cop management of unstable angina/nstemi yright - primarycare.tips · harvard medical school rapid...
TRANSCRIPT
![Page 1: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/1.jpg)
HARVARD MEDICAL SCHOOL
AlleviatingtheConfusioninReperfusion:
ManagementofUnstableAngina/NSTEMI
UpdateinInternalMedicine
DuanePinto,MD,MPH,FACCCOPYRIGHT
![Page 2: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/2.jpg)
HARVARD MEDICAL SCHOOL
Agenda
• RapidRuleOutStrategy
• GeneralGuidelinesandTherapies
• AssessingPatientRisk
• TimingofCatheterization
• NavigatingAnticoagulant/AntiplateletChoices
• NewerChoicesandnewdata
• TheFuture
COPYRIGHT
![Page 3: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/3.jpg)
HARVARD MEDICAL SCHOOL
EuropeanandUSGuidelinesforNSTEMI
• Firsttimea1Brecommendationforrapidruleout
protocolwithbloodtestat0and1hourusingHS-
Troponinwithadditionaltestingat3-6hrsifthe
first2arenotconclusiveandtheclinicalcondition
isstillsuggestiveofACS
Prospective validation of a 1-hour algorithm to rule-out and
rule-in acute myocardial infarction using a highsensitivity cardiac troponin T assay. CMAJ 2015;187:E243–E252.
COPYRIGHT
![Page 4: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/4.jpg)
HARVARD MEDICAL SCHOOL
RapidRuleOut
• 1320Patientstreatedaccordingtothe
algorithm
–AMIwasthefinaldiagnosisin17.3%ofpatients.
–786(59.5%)patientswereclassifiedas‘rule-out,’
–216(16.4%)wereclassifiedas‘rule-in’
– 318(24.1%)wereclassifiedtothe‘observational.’
Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a highsensitivity cardiac troponin T assay. CMAJ 2015;187:E243–E252.
COPYRIGHT
![Page 5: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/5.jpg)
HARVARD MEDICAL SCHOOL
RapidRuleOut
• ThenegativepredictivevalueforacuteMIintherule-
outzonewas99.9%.
• ThepositivepredictivevalueforacuteMIintherule-
inzonewas78.2%.
• Cumulative30-daymortalitywas0.0,1.6,and1.9%in
patientsclassifiedintherule-out,observational,and
rule-ingroups,respectively.
Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a highsensitivity cardiac troponin T assay. CMAJ 2015;187:E243–E252.
COPYRIGHT
![Page 6: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/6.jpg)
HARVARD MEDICAL SCHOOL
ImmediateManagement
•Thehistory,physicalexamination,12-leadECG,and
initialcardiacbiomarkertestsshouldbeintegrated
•Assignpatientswithchestpaininto1of4categories
–Noncardiacdiagnosis
–Chronicstable angina
–Possible ACS
–Definite ACS
6
COPYRIGHT
![Page 7: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/7.jpg)
HARVARD MEDICAL SCHOOL
UniversalDefinitionofMI
COPYRIGHT
![Page 8: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/8.jpg)
HARVARD MEDICAL SCHOOL
UniversalDefinitionofMI
COPYRIGHT
![Page 9: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/9.jpg)
HARVARD MEDICAL SCHOOL
Goals for the Management of Non-ST Elevation
Acute Coronary Syndromes
Unstable Angina
Prevent immediate risk of MI and improve long-term outcome
Non-STEMI
Minimize extent of MI to improve long-term outcome
Prevent repeat MI to improve long-term outcomeCOPYRIGHT
![Page 10: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/10.jpg)
HARVARD MEDICAL SCHOOL
GeneralTherapies
• AntiIschemicTherapy&
PainControl
–Oxygen
–Nitrates
• IfSBP>100without
CHF
–Morphine
• OralBetaBlockade
within24hrsUnlessHF,Lowoutput state,
PR>0.24,HeartBlock,Active
Asthma/ReactiveAirway
Disease
• ACE-Iwithin24hrsif
HForLVEF<=40%UnlessBP<100or>30mmHg
belowbaseline
COPYRIGHT
![Page 11: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/11.jpg)
HARVARD MEDICAL SCHOOL
COPYRIGHT
![Page 12: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/12.jpg)
HARVARD MEDICAL SCHOOL
COPYRIGHT
![Page 13: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/13.jpg)
HARVARD MEDICAL SCHOOL
Aspirin in the Treatment of ACS
Wallentin LC, et al. JACC 1991;18:1587-
93.
