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

6. 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

7. 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

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

11. 2 Yr Mortality and MI
Mortality
Death or MI

15. Culprit Lesion Morphology & Troponin Levels in UAP

18. 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)

33. Overview of GP IIb/IIIa Trials by Pooled Analysis

38. Conservative X Invasive Trials in ACS

39. Conservative X Invasive Trials in ACS

40. TIMI - IIIB

44. 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

59. Conservative X Invasive Trials in ACS

60. Conservative X Invasive Trials in ACS

61. Conservative X Invasive Trials in ACS

64. MI
Death or MI MI
Death or MI