CIACC Milano, 3 Dicembre 2011 Strategie di trattamento nelle Sindromi Coronariche Acute senza ST sopraslivellato Corrado Lettieri U.O. di Cardiologia, Ospedale Carlo Poma, Mantova

NSTEACS Recomendations 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 mellitus Renal dysfunction (GFR<60 mLK/min/1,73m 2 ) Reduced left ventricular function (EF<40%) Early post-infarction angina Prior MI PCI within 6 months Prior CABG Intermediate 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) URGENTEARLYNO / ELECTIVE

NSTEACS Recomendations for invasive evaluation and revascularisation ESC GUIDELINES 2011

Patients (N): Adapted from Cannon Circulation early conservative early invasive TIMI IIIB MATE VANQWISH 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:

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:

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:

Cannon et al, Eur Heart J 2004;25: 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:

NSTACS: early invasive? selective invasive?

Hirsch A, et al: EHJ 2009;30: NSTACS: early invasive? selective invasive?

Hirsch A, et al: EHJ 2009;30: NSTACS: early invasive? selective invasive?

Pazienti del braccio early invasive Hirsch A, et al: EHJ 2009;30: 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: Strategia Invasiva vs Conservativa

TIMI Risk Score PURSUIT Risk Score GRACE Risk Score No Diabete, no eco, no IRC No Diabete, no eco No Diabete, no eco, no IRC

CRUSADE Risk Score

NSTEACS: ADERENZA ALLE LG Coronarografia < 48 ore e rischio

NSTEACS Scelta della strategia e disponibilità di risorse

Età < RIVASCOLARIZZAZIONE PERCUTANEA NELLANZIANO Rischio della PCI in funzione delletà Batchelor et al. JACC 2000 mortalità/IMA/CVA mortalità

RIVASCOLARIZZAZIONE PERCUTANEA NELLANZIANO 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

NSTEACS Recomendations for GP IIb/IIIa inhibitors ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010 ESC GUIDELINES ON MYOCARDIAL REVASCULARIZATION 2010

NSTEACS Recomendations for GP IIb/IIIa inhibitors ESC GUIDELINES NSTEACS 2011 ESC GUIDELINES NSTEACS 2011 Durante PCI Upstream Routine