0.00
0.05
0.10
0.15
0.20
0.25
0 3 6 9 12
Months
Pro
bab
ilit
yo
f D
eath
or
MI
Placebo
Aspirin 75 mg
Risk ratio 0.5295% CL 0.37-0.72
COPYRIGHT
![Page 14: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/14.jpg)
HARVARD MEDICAL SCHOOL
Beta Blockers
It may be harmful to administer intravenous beta blockers to UA/NSTEMI patients
who have contraindications to beta blockade, signs of HF or low-output state, or
other risk factors* for cardiogenic shock.
*Risk factors for cardiogenic shock (the greater the number of risk
factors present, the higher the risk of developing cardiogenic
shock):
1.age >70 years
SBP <120 mmHg
2.sinus tachycardia >110 or heart rate >60
3.increased time since onset of symptoms of UA/NSTEMI.
Chen ZM, et al. Lancet 2005;366:1622–32.
COPYRIGHT
![Page 15: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/15.jpg)
HARVARD MEDICAL SCHOOL
GoalsforTherapyDuringNSTEMI
Patientriskdictatesmanagement
• Goals:
–UnstableAngina:PreventProgressiontoInfarct
–NSTEMI:MinimizeInfarctSizeandRecurrentMI
• Therapeuticagents
–Anticoagulants
–AntiPlatelets
• InvasiveManagement
–Angiographytofurtherclarifyrisk
– Revascularizationtoarrestthrombusprogression
COPYRIGHT
![Page 16: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/16.jpg)
HARVARD MEDICAL SCHOOL
I’mConfused
NSTEMI
Early
Invasivevs.
SelectiveInvasive
Which
Anticoagulant?
•LMWH
•UFH
•DTI
WhichAntiplatelet?
•Clopidogrel
•Prasugrel
StartMedsUpstreamvs.InCath
Lab?WhichStent?
•DrugElutingvs.Bare
MetalStent
WhatifPt.needsaCABG?
600mgvs.300mg
Clopidogrel?
WhatDoseofASA?
LMWH=Low Molecular Weight Heparin
UFH= Unfractionated Heparin
DTI= Direct Thrombin Inhibitor
COPYRIGHT
![Page 17: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/17.jpg)
HARVARD MEDICAL SCHOOL
EARLYINVASIVESTRATEGY
WHOANDWHEN?
COPYRIGHT
![Page 18: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/18.jpg)
HARVARD MEDICAL SCHOOL
TIMI
Risk
Score
All-CauseMortality,NeworRecurrentMI,orSevere
RecurrentIschemiaRequiringUrgentRevascularization
Through14DaysAfterRandomization%
0-1 4.7
2 8.3
3 13.2
4 19.9
5 26.2
6-7 40.9
TIMI Risk Score
Antman EM, et al. JAMA 2000;284:835–42. Copyright © 2000, American Medical Association. All
Rights reserved. The TIMI risk calculator is available at www.timi.org.Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157, Table 8.
TIMI = Thrombolysis in Myocardial Infarction.
COPYRIGHT
![Page 19: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/19.jpg)
HARVARD MEDICAL SCHOOL
MortalityandtheTIMIRiskScore
JAMA 2000;284:835–42 (159).
NSTEMI is generally caused by a partially occlusive, platelet-rich
thrombus in a coronary artery
COPYRIGHT
![Page 20: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/20.jpg)
HARVARD MEDICAL SCHOOL
RelativeRiskforAll-CauseMortality:EarlyInvasivevsSelectiveInvasiveTherapy
Bavry A, et al. J Am Coll Cardiol.
2006;48:1319-1325.
