Optimal Management of ACS Invasive vs Conservative Strategy

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Optimal Management ofACSInvasive vs
Conservative Strategy

• Layth Mimish
• Consultant Cardiologist
• The Cardiovascular Consultant Group
• Jeddah KSA

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Approach To ACS

• Risk stratification
• Appropriate acute medical management
• Identify coronary anatomy in higher risk
  patients, otherwise exercise imaging
• PCI vs CABG based on extent of coronary disease,
  LV function, and co morbid factors
• Long term medical management risk factors
  modification

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TIMI Risk Score for ACSUnfractionated Heparin
Cohort TIMI 11B (n1957)

• Age gt 65 years
• gt 3 CAD risk factors
• Prior CAD Stenosis gt 50
• ST segment changes on presentation
• gt 2 anginal events in last 24 Hrs
• ASA use lt 7years
• Increased serum cardiac markers

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FRISC Score

• Agegt70 years
• Diabetes Mellitus
• Previous MI
• Angina gt 30 days
• ST depression
• Elevated Troponin
• Elevated Fibrinogen
• Elevated II-6 (2P)

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2 Yr Mortality and MI
Mortality
Death or MI
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Culprit Lesion Morphology Troponin Levels in UAP
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Antithrombotic approaches in ACS

• Acute Medical Management
• ASA LMWH ( FRIC, FRISC III, ESSENCE, TIMI 11B)
• Direct Thrombin Inhibitors (GUSTO IIB, OASIS-2)
• GP IIb/IIIa Inhibitors (4P Trials, Oral trials,
  GUSTO-IV ACS, TIMI-18)
• ASA Clopidogril (CURE)
• Coronary Interventions
• Direct Thrombin Inhibitors (HELVETICA, Hirulog
  Trials)
• GIIbIIa Inhibitors (EPIC, EPILOG, CAPTURE,
  EPISTENT, IMPACT-2, RESTORE, ESPIRIT, TARGET)
• LMWH GPIIb/IIIa Inhibitors(NICE Registry)
• ASA Clopidogril (CREDO)

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Overview of GP IIb/IIIa Trials by Pooled Analysis
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Conservative X Invasive Trials in ACS
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Conservative X Invasive Trials in ACS
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TIMI - IIIB
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Study Limitations of VANQUISH

• High surgical mortality (7.7) 12 in invasive
  arm
• PTCA performed prior to era of stents and
  GPIIb/Iia blockers
• No PTCA for multivessel disease
• Results not necessarily applicable to females

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Conservative X Invasive Trials in ACS
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Conservative X Invasive Trials in ACS
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Conservative X Invasive Trials in ACS
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MI
Death or MI
MI
Death or MI
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