CIACCMilano, 3 Dicembre 2011
Strategie di trattamento nelle Sindromi Coronariche Acute senza ST sopraslivellato
Corrado Lettieri U.O. di Cardiologia, Ospedale Carlo Poma, Mantova
NSTEACSRecomendations for invasive evaluation and revascularisation
ESC GUIDELINES 2007
High-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)
Intermediate to high-risk features
Elevated troponin levels Dynamic ST- or T- wave changes
(symptomatic or silent)Diabetes mellitusRenal dysfunction (GFR<60 mLK/min/1,73m2)
Reduced left ventricular function (EF<40%)
Early post-infarction anginaPrior MIPCI within 6 monthsPrior CABGIntermediate to high GRACE Risk Score
Low-risk features
No recurrence of chest pain
No signs of heart failure
No new ECG changes
(arrival,6h,12h)
No elevation of troponins
(arrival,6h,12h)
URGENT EARLY NO / ELECTIVE
NSTEACSRecomendations for invasive evaluation and revascularisation
ESC GUIDELINES 2011
NSTEACSRecomendations for invasive evaluation and revascularisation
ESC GUIDELINES 2011
Patients (N): 920 2874 7018
Adapted from Cannon Circulation. 2003.
“early conservative”“early conservative” “early invasive”“early invasive”
TIMI IIIB
MATEVANQWISH
FRISC II
TACTICS-TIMI 18
VINO
RITA-3
TRUCS
ISAR-COOL
ICTUS
Strategia invasiva o conservativa nelle NSTEACS
Metha-analysis of contemporary randomized studies Early Invasive vs Conservative Therapy
Relative Risk of all-cause mortality
Bavry et al. JACC 2006;48:1319-25
Metha-analysis of contemporary randomized studies Early Invasive vs Conservative Therapy
Relative Risk of cardiovascular mortality at 5 years follow-up
Fox KA, et al. JACC 2010;55:2435-45
Early invasive vs selective invasive in NSTEACS
Kaplan-Meier estimates of the cumulative rate of the composite primary end point
of death, nonfatal MI or rehospitalization for anginal symptoms within 1 year
ICTUS
Winter, N Engl J Med 2005;353:1095-104
Cannon et al, Eur Heart J 2004;25:1471-1472
Relative mortality benefit with the revascularisation vs gradient in
rates of revascularisation between both randomisation arms
Strategia Invasiva vs Conservativa
NSTACS: early invasive? selective invasive?
Hirsch A, et al: EHJ 2009;30:645-654
Hirsch A, et al: EHJ 2009;30:645-654
NSTACS: early invasive? selective invasive?
Hirsch A, et al: EHJ 2009;30:645-654
NSTACS: early invasive? selective invasive?
Hirsch A, et al: EHJ 2009;30:645-654
NSTACS: early invasive? selective invasive?
Pazienti del braccio “early invasive”Pazienti del braccio “early invasive”
Hirsch A, et al: EHJ 2009;30:645-654
NSTACS: early invasive? selective invasive?
Rates of the Primary End Point of Death, Nonfatal MI, or Rehospitalization for an Acute Coronary Syndrome at Six Months, According to Baseline Characteristics
TACTICS-TIMI 18
Cannon et al., N Engl J Med 2001; 344:1879-87
Strategia Invasiva vs Conservativa
TIMI Risk ScoreTIMI Risk Score
PURSUIT Risk ScorePURSUIT Risk Score
GRACE Risk ScoreGRACE Risk Score
No Diabete, no eco, no IRCNo Diabete, no eco, no IRC
No Diabete, no ecoNo Diabete, no eco
No Diabete, no eco, no IRCNo Diabete, no eco, no IRC
CRUSADE Risk Score CRUSADE Risk Score
NSTEACS: ADERENZA ALLE LG
Coronarografia < 48 ore e rischio
NSTEACSScelta della strategia e disponibilità di risorse
Età < 55 55-59 60-64 65-69 70-74 75-79 80-84 85
RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO
Rischio della PCI in funzione dell’età
Batchelor et al. JACC 2000
mortalità/IMA/CVA
mortalità
RIVASCOLARIZZAZIONE PERCUTANEA NELL’ANZIANO
COMPLICANZE “EXTRACARDIACHE”
< 80 aa
> 80 aa
Batchelor et al. JACC 2000
%
Anziani e trials: una visione distorta?
CRUSADE JACC 2005
= < 75aa
= 75aa
PCI, ASA, betablockers, heparin, GPIIbIIIa inhibitors
NSTEACSRecomendations for GP IIb/IIIa inhibitors
ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010
ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010
NSTEACSRecomendations for GP IIb/IIIa inhibitors
ESC GUIDELINES NSTEACS 2011
ESC GUIDELINES NSTEACS 2011
Durante PCI
Upstream
Routine