn’t All About Time?Isn’t All About Time?
Fro
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o P
CI
Tim
e
Mec
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Pharm
acolo
gical
Risk
of Rx
99 33Self presentation
to hospital 911 EMS
Infarct specific
Patient specific
Risk of STEMI
Reperfusion Choice
Strategy
STEMISTEMI NEXUS
Armstrong ,Westerhout,Welsh, Circulation 2009Armstrong ,Westerhout,Welsh, Circulation 2009
NSTE ACS: NSTE ACS: Too Great a Theraputic Burden?Too Great a Theraputic Burden?
ASAASA Anti thrombin(s)Anti thrombin(s) Clopidogrel, PrasugrelClopidogrel, Prasugrel 2B /3A2B /3A Beta Blocker Beta Blocker ACE inhibitorACE inhibitor StatinStatin Anti inflammatoryAnti inflammatory Mechanical InterventionMechanical Intervention BMS vs DESBMS vs DES
GRACE Risk ModelGRACE Risk ModelVariablesVariables Age (continuous) Age (continuous) Killip classKillip class Blood pressureBlood pressure ST deviationST deviation Cardiac arrestCardiac arrest CreatinineCreatinine Elevated CK-MB / TnElevated CK-MB / Tn Heart rateHeart rate
VariablesVariables Age (continuous) Age (continuous) Killip classKillip class Blood pressureBlood pressure ST deviationST deviation Cardiac arrestCardiac arrest CreatinineCreatinine Elevated CK-MB / TnElevated CK-MB / Tn Heart rateHeart rate
—Granger et al Archives Int Med 2003www.umassmed.edu/outcomes/grace
C-index = 0.84, validated in clinical trial + registry populations
www.statcoder.com/grace.htm
Hospital Mortality
Mehta S et al. N Engl J Med 2009
Primary Outcome* Stratified by Baseline GRACE Risk Score
TIMACS
HR 0.65(0.48-0.89)
Non ST elev’n ACS n=3031
(1/3)
*Death, MI, Stroke @ 6mo Early =14h : Delayed= 50h
High – risk ACS (NSTEMI)
Opportunities in pre-hospital cardiovascular care
Cardiac Arrest
ST elevation AMI
Seamless pre-hospital diagnosis, triage and treatment
Bystander CPR and AEDRapid ACLS responseNovel EBM therapies
Pre-hospital triage Antiplatelets
Anticoagulants
Risk assessment and
management
Welsh & Armstrong Heart 2005
Perspectives on Acute Coronary Perspectives on Acute Coronary SyndromesSyndromes
Baseline risk and its evolution Baseline risk and its evolution Lesson of subsets and disease heterogeneity Lesson of subsets and disease heterogeneity Time and its potential for deceptionTime and its potential for deception Dose: Renal function, age, body weight, sexDose: Renal function, age, body weight, sex Bleeding is bad and choice of vascular access site a key Bleeding is bad and choice of vascular access site a key
modulator modulator Guidelines are roadmaps: detours may be necessaryGuidelines are roadmaps: detours may be necessary Beware of too rapid uptake of high profile meeting Beware of too rapid uptake of high profile meeting
presentationspresentations One strategy rarely meets all clinical needsOne strategy rarely meets all clinical needs Patients are partners: helping them make an informed Patients are partners: helping them make an informed
choice is an artchoice is an art
a