UA/NSTEMI Guidelines Audio-Webcast: A Presentation

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UA/NSTEMI Guidelines Audio-Webcast A
Presentation Discussion of Treatment Essentials
Based on the ACC/AHA Guidelines for the
Management of Patients With Unstable
Angina/Non-ST-Elevation Myocardial Infarction A
Report of the ACC/AHA Task Force on Practice
Guidelines Writing Committee to Revise the 2002
Guidelines for the Management of Patients with
Unstable Angina/Non-ST-Elevation Myocardial
Infarction.
Presented by Jeffrey L. Anderson, MD, FACC,
Moderator Elliott M. Antman, MD, FACC Robert M.
Califf, MD, MACCA. Michael Lincoff, MD, FACC
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Disclosures Jeffrey L. Anderson, MD, FACC
AstraZeneca
Bristol-Myers Squibb
Merck Sanofi
ThromboVision
3
Disclosures Elliott M. Antman, MD, FACC
Accumetrics Inotek Pharmaceuticals Corp.
Amgen, Inc. Integrated Therapeutics Corp.
AstraZeneca Merck
Bayer Healthcare LLC Millennium
Biosite Novartis Pharmaceuticals
Boehringer Mannheim The National Institutes of Health
Beckman Coulter, Inc. Nuvelo, Inc.
Bristol-Myers Squibb Ortho-Clinical Diagnostics, Inc.
Centocor Pfizer, Inc.
CV Therapeutics Roche Diagnostics GmbH
Dade Sanofi-Aventis Research Institute
Dendrion Sanofi-Synthelabo Recherche
Eli Lilly Schering-Plough
Genentech Sunoz Molecular
GlaxoSmithKline The National Institutes of Health
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Disclosures Robert M. Califf, MD, MACC
Abbott Laboratories AstraZeneca Boston Scientific Corautus Genetics, Inc.
Abbott Vascular Devices Aventis Bracco Diagnostics Cordis
Acorn Cardiovascular Aviron Flu Mist Bristol-Myers Squibb Corgentech
Actelion Bayer AG CanAm Bioresearch, Inc. Covalent Group
Acushphere, Inc. Bayer Corp Cardiac Sciences, Inc. Critical Therapeutics, Inc.
Advanced CV Systems Berlex Cardiodynamics CryoVascular Systems, Inc.
Advanced Stent Tech Biocompatibles, Ltd CardioKinetix, Inc. CTS Durham
Agilent Technologies Biogen Caro Research Cubist Pharmaceuticals
Ajinomoto Bioheart Celsion Corp. CV Therapeutics, Inc.
Alexion Biomarin Centocor Dade Behring
Allergan Bionsense Webster, Inc. Chase Medical Daiichi
Alsius Biosite Chugai Biopharmaceuticals, Inc. Dupont
Amgen Biotronik Coley Pharma Group Dyax
Amylin Pharmaceuticals Biotechnology General Corp Conceptis Echosens, Inc.
Ark Therapeutics, Ltd. Boehringer Ingleheim Conor Medsystems, Inc. Eclipse Surgical Technologies
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Disclosures Robert M. Califf, MD, MACC
Edwards Lifesciences Genzyme Corporation Inhibitex Medco Health Solutions
Enzon Gilead INO Therapeutics Medicure
Ernst and Young GlaxoSmithKline Integris Medi-Flex, Inc.
Esai Guidant InterMune Pharmaceuticals Medimmune
Ev3, Inc. Guilford Pharmaceuticals ISIS Pharmaceuticals Medtronic
Evalve, Inc. Hemosol IOMED Medtronic Vascular, Inc.
First Circle Medical, Inc. Hewlett Packard Johnson Johnson Merck
First Horizon Human Genome Sciences Jomed, Inc. MicroMed Tech, Inc.
Flow Cardia, Inc. Humana KAI Pharmaceuticals Millenium Pharmaceutical
Fox Hollow Pharmaceuticals IDB Medical Kerberos Proximal, Inc. Mitsubishi
Fujisawa Idun Pharmaceuticals, Inc. King Pharmaceuticals Mycosol, Inc.
Genentech Immunex Kuhera Myogen
General Electric Healthcare Indenix Pharmaceuticals Lilly NABI
General Electric Medical Systems INFORMD, Inc. Lumen Biomedical NitroMed
Genome Canada InfraReDx MedAcoustics NITROX
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Disclosures Robert M. Califf, MD, MACC
NovaCardia, Inc. Regado Biosciences, Inc. Summit Vicuron Pharmaceutical
Novartis, AG Group Roche Diagnostic Corp Suneis Wyeth-Ayerst
Novartis Pharmaceutical Roche Holdings, Ltd. Synaptic XOMA
Organon International Roche Labs Synthetic Blood International Xsira Pharmaceutical
Ortho Biotech Salix Pharmaceuticals Terumo Corp XTL Biopharmaceuticals
Osiris Therapeutics, Inc. Sanofi Pasteur The Medicines Company Xylum
Otsuka America Pharmaceutical, Inc. Sanofi-Aventis Theravance Yamanouchi
Pathway Medical Tech Sanofi-Synthelabo TherOx, Inc.
Pfizer Schering-Plough Titan Pharmaceuticals, Inc.
Pharmacia/Upjohn Scios Valeant Pharmaceuticals
Pharmanetics, Inc. Searle Valentis, Inc.
Pharsight Sicel Technologies Velocimed
Proctor and Gamble Siemens Veridex
Prometheus SmithKlineBeecham Vertex Pharmaceuticals
Recom Managed Systems Spectranetics VIASYS Healthcare, Inc.
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Disclosures A. Michael Lincoff, MD, FACC
Alexion Pharm Medtronic
Amer Bioscience Novartis
AstraZeneca Pfizer
Atherogenics Pharmacia Upjohn
Biosite Philips
Centocor Orphan Therapeutic
Converge Medical Sankyo
Cordis Sanofi
Dr. Reddys Laboratory Scios
Eli Lilly Takeda America
GlaxoSmithKline The Medicines Company
Glaxo Wellcome Vasogenix
Guilford


