the new sign guidelines malcolm metcalfe aberdeen royal infirmary
TRANSCRIPT
SIGN 93 - ACSPrinciple recommendations
• Patients with NSTEMI at medium or high risk of early recurrent cardiovascular events should undergo early coronary angiography +/- intervention.– GRACE score rather than TIMI recommended
• Patients with STEMI treated with thrombolysis should be considered for coronary angiography +/- intervention– 4 RCTs. Eg GRACIA -1, at 1 year 12% ARR, 56%RRR
combined end point.
GRACE scorewww.outcomes-umassmed.org/grace
The in-hospital GRACE model was based upon data from 11,389 patients with either an STEMIor a non-ST elevation ACS (1). This model was then validated based upon data from anadditional 3972 patients from GRACE and 12,142 patients from the GUSTO I Ib trial. Eightindependent risk factors were found to account foralmost 90 percent of the prognostic information:
Age
Killip class
Systolic blood pressure
Presence of ST segment deviation
Cardiac arrest during presentation
Serum creatinine concentration
Presence of elevated serum cardiac biomarkers
Heart rate
Point scores were assigned for each predictive factor and are added together to arrive at an estimate of the risk of in-hospital mortality.
Killip class
Class I - no evidence of HF
Class I I - findings consistent with mild to moderateHF (S3, lung rales less than one- half way up theposterior lung fields, or jugular venous distension)
Class I I I - overt pulmonary edema
Class IV - cardiogenic shock
Pharmacological highlights
• Clopidogrel in NSTEMI for only 3 months (saves £2M)
• All patients with established vascular disease should be on ACEI
• Patients with MI, LVD (LVEF <40%) with either heart failure or diabetes should be given eplerenone
SIGN 94 - Arrhythmias
• Defibrillation in patients with VF or pulseless VT should be administered without delay in witnessed cardiac arrests and following 2 minutes of CPR in unwitnessed cardiac arrests [B].
• Automated external defibrillators should be sited in locations which have a high probability of cardiac arrests [B].
• IV amiodarone should be considered for the management of refractory VT/VF [A]
SIGN 94 - Arrhythmias
• In AF rate control is the recommended strategy for asymptomatic patients [A]
• Ventricular rate in AF should be controlled with B blockers, rate-limiting Ca antagonists or digoxin [A].
• Ablation and pacing should be considered for patients with AF who remain severely symptomatic or who have LV dysfunction in association with poor rate
control or intolerance of rate-limiting medication [B].
SIGN 94 - Arrhythmias
• Patients 1 month after MI with symptomatic LV dysfunction (<35%) should be considered for ICD [A].
• Patients with NSVT (esp if inducible), LVEF < 25% or prolonged QRS should be offered ICD [B]
• Patients with above but also NYHA III-IV and QRS >120 should be considered for CRT-D [A]
• Patients surviving cardiac arrest in absence of ischaemia or other treatable cause should be considered for ICD [A]
SIGN 95Management of CHF
• BNP and/or ECG should be used to indicate the necessity for echocardiography in patients with suspected heart failure [A].
• A CXR is still recommended early in the diagnostic pathway to investigate other potential causes of SOB [B].
Pharmacology
• ACEIs recommended for all grades of LVSD [A]• B Blockers recommended for all stable LVSD patients
[A]• Patients intolerant of ACEI should be given ARB [A]• Patients with LVSD who are still symptomatic despite
above can be considered for an ARB as additional therapy [B]
• Digoxin should be considered as add on therapy [B]
Devices
• For patients in SR with drug refractory symptoms due to LVSD and who are in NYHA III or IV with a QRS duration >120ms - CRT should be considered [A].
