Final ACS Risk Stratification Management for 12th VN

Acute Coronary Syndromes
Risk Stratification & Management
Matching Treatment to Risk
Khôi M. Lê, MD
Desert Cardiology Center
Eisenhower Medical Center
Rancho Mirage, California
USA

1


Hospitalizations in the U.S. due to
ACS
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI†

STEMI

1.24 million

0.33 million

Admissions per year

Admissions per year

*Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.
Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69–171.

2


Age- and Sex-Adjusted Incidence Rates of Acute
Myocardial Infarction, 1999 to 2008

•Yeh RW et al. N Engl J Med 2010;362:2155-2165


Adjusted Odds Ratio for 30-Day Mortality, According to Year

•Yeh RW et al. N Engl J Med 2010;362:2155-2165


Standard treatment for ACS
Beta-blocker
Antianginal drugs Nitroglycerin
Diltiazem
Lipid-lowering drugs Statins
Aspirin
Antiplatelet drugs Clopidogrel
Prasugrel

Heparin
Enoxaparin
Antithrombotic drugs
Fondaparinux
Bivalirudin
Invasive management Angiogram ± revascularization

5


Risk Stratification
• Clinical factors
– Age, history of coronary disease, LV function, diabetes
mellitus
– Prolonged/recurrent resting CP or CP with dyspnea
– Presence or absence of heart failure, hypotension,
tachycardia, cardiac arrest

• ECG
– ST segment shifts
– T wave changes

• Laboratory data
– Cardiac markers/enzymes
– Serum creatinine


TIMI risk score
Points
Age ≥ 65 years

1

≥ 3 CAD risk factors

1

Prior CAD stenosis ≥ 50%

1

≥ 2 anginal events within last 24 h

1

ASA use during 7 days prior to hosp

1

Elevated cardiac markers

1

ST segment change ≥ 0.05 mV

1

High risk: Total ≥ 5
7


30-day and 1-year endpoint rates by risk group for the TIMI score

de Araújo Gonçalves P et al. Eur Heart J 2005;26:865-872

PURSUIT risk score
Points
Age

0-14

Male

1

CCS-class in previous 6 weeks

0-2

Heart failure

2

ST-segment depression

1

High risk: Total ≥ 14

9


30-day and 1-year endpoint rates by risk group for the PURSUIT score

de Araújo Gonçalves P et al. Eur Heart J 2005;26:865-872

Global Registry of Acute Coronary Events
(GRACE) risk score
Points
Age

0-91

Heart rate

0-46

Systolic BP

0-63

Creatinine

2-31

Killip class

0-64

Cardiac arrest at admission

43

Elevated cardiac markers

15

ST-segment deviation

30

High risk: Total ≥ 140
Eagle KA, et al.
11
JAMA 2004;291:2727-33 11


Admission Risk Calculator
www.outcomes.org/grace


Discharge Risk Calculator
www.outcomes.org/grace


30-day and 1-year endpoint rates by risk group for the GRACE score

de Araújo Gonçalves P et al. Eur Heart J 2005;26:865-872


In-hospital and 1 year outcomes
Physicians’
assessment

PURSUIT

TIMI

GRACE

15
•Yan A T et al. Eur Heart J 2007;28:1072-1078


GRACE and PURSUIT superior to TIMI
Receiver-operating characteristic curves for predicting in-hospital and 1-year mortality

In-hospital mortality

•Yan A T et al. Eur Heart J 2007;28:1072-1078

1-year mortality


Why are GRACE and PURSUIT
superior?
• Age as a continuous variable
– Only included as a categorical variable in TIMI

• Heart failure on admission
– Not in TIMI

• Baseline serum creatinine (only in GRACE)

17


Admission risk score correlates with
benefit from revascularization

de Araújo Gonçalves P et al.
Eur Heart J 2005;26:865-872


Meta-analysis of FRISC-II, ICTUS, RITA-3
Routine versus selective invasive in ACS

Risk of CV Death or MI

Fox, K. A. A. et al. J Am Coll Cardiol 2010;55:2435-2445


Meta-analysis of FRISC-II, ICTUS, RITA-3
Routine versus selective invasive in ACS

•Sustained advantage of routine invasive approach
•Degree of benefit corresponds to clinical risk
Fox, K. A. A. et al. J Am Coll Cardiol 2010;55:2435-2445
•Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.


Early versus Delayed Invasive Intervention in Acute
Coronary Syndromes
The TIMACS Study

• 3031 patients with ACS
randomized to early
(median 14 h) or delayed
(median 50 h) angiography
• Primary outcome: Death,
MI, stroke at 6 mos
• Secondary outcomes:
Death, MI, refractory
ischemia

Mehta SR et al. N Engl J Med 2009;360:2165-2175

21


TIMACS: High-risk patients benefit from early
intervention
Kaplan-Meier Cumulative Risk of the Primary Outcome, Stratified
According to GRACE Risk Score at Baseline

Mehta SR et al. N Engl J Med 2009;360:2165-2175


Major bleeding and 30 day mortality
34 146 ACS patients from OASIS, OASIS-2, CURE

5-fold ↑
mortality

23

Eikelboom, J. W. et al. Circulation 2006;114:774-782


CRUSADE: Multivariable Predictors of Bleeding
2

Variable

Derivation Cohort
OR
95% CI

Validation Cohort
OR
95% CI

Baseline HCT <36% (vs. ≥ 36%)

434.6

2.28

2.11-2.46

2.17

1.92-2.44

CrCl (per 10 mL/min decrease)

433.2

1.12

1.10-1.13

1.11

1.09-1.13

Heart rate (per 10 bpm increase)

159.2

1.08

1.07-1.10

1.09

1.07-1.12

Female

77.8

1.31

1.23-1.39

1.33

1.19-1.50

Signs of heart failure

37.7

1.23

1.15-1.31

1.13

1.01-1.28

Prior vascular disease

30.4

1.19

1.12-1.27

1.10

0.98-1.24

Diabetes mellitus

26.6

1.16

1.10-1.23

1.25

1.12-1.40

SBP ≤ 110 mm Hg (vs. 110-180)

12.6

1.26

1.16-1.36

1.27

1.10-1.47

1.24

1.14-1.35

1.18

1.02-1.37

SBP ≥ 180 mm Hg (vs. 110-180)

c-Statistic

0.72

Prior vascular disease defined as h/o stroke or peripheral arterial disease
Heart rate is truncated @ <70 bpm
CrCl: Cockcroft-Gault is truncated @ >90 mL/min

0.71


www.crusadebleedingscore.org