Current and Future Perspectives on Acute Coronary Syndromes

1
Current and Future Perspectives on Acute Coronary
Syndromes

• Paul W. Armstrong MD
• AMI Quebec
• Montreal October 1, 2010

2
Pivotal Role of Time

• Timing of Symptom Onset
• Time to 1st Medical Contact
• Time to Reperfusion
• Time as Modulator of Rx Effect
• Time as Modulator of Rx Choice
• Time Interaction Risk Assessment

Strategic Alignment
Paramedical Program,
IT ECG,
Molecular
Chemistry
Coronary
Intervention
3
Treatment Delayed is Treatment Denied
2.4hrs
Symptom Recognition
Call to Medical System
ED
Cath Lab
PreHospital
CCU
Increasing Loss of Myocytes
Delay in Initiation of Pharmacologic Reperfusion
Armstrong Collen Antman Circulation 2003
4
Reperfusion Options for STEMI PtsStep One
Assess Time and Risk
Risk of Lysis
Time Since Symptoms
Time Required to Initiate Invasive Strategy
Risk of STEMI
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Reperfusion Relationships Time Myocardial
Salvage, Lives Saved
Frequency Aborted MI
100.0
80.0
60.0
Salvageable Ischemic Myocardium ?----
40.0
20.0
0.0
5.0
4.0
3.0
2.0
1.0
lt1.0
Duration of occlusion/ Treatment delay (h)
Armstrong ,Westerhout, Welsh, Circulation 2009
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Efficacy vs Effectiveness ..Isnt All About
Time?
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STEMI NEXUS
Reperfusion Choice
Strategy
9
3
Armstrong ,Westerhout,Welsh, Circulation 2009
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NSTE ACS Too Great a Theraputic Burden?

• ASA
• Anti thrombin(s)
• Clopidogrel, Prasugrel
• 2B /3A
• Beta Blocker
• ACE inhibitor
• Statin
• Anti inflammatory
• Mechanical Intervention
• BMS vs DES

9
GRACE Risk Model
Hospital Mortality

• Variables
• Age (continuous)
• Killip class
• Blood pressure
• ST deviation
• Cardiac arrest
• Creatinine
• Elevated CK-MB / Tn
• Heart rate

C-index 0.84, validated in clinical trial
registry populations
www.statcoder.com/grace.htm
www.umassmed.edu/outcomes/grace
Granger et al Archives Int Med 2003
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TIMACS
Primary Outcome Stratified by Baseline GRACE
Risk Score
Non ST elevn ACS n3031
(1/3)
HR 0.65(0.48-0.89)
Death, MI, Stroke _at_ 6mo Early 14h Delayed
50h
Mehta S et al. N Engl J Med 2009
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Opportunities in pre-hospital cardiovascular care
ST elevation AMI
Seamless pre-hospital diagnosis, triage and
treatment
Risk assessment and management
Bystander CPR and AED Rapid ACLS response Novel
EBM therapies
Pre-hospital triage Antiplatelets Anticoagulants
Cardiac Arrest
High risk ACS (NSTEMI)
Welsh Armstrong Heart 2005
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Perspectives on Acute Coronary Syndromes

• Baseline risk and its evolution
• Lesson of subsets and disease heterogeneity
• Time and its potential for deception
• Dose Renal function, age, body weight, sex
• Bleeding is bad and choice of vascular access
  site a key modulator
• Guidelines are roadmaps detours may be necessary
• Beware of too rapid uptake of high profile
  meeting presentations
• One strategy rarely meets all clinical needs
• Patients are partners helping them make an
  informed choice is an art

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