1 / 17

Benjamin Scirica, MD MPH Investigator, TIMI Study Group

Risk Stratification Based on Ischemia Detected on Continuous ECG Monitoring in Non-ST-elevation Acute Coronary Syndromes. Benjamin Scirica, MD MPH Investigator, TIMI Study Group Associate Physician, Brigham and Women’s Hospital Instructor in Medicine, Harvard Medical School. Disclosures.

paco
Télécharger la présentation

Benjamin Scirica, MD MPH Investigator, TIMI Study Group

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Risk Stratification Based on Ischemia Detected on Continuous ECG Monitoring in Non-ST-elevation Acute Coronary Syndromes Benjamin Scirica, MD MPH Investigator, TIMI Study Group Associate Physician, Brigham and Women’s Hospital Instructor in Medicine, Harvard Medical School

  2. Disclosures The TIMI Study Group has received research/grant support in the past 2 years through the Brigham and Women’s Hospital from : AstraZeneca Bristol-Myers Squibb Company CV Therapeutics, Inc. Eli Lilly and Company Daiichi Sankyo GlaxoSmithKline Merck & Co., Inc. Millennium Pharmaceuticals, Inc. Novartis Pharmaceuticals Nuvelo, Inc. Ortho-Clinical Diagnostics, Inc. Pfizer Inc Sanofi-Aventis Sanofi-Synthelabo Recherche Schering-Plough Research Institute Dr Scirica has received research support from: AstraZeneca Bristol-Myers Squibb CV Therapeutics, Inc. Daiichi Sankyo Novartis Pharmaceuticals Sanofi-Aventis Dr Scirica is on the speaker’s bureau of: Pfizer Inc Dr Scirica has received honoraria for educational presentations/advisory boards from: CV Therapeutics, Inc. Novartis Pharmaceuticals

  3. ST-elevation ACS UA NSTEMI STEMI UA NQWMI QwMI ACUTE CORONARY SYNDROMES Non–ST-elevation ACS CK-MB Tn

  4. TIMI ECG Core Laboratory TIMI CECG Core Lab ST Depression Analysis Typical Episode of Ischemic ST-segment Depression Duration - 13.5 min Max ST dev. 2.1 mm ST deviation from baseline Definition of Ischemia ST depression > 1 mm from baseline lasting > 1 min in duration Before Episode During Ischemic Episode

  5. Ischemia No Ischemia Clinical Significance of Recurrent Ischemia in NSTEACS FAST Study (n=630 pt) P<0.001 P<0.01 P<0.001 P<0.02 Incidence (%) P<0.001 Adj HR 5.7 P<0.001 N=37 N=33 N=37 N=33 (Gottlieb SO, et al. NEJM 314;1986 (Jernberg, et al. JACC 1999)

  6. MI Death Clinical Significance of Recurrent Ischemia in Non-STEMI ACS Meta-analysis of 995 patients from CAPTURE, PURSUIT, and FROST 5 Day 30 Day P<0.001 P<0.001 Incidence (%) of Death and Death/MI N=724 N=137 N=63 N=71 N=724 N=137 N=63 N=71 Number of Events / 24hrs (Akkerhuis, et al. Eur Heart J 2001;22:1997)

  7. UA/NSTEMI (Moderate-High Risk) N = 6560 Standard Therapy RANDOMIZE (1:1) Double-blind RanolazineIV to PO Placebo Matched IV/PO Holter Continuous 7-day recording Long-term Follow-up (Median 348 Days)

  8. PLACEBO(n=3,189) RANOLAZINE (n=3,162) Holter Cohort 6,351 pts (97% of entire trial) Age (yrs, median) Female (%) Prior MI (%) DM (%) Prior Revasc (%) TRS (%) Low (0-2) Moderate (3-4) High (>4) NSTEMI on admission (%) Cath during Index Event (%) 64 34 34 34 27 27 52 21 51 59 64 36 34 34 26 27 53 20 51 69 Baseline Characteristics Results

  9. Female 1.3 (1.1, 1.5) Variable Adj HR (95% CI) Low TRS 1.0 (referent) Mod TRS 1.5 (1.2, 1.8) High TRS 2.6 (2.1, 3.3) No Early Inv. Rx 1.1 (0.98, 1.3) BNP >80 pg/ml 1.4 (1.2, 1.7) + Ultra TnI 1.2 (0.99, 1.4) 0.5 5 1 Hazard Ratio Clinical Correlates of Ischemia

  10. No episodes [869 / 5095] 1 to 2 episodes [156 / 590] > 2 episodes [191 / 648] Primary endpoint according to number episodes of ischemia excluding events during first 7 days 40 30 CV death / MI / Recurrent Ischemia (%) 20 10 p<0.0001 0 0 100 200 300 400 500 Days from randomization

  11. No episodes [173 / 5095] 1 to 2 episodes [42 / 590] > 2 episodes [71 / 648] CV death according to number episodes of ischemia excluding events during first 7 days 15 10 CV death (%) 5 p<0.0001 0 0 100 200 300 400 500 Days from randomization

  12. CV Death / MI / Severe Recurrent Ischemia by TIMI Risk Score and Presence of Ischemia on CECG p<0.001 p<0.001 p=0.02 1657 259 2701 638 758 342 TIMI Risk Score Category

  13. CV Death by TIMI Risk Score and Presence of Ischemia on CECG p<0.001 p<0.001 p=0.2 1657 259 2701 638 758 342 TIMI Risk Score Category

  14. No episodes [611 / 3038] 1 to 2 episodes [106 / 337] > 2 episodes [249 / 475] Primary Endpoint by Occurrence of Ischemia Conservative Strategy 50 40 30 CV death / MI / Recurrent Ischemia (%) 20 p<0.0001 10 0 0 100 200 300 400 500 Days from randomization

  15. No episodes [386 / 2142] 1 to 2 episodes [83 / 272] > 2 episodes [63 / 191] Primary Endpoint by Occurrence of Ischemia Early Invasive Strategy 40 30 CV death / MI / Recurrent Ischemia (%) 20 10 p<0.0001 0 0 100 200 300 400 500 Days from randomization

  16. Conclusions • Among a contemporary cohort of patients with NSTEACS, recurrent ischemia is common • Recurrent ischemia as detected on cECG is strongly associated with death and recurrent MI in the months after ACS • Ischemia on cECG is a sensitive method to detect myocardial perfusion after PCI • This relationship is consistent even in patients at different clinical risk and in patients who undergo an early invasive management strategy

More Related