CIACC Milano, 3 Dicembre 2011

1. CIACC Milano, 3 Dicembre 2011 Strategie di trattamento nelle Sindromi Coronariche Acute senza ST sopraslivellato Corrado Lettieri U.O. di Cardiologia, Ospedale Carlo Poma, Mantova

2. NSTEACSRecomendations for invasive evaluation and revascularisationESC GUIDELINES 2007 High-risk features Intermediate to high-risk features Low-risk features • Persistent or recurrent angina with/without ST changes (≥2mm) or deep neg. T resistant to anti anginal treatment • Clinical symptoms of heart failure or hemodynamic instability • Life-threatenting arrhythmias (VF, VT) • No recurrence of chest pain • No signs of heart failure • No new ECG changes (arrival,6h,12h) • No elevation of troponins (arrival,6h,12h) • Elevated troponin levels • Dynamic ST- or T- wave changes (symptomatic or silent) • Diabetes mellitus • Renal dysfunction (GFR<60 mLK/min/1,73m2) • Reduced left ventricular function (EF<40%) • Early post-infarction angina • Prior MI • PCI within 6 months • Prior CABG • Intermediate to high GRACE Risk Score URGENT EARLY NO / ELECTIVE

3. NSTEACSRecomendations for invasive evaluation and revascularisationESC GUIDELINES 2011

4. NSTEACSRecomendations for invasive evaluation and revascularisationESC GUIDELINES 2011

5. Strategia invasiva o conservativa nelle NSTEACS ISAR-COOL RITA-3 ICTUS VANQWISH VINO MATE TRUCS TIMI IIIB TACTICS-TIMI 18 FRISC II “early conservative” “early invasive” Patients (N): 920 2874 7018 Adapted from Cannon Circulation. 2003.

6. Metha-analysis of contemporary randomized studiesEarly Invasive vs Conservative TherapyRelative Risk of all-cause mortality Bavry et al. JACC 2006;48:1319-25

7. Metha-analysis of contemporary randomized studiesEarly Invasive vs Conservative TherapyRelative Risk of cardiovascular mortality at 5 years follow-up Fox KA, et al. JACC 2010;55:2435-45

8. Early invasive vs selective invasive in NSTEACSKaplan-Meier estimates of the cumulative rate of the composite primary end point of death, nonfatal MI or rehospitalization for anginal symptoms within 1 yearICTUS Winter, N Engl J Med 2005;353:1095-104

9. Strategia Invasiva vs Conservativa Relative mortality benefit with the revascularisation vs gradient in rates of revascularisation between both randomisation arms Cannon et al, Eur Heart J 2004;25:1471-1472

10. NSTACS: early invasive? selective invasive? Hirsch A, et al: EHJ 2009;30:645-654

11. NSTACS: early invasive? selective invasive? Hirsch A, et al: EHJ 2009;30:645-654

12. NSTACS: early invasive? selective invasive? Hirsch A, et al: EHJ 2009;30:645-654

13. NSTACS: early invasive? selective invasive? Hirsch A, et al: EHJ 2009;30:645-654

14. NSTACS: early invasive? selective invasive? Pazienti del braccio “early invasive” Hirsch A, et al: EHJ 2009;30:645-654

15. Strategia Invasiva vs Conservativa Rates of the Primary End Point of Death, Nonfatal MI, or Rehospitalization for an Acute Coronary Syndrome at Six Months, According to Baseline CharacteristicsTACTICS-TIMI 18 Cannon et al., N Engl J Med 2001; 344:1879-87

16. GRACE Risk Score TIMI Risk Score No Diabete, no eco, no IRC PURSUIT Risk Score No Diabete, no eco No Diabete, no eco, no IRC

17. CRUSADE Risk Score

18. NSTEACS: ADERENZA ALLE LG Coronarografia < 48 ore e rischio

19. NSTEACS Scelta della strategia e disponibilità di risorse

20. RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO Rischio della PCI in funzione dell’età mortalità/IMA/CVA mortalità Età < 55 55-59 60-64 65-69 70-74 75-79 80-84  85 Batchelor et al. JACC 2000

21. RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO COMPLICANZE “EXTRACARDIACHE” < 80 aa > 80 aa % Batchelor et al. JACC 2000

22. Anziani e trials: una visione distorta? =  75aa = < 75aa PCI, ASA, betablockers, heparin, GPIIbIIIa inhibitors CRUSADE JACC 2005

23. NSTEACSRecomendations for GP IIb/IIIa inhibitors ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010

24. NSTEACSRecomendations for GP IIb/IIIa inhibitors ESC GUIDELINES NSTEACS 2011 Durante PCI Upstream Routine