692
121515
130
60132102
63937
1293
246745
Follow-up,MonthsConservativeInvasive
Deaths, n
Study
FRISC-II
TRUCS
TIMI-18
VINO
RITA-3
ISAR-COOL
ICTUS
Overall RR (95% CI) 0.75 (0.63-0.90)
0.1 1 10
Favors Early Invasive
Therapy
Favors Conservative
Therapy
COPYRIGHT
![Page 21: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/21.jpg)
HARVARD MEDICAL SCHOOL
Timetocatheterization(hrs)
EARLY LATE
FRISC2(1999) 96 408
TRUCS(2000) 48 120
TIMI-18(2001) 22 79
VINO(2002) 6 1464
RITA3(2002) 48 1020
ELISA(2003) 6 50
ISAR-COOL(2003) 3 86
ICTUS(2005) 23 283
TIME-ACS(2009) 14 50
COPYRIGHT
![Page 22: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/22.jpg)
HARVARD MEDICAL SCHOOL
PrimaryOutcome
Death,MI,orStroke
Days
Cu
mu
lati
ve H
azard
0.0
0.0
20.0
60.1
0
0 30 60 90 120 150 180
Death/MI/Stroke at 180 days
Early
No. at Risk
Delayed
Early
1438 1328 1269 1254 1234 1229 1211
1593 1484 1413 1398 1391 1382 1363
Delayed
HR 0.8595% CI 0.68-1.06
P= 0.15
TIMACS
N Engl J Med. 2009 May 21;360(21):2165-75.
COPYRIGHT
![Page 23: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/23.jpg)
HARVARD MEDICAL SCHOOL
ESCGuideline2016
• ImmediateInvasiveStrategywithin2hoursforveryhigh
riskpatients
–Shock,severeheartfailure,arrhythmia,ongoingchestpain
• Earlyinvasivewithin24hoursforhighrisk
• Invasive(within72hours)forintermediateriskCOPYRIGHT
![Page 24: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/24.jpg)
HARVARD MEDICAL SCHOOL
Summary
• RiskstratifypatientswithUA/NSTEMIusingsimpleclinical
scores(TIMI,GRACE)
• Selectforfurtherinvasivework-upthosewhoareatmoderate
andhighriskforischemiccomplications
• Catheterizationshouldbeurgentbutnotemergentforhighrisk
individuals
• Lowriskindividualsshouldhavenoninvasivework-upfirst
COPYRIGHT
![Page 25: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/25.jpg)
HARVARD MEDICAL SCHOOL
MEDICATIONSFORUA/NSTEMI
PLATELETSANDTHROMBUS
COPYRIGHT
![Page 26: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/26.jpg)
HARVARD MEDICAL SCHOOL
Questions
• Whichpatientsformoreaggressiveantiplateletmedications?
• Whentoadminister(pre-cath,atcath,post-cathetc)?
• Whichones(oral,IVorboth)?
• Neweragents?
COPYRIGHT
![Page 27: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/27.jpg)
HARVARD MEDICAL SCHOOL
EmbolisminNSTEMI
COPYRIGHT
![Page 28: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/28.jpg)
HARVARD MEDICAL SCHOOL
WHICHORALAGENTBESIDESASPIRIN?
COPYRIGHT
![Page 29: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/29.jpg)
HARVARD MEDICAL SCHOOL
P2Y12 Inhibitors
Clopidogrel Prasugrel Ticagrelor
Class Thienopyridine Thienopyridine Triazolopyrimidine
Bindingto
ReceptorIrreversible Irreversible Reversible
ActivationProdrug,limited
bymetabolisation
Prodrug,notlimited
bymetabolisationActivedrug
Nonresponders Yes No No
OnsetofEffect 2–4h 30min 30min
DurationofEffect 3–10days 5–10days 3–4days
Withdrawal
Before
MajorSurgery5days 7days 5days
HammCW,etal.EurHeartJ.2011;32:2999–3054.www.escardio.org/guidelines.
COPYRIGHT
![Page 30: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/30.jpg)
HARVARD MEDICAL SCHOOL
ClopidogrelDuringUA/NSTEMI
CURE investigators. N Engl J Med. 2001;345:494-502.
CV death, MI, stroke (%)
RR = 0.80P<.001
Days After Enrollment
0
4
8
12
0 100 200 300 400
9.3
11. 4
Placebo (n=6303)
Clopidogrel (n=6259)COPYRIGHT
![Page 31: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/31.jpg)
HARVARD MEDICAL SCHOOL
0
5
10
15
0 30 60 90 180 270 360 450
HR 0.81
(0.73-0.90)P=0.0004
Prasugrel
Clopidogrel
Days
En
dp
oin
t (%
)
12.1
9.9
HR 1.32
(1.03-1.68)P=0.03
Prasugrel
Clopidogrel1.8
2.4
138
events
35
events
CV Death / MI / Stroke
TIMI Major NonCABG Bleeds
NNT = 46
NNH = 167
Wiviott et al NEJM 2007
COPYRIGHT
![Page 32: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/32.jpg)
HARVARD MEDICAL SCHOOL
32
TRITON-TIMI38:NetClinicalBenefit
BleedingRiskSubgroups
Post-hocanalysis
OVERALL
≥ 60 kg
< 60 kg
< 75
≥ 75
No
Yes
0.5 1 2
PriorStroke / TIA
Age
Wgt
Risk (%)
+ 37
-16
-1
-16
+3
-14
-13
Prasugrel Better Clopidogrel BetterHR
Pint = .006
Pint = .18
Pint = .36
Wiviott SD, et al. N Engl J Med. 2007;357:2001-2015.
