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STEP BY STEP APPROACH TO NSTEACS

José F. Díaz Juan R Jimenez University Hospital Huelva. Spain. STEP BY STEP APPROACH TO NSTEACS. Invasive vs conservative Timing of intervention Antithrombotic drugs Type of revascularization. Invasive vs Conservative. Death/MI from randomization to the end of follow-up.

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STEP BY STEP APPROACH TO NSTEACS

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  1. José F. Díaz Juan R Jimenez University Hospital Huelva. Spain STEP BY STEP APPROACH TO NSTEACS

  2. Invasive vs conservative • Timing of intervention • Antithrombotic drugs • Type of revascularization

  3. Invasive vs Conservative Death/MI from randomization to the end of follow-up Conservative better Invasive better TIMI IIIB VANQWISH MATE FRISC II TACTICS VINO RITA 3 TOTAL OR 0.82 95% CI, 0.72-0.93 P<0.01 0.1 10 OR (95% CI) Mehta. JAMA 2005; 293: 2908-17

  4. Invasive vs Conservative N=1810 Fox. Lancet 2007; 366: 914-20

  5. Invasive vs Conservative N=1200 Hirsch. Lancet 2007; 369: 827-35

  6. Revascularization gradient Eur Heart J 2004: 25: 1471-2

  7. ICTUS: revascularization rates Hirsch. Lancet 2007: 369: 827-35

  8. ICTUS: revascularization vs no revascularization Hirsch. EHJ 2008; sept 29 ahead pub

  9. Invasive vs Conservative O’Donaghue. JAMA 2008: 300: 71-80

  10. Invasive vs Conservative Bavry. JACC 2006; 48: 1319

  11. InvasivevsConservative All-cause mortality as a function of time Bavry. JACC 2006; 48: 1319

  12. Timing of intervention • Early intervention better: ISAR-COOL • Delayed intervention better: • ICTUS • Mehta meta-analysis • TIMACS, OPTIMA, ABROAD • GRACE and CRUSADE registries

  13. Early intervention

  14. ISAR-COOL Death or MI at 30 days 15% Prolonged antothrombotic treatment 10% p=0.04 5% Early intervention 0 5 10 15 20 25 30 Days after randomization Neuman. JAMA 2003: 290: 1593-9

  15. ICTUS: MI(%) at 1 year p<0.01 p NS Timingdependingonthe basis ofriskstratificaton Hirsch. Lancet 2007: 369: 827-35

  16. TIMACS Mehta. NEJM 2009: 360: 2165-75

  17. TIMACS Mehta. NEJM 2009: 360: 2165-75

  18. Drugs in PCI

  19. ISAR-REACT 2 N=2022 JAMA 2006: 295: 1531

  20. PRISM PLUS n=1915 NEJM 1998; 338: 1488-97

  21. IIbIIIa inhibitors • Intermediate to high risk patients (IIa-A) • Eptifibatide • Tirofiban • When epti/tirofiban prior to angiography, should be mantained during/after PCI (IIa-B) • Not IIbIIIa-pretreated patients should be treated with abciximab (I-A) • Bivalirudin might be an alternative to IIbIIIa plus heparin/enoxaparin (IIa-B)

  22. TRITON: Prasugrel p=0.0004 p=0.03 Wiviott, NEJM 2007; 357: 2001-15

  23. TRITON: Prasugrel Wiviott, Lancet 2008; 371: 1353-63

  24. PLATO: Ticagrelor CV death, MI or stroke

  25. PLATO: Ticagrelor

  26. PLATO: Ticagrelor Major bleeding

  27. Management strategy NSTEACS EARLY (< 72 h) URGENT (< 120 ‘) ELECTIVE

  28. Urgent (<120’) Abciximab/bivalirudin

  29. Early (<72h) Tirofiban/eptifibatide

  30. Elective

  31. Type of revascularization Invasive arm

  32. PCI: considerations • Treatment of non-significant lesions not recommended (III-C) • Complete vs “culprit vessel” not adressed • BMS or DES depending on (I-C): • Benefit ratio • Comorbidities • Need for surgery in the short medium follow-up

  33. Complete vs incomplete revascularization Complete Incomplete Hannan. JACC-CI 2009; 2: 17-25

  34. ACS only patients Incidence of Death, MI or revascularization p<0.05 Shishehbor. JACC 2007; 49: 849-57

  35. DES vs BMS: GRACE registry All cause mortality (n=6447)

  36. DES vs BMS for ACS: 2 years follow-up Death n=2456 TVR MI Mauri. NEJM 2008; 359: 1330-42

  37. GRACE registry (n=15088) -21% -15% Heart 2007; 93:177-82

  38. “If you know what you have to do and you do not do it then you are worse than before” Confucius

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