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Current and Future Perspectives on Acute Coronary Syndromes

Current and Future Perspectives on Acute Coronary Syndromes. Paul W. Armstrong MD AMI Quebec Montreal October 1, 2010. Pivotal Role of Time. Timing of Symptom Onset Time to 1 st Medical Contact Time to Reperfusion Time as Modulator of Rx Effect Time as Modulator of Rx Choice

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Current and Future Perspectives on Acute Coronary Syndromes

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  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 PreHospital ED CCU Cath Lab 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 Risk of STEMI Time Required to Initiate Invasive Strategy

  5. 35.0 30.0 % Rate Aborted MI 25.0 Absolute 35-day mortality benefit per 1000 Lytic-treated patients 20.0 15.0 10.0 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 <1.0 1.0 2.0 3.0 4.0 5.0 Duration of occlusion/ Treatment delay (h) Armstrong ,Westerhout, Welsh, Circulation 2009

  6. Efficacy vs Effectiveness …..Isn’t All About Time?

  7. To PCI From Sxonset Health care resources Time Patient Behavior Self presentation to hospital 911 EMS Infarct specific Mechanical Risk of Rx Pharmacological Risk of STEMI Patient specific Circumstance Geography STEMINEXUS Reperfusion Choice Strategy 9 3 Armstrong ,Westerhout,Welsh, Circulation 2009

  8. 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. Hospital Mortality Variables • Age (continuous) • Killip class • Blood pressure • ST deviation • Cardiac arrest • Creatinine • Elevated CK-MB / Tn • Heart rate GRACE Risk Model 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

  10. TIMACS Primary Outcome* Stratified by Baseline GRACE Risk Score Non ST elev’n ACS n=3031 (1/3) HR 0.65(0.48-0.89) *Death, MI, Stroke @ 6mo Early =14h : Delayed= 50h Mehta S et al. N Engl J Med 2009

  11. 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

  12. 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 a

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