“Adjunctive Therapy” Non ST segment elevation ACS Dr M R Thomas King’s College Hospital. Advanced Angioplasty 2002

Plaque Rupture Unstable angina Non ST elevation AMI ST elevation AMI

“Adjunctive Therapy” Non ST segment elevation ACS Pre-PCI (assume DGH admission) Pre-PCI (assume DGH admission) Peri-PCI Peri-PCI Post PCI Post PCI UK Perspective!!

“Adjunctive Therapy” Non ST segment elevation ACS Pre PCI Obvious medical therapy. - aspirin. - anti-anginals. - lipid lowering. MIRACL: 80mg atorvastatin v placebo Un angina/non Q MI Rx for 16 weeks Primary endpoint: death, non fatal MI,cardiac arrest and emergency re-hospitalisation MIRACL TRIAL P=0.048

Is there a need for revascularisation? And therefore generally transfer to a tertiary centre.

Cons v Invasive Strategies 4 randomised clinical trials

High surgical mortality. 7.7% overall and 12% in the invasive arm

Median time to angiography 4 days Median time to revascularisation 4 (PCI) to 7 (CABG)

Median time to angiography 22 hrs Median time to revasc 25 (PCI) to 89 (CABG) hrs

“Adjunctive Therapy” Non ST segment elevation ACS So assuming some or all patients will need revasularisation (PCI) what is the best type and combination of drugs pre PCI Heparin, UFH or LMWH Heparin, UFH or LMWH IIb/IIIa receptor inhibitors IIb/IIIa receptor inhibitors Clopidogrel Clopidogrel

Heparin: LMWH or UFH Essence and TIMI 11B These trials have demonstrated an advantage of LMWH over UFH in UA and other trials have shown at least equivalence. Also ease of use compared to UFH. Worries about combination with IIb/IIIa now resolved.

Incidence of death/MI in patients at 1 year: effects of enoxaparin more marked in PCI patients, TIMI 11B/ESSENCE meta-analysis OR (95% CI) 0.61 (0.35,1.06) OR (95% CI) 0.72(0.49,1.04) OR (95% CI) 0.92(0.81,1.04)

IIb/IIIa receptor inhibitors “National Institute of Clinical Excellence” Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes. September 2000 (1) For high risk patients with unstable angina or non-Q MI, the intravenous use of GP IIb/IIIa inhibitors in addition to low (adjusted) dose UFH is recommended. (2) In unstable angina, raised blood levels of troponin should be used to identify those at high risk. NB: Pre GUSTO IV ACS

In the absence of revascularisation value of IIb/IIIa receptor inhibitors “small” and evidence favours small molecules.

CURE CURE (OASIS-4) Clopidogrel in Unstable Angina to prevent Recurrent ischemic Events

Cumulative Hazard Rates for CV Death/MI/Stroke P < Clopidogrel Placebo Cumulative Hazard Rates Months of Follow-up Plac Clop No of Pts 9.3% 11.4% 20% RR cp 20% Prism + 6/12 9.6% Pursuit 30 days

Transfer for revascularisation. Does everyone need to be transferred for angiography and possible revascularisation?

Risk stratification Baseline ST segment change Recurrent Ischaemia

Value of Baseline CPK-MB in ACS (PURSUIT)

Prognostic value of Baseline Troponins Gusto IIA: 30 day mortality (%) P<0.001

TACTICS-TIMI 18: Stratified by Troponin T OR=0.95 p=NS OR=0.47 p=0.002

Low risk patients Data supports an ischaemia-guided approach with treadmill exercise or pharmacological stress.

Transfer! So we have transferred the high risk patient: - troponin +, recurrent ischaemia, ST depression. ON - aspirin, LMWH, clopidogrel, IIb/IIIa in ideal world!! (24 hrs) BUT in UK aspirin, LMWH and clopidogrel (2 weeks!)

Transfer Is there a problem with LMWH and IIb/IIIa?

“Acute II” First randomised trial of IIb/IIIa blockers and LMWH in ACS. 525 ACS patients on aspirin and Tirofiban (Aggrastat). Randomised to LMWH (enoxaparin) or UFH. Primary endpoint: SAFETY.

Safety endpoints in Acute-2

30 day event rates in ACUTE II Paragon-B appears to similar results for Lamifiban

International Task Force Recommendations (Feb 2001) (Karl Karsch from UK)

IIb/IIIa receptor inhibitors Which patients…….all or defined by coronary anatomy? Which compound………?any Delivered when………?upstream or after diagnostic angiogram.

“Adjunctive Therapy” Non ST segment elevation ACS Post Discharge 2ary prevention, lipids etc 2ary prevention, lipids etc Aspirin Aspirin Clopidogrel Clopidogrel

PCI - A prospective, randomized, double- blind substudy of patients undergoing PCI in the CURE trial

Primary Endpoint: CV Death, MI, Urgent Revascularization Mehta SR et al. Lancet 2001:358:527-33

CV Death, MI: From PCI to End of Followup Mehta SR et al. Lancet 2001:358:527-33

CV Death or MI at Various Intervals RRR 31% 32% 34% 21% * *P=0.002 Mehta SR et al. Lancet 2001:358:527-33

Guidelines “Guidelines for the management of patients with acute coronary syndromes without persistent ECG ST elevation” Heart 2001;85:

We live in the UK Questions Where should diagnostic angiography be performed? Where should interventional cardiology be performed? Who should perform interventional procedures? How do we increase the availability of both of the above? ALL OF THE ABOVE IS AS/MORE IMPORTANT AS THE DATA!

Conclusions I think we know the data: aspirin, lipid lowering, clopidogrel, LMWH, risk assessment and IIb/IIIa with early revascularisation in the high risk group. Providing an optimal service in the UK via the NHS…….now that’s a different story!!