Optimal Management ofACS

Invasive vs Conservative StrategyLayth 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 ACSUnfractionated Heparin Cohort TIMI 11B (n=1957)

Age > 65 years> 3 CAD risk factorsPrior CAD Stenosis > 50%ST segment changes on presentation> 2 anginal events in last 24 HrsASA use < 7years Increased serum cardiac markers

FRISC Score

Age>70 yearsDiabetes MellitusPrevious MIAngina > 30 daysST depressionElevated TroponinElevated FibrinogenElevated 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 diseaseResults not necessarily applicable

to females

Conservative X Invasive Trials in ACS

Conservative X Invasive Trials in ACS

Conservative X Invasive Trials in ACS

MIDeath or MIMI Death or MI