COPYRIGHT
![Page 33: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/33.jpg)
HARVARD MEDICAL SCHOOL
ESCGuideline2016
• ClassIII
indicationfor
Prasugrel
beforeanatomy
isknownbased
onthe
ACCOASTTrialCOPYRIGHT
![Page 34: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/34.jpg)
HARVARD MEDICAL SCHOOL
No. at risk
Clopidogrel
Ticagrelor
9,291
9,333
8,560
8,678
8,405
8,520
8,177
Days after randomisation
6,703
6,796
5,136
5,210
4,109
4,191
0 60 120 180 240 300 360
6
5
4
3
2
1
0
7
Cu
mu
lati
ve i
ncid
en
ce (
%)
Clopidogrel
Ticagrelor
5.8
6.9
8,279
HR 0.84 (95% CI 0.75–0.95), p=0.005
0 60 120 180 240 300 360
6
4
3
2
1
0
Clopidogrel
Ticagrelor
4.0
5.1
HR 0.79 (95% CI 0.69–0.91), p=0.001
7
5
9,291
9,333
8,865
8,294
8,780
8,822
8,589
Days after randomisation
7079
7119
5,441
5,482
4,364
4,4198,626
Myocardial infarction Cardiovascular death
Cu
mu
lati
ve i
ncid
en
ce (
%)
Ticagrelor:PLATO
N Engl J Med. 2009 Sep 10;361(11):1045-57. Epub 2009 Aug 30.
COPYRIGHT
![Page 35: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/35.jpg)
HARVARD MEDICAL SCHOOL
WHENTOGIVETHEORALAGENTS?
COPYRIGHT
![Page 36: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/36.jpg)
HARVARD MEDICAL SCHOOL
TimingofClopidogrelLoadingInUSPractice
Dean BB et al. Am J Health-Syst Pharm 2010; 67: 1430-7.
COPYRIGHT
![Page 37: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/37.jpg)
HARVARD MEDICAL SCHOOL
COPYRIGHT
![Page 38: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/38.jpg)
HARVARD MEDICAL SCHOOL
Recommendation COR LOE
Amsterdam E, et al. Circulation. 2014.
Post-Discharge:Aspirinindefinitely I AAspirin81mginpreferencetohigherdoses IIa B
Iftreatedmedically(norevascularization):clopidogrelorticagreloraddedtoaspirinandcontinuedforupto12months
I B
IftreatedwithPCI:clopidogrel,prasugrel,orticagreloraddedtoaspirinandcontinuedatleast12months
I B
Ticagrelor(PCIormedRx)orprasugrel(PCI)inpreferencetoclopidogrel IIa B
TherapyatthetimeofPCI:P2Y12at thetimeofPCI:clopidogrel(LOE=A),prasugrel(LOE=B),ticagrelor(LOE=B,)orGPI(LOE=A)
I B
Prasugrelorticagrelorinpreferencetoclopidogrelinpatientsundergoingcoronarystenting
IIa B
PrasugrelpotentiallyharmfulaspartofDAPTinpatientswithapriorhistory ofCVAand/orTIA
III:Harm
B
InitialTherapy:Aspirin(160-325mg)assoonaspossibleafterhospitalpresentation,followedby81mgdaily
I A
AP2Y12 inhibitor(clopidogrelorticagrelor)inadditiontoaspirintoallpatientswithNSTE-ACSwithoutcontraindications
I B
Ticagrelorinpreferencetoclopidogrel IIa B
2014 ACCF/AHA Select Recommendations for Oral Antiplatelet Agents with NSTE-ACS
COPYRIGHT
![Page 39: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/39.jpg)
HARVARD MEDICAL SCHOOL
Preloading May Not Actually Be Preloading
COPYRIGHT
![Page 40: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/40.jpg)
HARVARD MEDICAL SCHOOL
Circulation
Volume 130(21):1904-1914November 18, 2014
COPYRIGHT
![Page 41: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/41.jpg)
HARVARD MEDICAL SCHOOL
CangrelorNowApprovedforPCIDirect platelet P2Y12 receptor antagonist
●ATP analogue MW=800 Daltons
●Parenteral administration
●Rapid inhibition (> 90%) at 4 mg/kg/min after a weight-
based bolus
●Full recovery of platelet function in <60 minutes
●t 1/2 - 3- 5 minutes
●Putative metabolism by endothelial-associated
ectonucleotidases/CD 39
N N
N N
NH
SCF3
OHOH
OO
PO
OPP
OO
OCl
Cl
OO
O
S
4Na
+
Meadows TA, Bhatt DLCirc Res 2007;100:1261-75; Akers J Clin Pharmacol. 2010;50:27-35; Steinhubl Thromb Res. 2008;121:527-34.