• Caveats– benefit may be greatest for NYHA II-III– RBBB does not appear to benefit
Mean Follow-up 36.4 months (range 26.1 to 52.6)
CRT Deaths = 101 (24.7%) (cross-over 4.6%)
Medical Therapy Deaths = 154 (38.1%) (cross-over 23.5%)
CARE-HF Extension StudyEffect of CRT on All-Cause
Mortality
409 383 358 338 209 85404 372 331 298 178 63
CRTMedical therapy
Number at risk 96
CRT
MedicalTherapy
0 400 16000.00
0.25
0.50
0.75
1.00S
urvi
val
Time (days)800 1200
Hazard Ratio 0.60 (95% CI 0.47 to 0.77; P<0.0001)
Also 52% reduction in the rate of hospitalisation
for worsening heart failure
CARE-HF Extension StudyTime to Sudden Cardiac Death
CRT
MedicalTherapy
0 16000.00
0.25
0.50
0.75
1.00
Sur
viva
l
Time (days)400 800 1200
Medical = 54 sudden deaths (13.4%)
CRT = 32 sudden deaths (7.8%)
Absolute difference = 22 (5.6%)Mean Follow-up 36.4 months (range 26.1 to 52.6)
HR 0.54 (95% CI 0.35 to 0.84)
P=0.006
You Don't Need an ICD
to Reduce the Risk of SCD
SIGN 96 - Stable angina
• B blockers first choice [A]• Rate-limiting Ca antgonists 2nd choice [A]• All patients should receive statin and aspirin• LMS - CABG [A]• 3VD - CABG preferred [A]• Other disease either PCI or CABG [A]• B Blockers are recommended in high-risk
patients with cad undergoing non-cardiac surgery [A]
RISK FACTORS(SIGN 97 RISK ESTIMATION & PREVENTION
OF CORONARY DISEASE)
• Change in emphasis to embrace social deprivation (ASSIGN)– classical risk factors– FH if <60 years– SIMD (by postcode)
• Calculation will be via computer desktop and value expressed as continuous variable.
RISK FACTOR MANGEMENT
– age– sex– smoking status– BP– DM– waist/Hip ratio– dietary pattern– physical activity– alcohol consumption– lipid levels– psychosocial factors (“stress”)
Framingham factors underestimate risk in high risk individuals (eg social deprivation)
PREDICTED AND OBSERVED HEART DEATHS IN RENFREW PAISLEY (MIDSPAN)
0
5
10
15
20
25
1 2 3 4 5
Quintiles of Framingham risk
CV
D m
ort
alit
y % Observed
Predicted
Is it feasible, will it do any good?
• Whilst good evidence that deprivation score is proportional to risk little evidence that targeting it will gain advantage (level D evidence)
• Makes things more complex
• Expensive– statins £43M, better BP control £2.8M
TREATMENT THRESHOLD
• Individuals should be considered to be at high risk if the chance of an initial major vascular event is >20% over 10 years.
Absolute Reduction in LDL-Cholesterol (mmol/l) and Absolute Reduction in Risk of
Major Cardiac Event (MCE)
4S
A TO Z
AF/Tex-CAPSASCOT
CARDS
GREACEHPS
LIPID
LIPS
LRC-CPPTMIRACL
PROVE-IT
Post-CABG
WOSCOPS
.
.
.
CARE
PROSPER
Intervention/SecondaryIntervention/Primary
Intervention/Both
Control/SecondaryControl/Primary
Control/Both
0%10
%20
%30
%M
ajor
Car
diac
Eve
nt (
%)
1 2 3 4 5LDL-Cholesterol (mmol/l) Adapted from Joint British
Societies’ Guidelines1
STATIN EXPENSE
• The more aggressive the policy the more expensive the treatment.
• Benefits unclear.• Recommendation therefore to keep to
existing standards of achieving TC <5mmol/l (LDL <3) This however is the minimum standard and for certain high risk patients a more aggressive policy may be appropriate
ASPIRIN
• Despite widespread belief of benefit still controversial.– no dispute re secondary prevention– more complex for primary prevention
• reduces MI by 30% in males, 0% in females• increases haemorrhagic CVA by 40%• increases gi bleeding by 70%• generally no overall benefit
• however when cvs risk >15% may be of net benefit.
• Consider use for high risk individuals
ACEIs for patients with vascular disease but not LV systolic dysfunction
• Good evidence for benefit in higher risk patients (level A)– PVD– CVD– Diabetes
• No evidence of significant benefit for low-risk individuals