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Evolution of Guidelines for ACS
1990
1992
1994
1996
1998
2000
2002
2004
2007
1990ACC/AHAAMI R. Gunnar
1994AHCPR/NHLBIUA E. Braunwald
1996 1999 Rev
Upd ACC/AHA AMI T. Ryan
2000 2002
2007
Rev Upd
Rev ACC/AHA UA/NSTEMI E.
Braunwald J. Anderson
Figure 1. Evolution of Guidelines for Management
of Patients with AMI The first guideline
published by the ACC/AHA described the management
of patients with acute myocardial infarction
(AMI). The subsequent three documents were the
Agency for Healthcare and Quality/National Heart,
Lung and Blood Institute sponsored guideline on
management of unstable angina (UA), the
revised/updated ACC/AHA guideline on AMI, and the
revised/updated ACC/AHA guideline on unstable
angina/non-ST segment myocardial infarction
(UA/NSTEMI). The present guideline is a revision
and deals strictly with the management of
patients presenting with ST segment elevation
myocardial infarction (STEMI). The names of the
chairs of the writing committees for each of the
guidelines are shown at the bottom of each box.
Rev, Revised Upd, Update
2004 2007 Rev
Upd ACC/AHA STEMI E. Antman
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Hospitalizations in the U.S. Due to Acute
Coronary Syndromes (ACS)
Acute Coronary Syndromes
1.57 Million Hospital Admissions - ACS
UA/NSTEMI
STEMI
1.24 million Admissions per year
.33 million Admissions per year
Heart Disease and Stroke Statistics 2007
Update. Circulation 2007 11569-171. Primary
and secondary diagnoses. About 0.57 million
NSTEMI and 0.67 million UA.
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Risk Stratification
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Risk Stratification