COPYRIGHT
![Page 42: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/42.jpg)
HARVARD MEDICAL SCHOOL
COPYRIGHT
![Page 43: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/43.jpg)
HARVARD MEDICAL SCHOOL
Summary:WhattoDoforOralandIntravenousAntiplatelets
• ASA325mgorally,uncoated,chew-OK
• Clopidogrel 600mg,TicagrelorOKespifyouthinkwillnotneedCABG
• PrasugrelOKbutNO ifpriorTIA/Strokeandcautionage>75,weight<60kg
• ASA81mgadaywithticagrelor
• GPI:OKtowaitforcathlabbutstartiffailabove(recurrentchestpain,ECGchanges)
• Cangreloranoption incathlabforpatientswithunknownbleeding risk,inadequate
oralantiplatelet therapyorpossibility ofurgentCABGCOPYRIGHT
![Page 44: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/44.jpg)
HARVARD MEDICAL SCHOOL
Anticoagulantchoices
Unfractionated heparin
LMW Heparin
BivalirudinFondaparinux
COPYRIGHT
![Page 45: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/45.jpg)
HARVARD MEDICAL SCHOOL
SummaryAnticoagulants
• UnfractionatedHeparin– HITRisk,NeedtoTitrate,VariableResponse,plateletactivation,inferioroutcomes
• LMWH– Mainadvantage iseaseofadministration.
– Notcath labfriendly.
– Avoidifthinkgoing toCABG
– Avoidinrenal failure
• Fondaparinux– Goodformedical management esp.ifbleeding risk
– Notfavoredifinvasivemanagement selected
• Bivalirudin– Notaplatelet activator
– Lessbleeding andsimilar outcomeswhencompared toheparin pairedwithIVantiplatelets
COPYRIGHT
![Page 46: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/46.jpg)
HARVARD MEDICAL SCHOOL
GuidelineRecommendation:AccessSite
• Europeans
–RadialPreferredinexperiencedcenters
•Americans
–RadialanoptionCOPYRIGHT
![Page 47: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/47.jpg)
HARVARD MEDICAL SCHOOL
Rate Ratio 0.83; 95% CI, 0.73 to 0.96; p=0.0092
11.7%
9.8%
NNTB: 53FemoralRadial
Primary EP: NACE
COPYRIGHT
![Page 48: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/48.jpg)
HARVARD MEDICAL SCHOOL
Summary
• RiskstratifypatientswithUA/NSTEMI usingsimple clinical scores(TIMI,GRACE)
• Select forfurther invasivework-upthosewhoareatmoderateandhighriskfor
ischemic complications
• Catheterization shouldbeurgentbutnotemergent forhighriskindividuals
• Lowriskindividuals shouldhavenoninvasivework-upfirst
• Thinktwiceaboutoxygenandmorphine routinely
• Oralagentsmaynotbeonboardifinlabrapidly
• Radialpreferred
COPYRIGHT
![Page 49: COP Management of Unstable Angina/NSTEMI YRIGHT - primarycare.tips · HARVARD MEDICAL SCHOOL Rapid Rule Out •1320 Patients treated according to the algorithm –AMI was the final](https://reader030.vdocuments.us/reader030/viewer/2022040323/5e64cc5e0d935d1b324dc142/html5/thumbnails/49.jpg)
HARVARD MEDICAL SCHOOL
References:ESCandAmericanGuidelines
• RoffiM,etal.EurHeartJ2016;37:267–315.
• Amsterdam EA.Circulation 2014;130:2354–2394.
COPYRIGHT