Optimal Management of ACS Invasive vs Conservative Strategy Layth Mimish Consultant Cardiologist The Cardiovascular Consultant Group Jeddah KSA

Approach To ACS Risk stratification Appropriate acute medical management Identify coronary anatomy in higher risk patients, otherwise exercise imaging PCI vs CABG based on extent of coronary disease, LV function, and co morbid factors Long term medical management ; risk factors modification

TIMI Risk Score for ACS Unfractionated Heparin Cohort TIMI 11B (n=1957) Age > 65 years > 3 CAD risk factors Prior CAD Stenosis > 50% ST segment changes on presentation > 2 anginal events in last 24 Hrs ASA use < 7years Increased serum cardiac markers

FRISC Score Age>70 years Diabetes Mellitus Previous MI Angina > 30 days ST depression Elevated Troponin Elevated Fibrinogen Elevated II-6 (2P)

2 Yr Mortality and MI Mortality Death or MI

Culprit Lesion Morphology & Troponin Levels in UAP

Antithrombotic approaches in ACS Acute Medical Management ASA & LMWH ( FRIC, FRISC I&II, ESSENCE, TIMI 11B) Direct Thrombin Inhibitors (GUSTO IIB, OASIS-2) GP IIb/IIIa Inhibitors (4P Trials, Oral trials, GUSTO-IV ACS, TIMI-18) ASA & Clopidogril (CURE) Coronary Interventions Direct Thrombin Inhibitors (HELVETICA, Hirulog Trials) GIIbIIa Inhibitors (EPIC, EPILOG, CAPTURE, EPISTENT, IMPACT-2, RESTORE, ESPIRIT, TARGET) LMWH & GPIIb/IIIa Inhibitors(NICE Registry) ASA & Clopidogril (CREDO)

Overview of GP IIb/IIIa Trials by Pooled Analysis

Conservative X Invasive Trials in ACS

Conservative X Invasive Trials in ACS

TIMI - IIIB

Study Limitations of VANQUISH High surgical mortality (7.7%) & 12% in invasive arm PTCA performed prior to era of stents and GPIIb/Iia blockers No PTCA for multivessel disease Results not necessarily applicable to females

Conservative X Invasive Trials in ACS

Conservative X Invasive Trials in ACS

Conservative X Invasive Trials in ACS

MI Death or MI MI Death or MI