1. Amr Hassan Mostafa, MD, FSCAI A. Professor of Cardiology Cairo University Cairo, Egypt Egypt Combat MI, March 24-25, Cairo Sheraton

2. Definitions – Acute coronary syndrome  Any constellation of clinical symptoms that are compatible with acute myocardial ischemia.  It encompasses a spectrum from AMI  NSTEMI  UA  NSTEMI – acute process of myocardial ischemia resulting in myocardial necrosis.The initial ECG does not show ST elevation

3. CK- MB or Troponin Troponin elevated or not ACS without persistent ST-segment elevation ACS with persistent ST-segment elevation

4. Non ST Elevation Acute Coronary Syndrome  A heterogeneous population  Varying risks of early and long-term adverse events  Early risk stratification at admission is essential for a tailored therapeutic strategy  Various ACS risk scores are available

5. Why be concerned re risk stratification………  Are the symptoms a manifestation of ACS?  Therapy/ site of care will vary dependent on diagnosis  To determine prognosis/short term survival  To determine need for early revascularization

6. ACS Risk Scores  TIMI: Thrombolysis In Myocardial Infarction  PURSUIT: Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin  GRACE: Global Registry of Acute Coronary Events

7. ACS Risk Scoring  TIMI Age- Use of aspirin Risk Factors- Known CAD > 1 episode rest pain- ST segment deviation Cardiac risk markers  PURSUIT Age, Sex- CCS class in last 6/52 Signs of CCF- ST depression on ECG  GRACE Age- Heart rate and systolic BP Creatinine- CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers- ST segment deviation

8. TIMI Risk Score  Age ≥ 65 years  ≥3 Risk factors for coronary artery disease  Significant coronary stenosis  ST Segment deviation  Severe anginal symptoms (≥2 anginal events in last 24 hours)  Prior aspirin use (within last 7 days)  Elevated serum cardiac markers Antman et al. JAMA 2000;284:835-842

9. ACC/AHA/SCAI 2007 PCI Guidelines Focused Update 9 TIMI Risk Score for UA/NSTEMI TIMI Risk ScoreAll-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 Days After Randomization, % 0-14.7 28.3 313.2 419.9 526.2 6-740.9 TIMI, Thrombolysis in Myocardial Infarction. King SB III, Smith SC Jr., et al. J Am Coll Cardiol 2008;51:172-209. Table 4. Available at: http://content.onlinejacc.org/cgi/content/full/51/2/172 http://content.onlinejacc.org/cgi/content/full/51/2/172

10. Antman et al. JAMA 2000;284:835-842

11. ACS Risk Scoring  TIMI Age- Use of aspirin Risk Factors- Known CAD > 1 episode rest pain- ST segment deviation Cardiac risk markers  PURSUIT Age, Sex- CCS class in last 6/52 Signs of CCF- ST depression on ECG  GRACE Age- Heart rate and systolic BP Creatinine- CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers- ST segment deviation

12. Thresholds of Risk

13. SBP (per 20 mmHg increase) 0.70.69-0.78 Initial serum creatinine 1.21.15-1.35 Heart rate 30bpm 1.31.16-1.48 Initial cardiac enzyme + 1.61.32-2.00 Age (per 10 yr) 1.71.55-1.85 Killip class 2.01.81-2.29 2.41.90-3.00 Pre-hosp arrest 4.3 2.80-6.72 -2 –1 0 1 2 3 4 5 6 7 8 Multivariable Risk Model

14. Discharge Risk score – An Audit Standard ?

15. Unique Features of GRACE  Multi-national perspective  Full spectrum of coronary syndromes  Increased data on demographics, presentation, management and outcome  Regular audits of data quality  Feedback to participating sites  6-month follow-up

16. ACS Risk Scoring  TIMI Age- Use of aspirin Risk Factors- Known CAD > 1 episode rest pain- ST segment deviation Cardiac risk markers  PURSUIT Age, Sex- CCS class in last 6/52 Signs of CCF- ST depression on ECG  GRACE Age- Heart rate and systolic BP Creatinine- CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers- ST segment deviation

17. Distribution of the 30-day and 1-year endpoint rates in the different risk groups de Araújo Gonçalves P et al. Eur Heart J 2005;26:865-872 © The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oupjournals.org

18. Comparison of TIMI Risk Scores for Death: Antman Data Vs. GRACE Data 0 1 2 3 4 5 6 7 0/12345'6/7 TIMI Risk Score Antman GRACE Death Rate (%)

19. ACC/AHA/SCAI 2007 PCI Guidelines Focused Update

20. Confounding Factors  Risk scores are largely developed from registries & not CRT’s  High risk pts usually receive more aggressive antithrombotics & early revascularisation  Risk scores can only predict short term prognosis as they do not include important coronary anatomic or physiologic information

21. Single Vessel Disease Two Vessel Disease Three Vessel Disease 75% Left Main Stem 95% Left Main Stem 0.00.51.01.52.02.5 Harzard Ratio Survival Benefits of Revascularisation

22. 25 20 15 10 5 0 05-4950-85>85 Severity of Luminal Stenosis (%) Frequency (%) of 5 year Vessel Occlusion or Myocardial Infarction <50% 50-70% >70% 68% 18% 14% Severity of Underlying Luminal Stenosis in Patients with an Acute Myocardial Infarction Luminal Stenosis Frequency Degree of Stenosis in the Culprit Lesion of Acute Myocardial Infarction

23. ACS Risk Scoring  TIMI Age- Use of aspirin Risk Factors- Known CAD > 1 episode rest pain- ST segment deviation Cardiac risk markers  PURSUIT Age, Sex- CCS class in last 6/52 Signs of CCF- ST depression on ECG  GRACE Age- Heart rate and systolic BP Creatinine- CCF (Killip class) Cardiac arrest at admission Elevated cardiac markers- ST segment deviation

24. ACS Risk Scores  Balance between complexity and utility  Score that include continuous variables more powerful but more complex to compute Simple PC/PDA programmes now available  Objective data more robust GRACE most powerful and has most objective data

25. Risk Assessment In Acute Coronary Syndromes Evaluation of Treatment Benefit In Acute Coronary Syndromes

26. Take Home Message All risk scores were developed to predict short term prognosis GRACE risk scoring appears the most predictive of short & intermediate term prognosis GRACE risk scoring includes CHF & renal dysfunction at the time of presentation with ACS

27. Take Home Message Risk scores need to be carefully applied Risk scores may be population dependent and not reflect ‘true life’ populations Low risk is not no risk High risk does not equate to most benefit from intervention