• Integral prerequisite to decision making
• Intensive initial assessment
• Continuous clinical assessment
• Targeted ECG and marker data
• Risk based on contingent probabilities
• Probability of obstructive CAD causing ischemia
• Risk given presence of obstructive CAD
• Risk scores should be a routine part of
  assessment throughout the hospital course and
  periodically after discharge

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Risk Assessment Dependent on Contingent
Probabilities

• Likelihood of obstructive CAD as cause of
  symptoms
• Dominated by acute findings
• Exam
• Symptoms
• Markers
• Traditional risk factors are of limited utility
• Does this patient have symptoms due to acute
  ischemia from obstructive CAD?

• Risk of bad outcome
• Dominated by acute findings
• Older age very important
• Hemodynamic abnormalities critical
• ECG, markers
• What is the likelihood of death, MI, heart
  failure?

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Physiological monitoring
Periodic physical exams
Cardiac markers
ECG
Risk
24h
3-4 days
6 months
Time
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Risk Scores
TIMI GRACE Future
History Age Hypertension Diabetes Smoking ?cholesterol Family history History of CAD Age Continuous assessment
Presentation Severe angina Aspirin within 7 days Elevated markers ST segment deviation Heart rate Systolic BP Elevated markers Heart failure Cardiac arrest Elevated markers ST segment deviation New markers Electronic health records
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Early Hospital Care
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Algorithm for Patients with UA/NSTEMI Managed by
an Initial Invasive Strategy
Diagnosis of UA/NSTEMI is Likely or Definite
ASA (Class I, LOE A) Clopidogrel if ASA
intolerant (Class I, LOE A)
A
Proceed with an Initial Conservative Strategy
Select Management Strategy
B
Invasive Strategy Initiate A/C Rx (Class I, LOE
A) Acceptable options enoxaparin or UFH (Class
I, LOE A) bivalirudin or fondaparinux (Class
I, LOE B)
B1
Prior to Angiography Initiate at least one (Class
I, LOE A) or both (Class IIa, LOE B) of the
following Clopidogrel IV GP IIb/IIIa inhibitor
B2
Factors favoring admin of both clopidogrel and GP
IIb/IIIa inhibitor include Delay to
Angiography High Risk Features Early recurrent
ischemic discomfort
Proceed to Diagnostic Angiography
Anderson JL. J Am Coll Cardiol 200750e1-157.
Figure 7
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Algorithm for Patients with UA/NSTEMI Managed by
an Initial Conservative Strategy
Diagnosis of UA/NSTEMI is Likely or Definite
ASA (Class I, LOE A) Clopidogrel if ASA
intolerant (Class I, LOE A)
A
Proceed with Invasive Strategy
Select Management Strategy
Conservative Strategy Initiate A/C Rx (Class I,
LOE A) Acceptable options enoxaparin or UFH
(Class I, LOE A) or fondaparinux (Class I, LOE
B), but enoxaparin or fondaparinux are preferable
(Class IIA, LOE B)
C1
Initiate clopidogrel (Class I, LOE A) Consider
adding IV eptifibatide or tirofiban (Class IIb,
LOE B)
C2
(Continued)
Anderson JL. J Am Coll Cardiol 200750e1-157.
Figure 8
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Algorithm for Patients with UA/NSTEMI Managed by
an Initial Conservative Strategy
(Continued)
Any subsequent events necessitating angiography?
D
Yes
No
(Class I, LOE B)
L
Evaluate LVEF
M
(Class I, LOE B)
(Class IIa, LOE B)
N
EF 0.40 or less
O
EF greater than 0.40
Stress Test
(Class IIa, LOE B)
E-1
E-2
Proceed to Dx Angiography
Low Risk
Not Low Risk
(Class I, LOE A)
(Class I, LOE A)
K
Cont ASA indefinitely (Class I, LOE A) Cont
clopidogrel for at least one month (Class I, LOE
A) and ideally up to 1 yr (Class I, LOE B) DC IV
GP IIb/IIIa if started previously (Class I, LOE
A) DC A/C Rx (Class I, LOE A)
Anderson JL. J Am Coll Cardiol 200750e1-157.
Figure 8
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Revascularization and Late Hospital Care
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Management after Diagnostic Angiography in
Patients with UA/NSTEMI
Dx Angiography
F
Select Post Angiography Management Strategy
CABG
PCI
Medical therapy
G
CAD on angiography
H
No significant obstructive CAD on angiography

• Cont ASA (Class I, LOE A)
• DC clopidogrel 5 to 7 d prior to elective CABG
  (Class I, LOE B)
• DC IV GP IIb/IIIa 4 h prior to CABG (Class I,
  LOE B)
• Cont UFH (Class I, LOE B) DC enoxaparin 12 to
  24 h prior to CABG DC fondaparinux 24 h prior to
  CABG DC bivalirudin 3 h prior to CABG. Dose with
  UFH per institutional practice (Class I, LOE B)

• Cont ASA (Class I, LOE A)
• LD of clopidogrel if not given pre angio (Class
  I, LOE A)
• IV GP IIb/IIIa if not started pre angio (Class I,
  LOE A)
• DC A/C Rx after PCI for uncomplicated cases
  (Class I, LOE B)

J

• Cont ASA (Class I, LOE A)
• LD of clopidogrel if not given pre angio (Class
  I, LOE A)
• DC IV GP IIb/IIIa after at least 12 h if started
  pre angio (Class I, LOE B)
• Cont IV UFH for at least 48 h (Class I, LOE A)
  or enoxaparin or fondaparinux for dur of hosp
  (LOE A) either DC bivalirudin or cont at a dose
  of 0.25 mg/kg/hr for up to 72 h at physicians
  discretion (Class I, LOE B)

I
Antiplatelet and A/C Rx at physicians
discretion (Class I, LOE C)
Anderson JL. J Am Coll Cardiol 200750e1-157. In
press. Figure 9
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Long-Term Antithrombotic Therapy at Hospital
Discharge after UA/NSTEMI
UA/NSTEMI Patient Groups at Discharge
Medical Tx w/o Stent
Bare Metal Stent
Drug Eluting Stent
ASA 162 to 325 mg/d for at least 3 to 6 months,
then 75 to 162 mg/d indefinitely (Class I LOE
A) Clopidogrel 75 mg/d for at least 1 yr (Class
I LOE B)
ASA 162 to 325 mg/d for at least 1 mo, then 75
to 162 mg/d indefinitely (Class I LOE A)
Clopidogrel 75 mg/d for at least 1 mo and up
to 1 yr (Class I LOEB)
ASA 75 to 162 mg/d indefinitely (Class I LOE A)
Clopidogrel 75 mg/d at least 1 mo (Class I
LOE A) and up to 1 yr (Class I LOE B)
Indication for Anticoagulation?
Yes
No
Add Warfarin (INR 2.0 to 2.5) (Class IIb LOE B)
Continue with dual antiplatelet tx as above.
Anderson JL. J Am Coll Cardiol 200750e1-157.
Figure 11.
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Preparation for Discharge After UA/NSTEMI

• Antiplatelet Rx
• ASA 75 - 162 mg/day
• Clopidogrel 75 mg/day
• Beta Blocker
• ACEI / ARB
• Especially if DM, HF, EF lt40, HTN
• Statin
• LDL lt100 mg/dL (ideally lt70 mg/dL)
• Secondary Prevention Measures
• Smoking Cessation
• BP lt140/90 mm HG or lt130/80 mm HG for DM or
  chronic kidney disease
• HbA1C lt7
• BMI 18.5-24.9
• Physical Exercise 30-60 min at least 5 days/wk

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Panel Discussion