ventricular tachycardia Ppt Powerpoint Presentation slides-Medical Slideshow Tachycardia Ventricular Tachycardia, Supraventricular Tachycardia .

ventricular tachycardia

Rating :

Rate It:

Send This

Download

Comment

Favourite

more

Notes

Show Notes

Slide 1 :

Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS) From the Committee on Post-Graduate Education, Council on Clinical Cardiology, American Heart Association Date Posted: July, 2004.

Slide 2 :

Non-ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS) Pathophysiology, Epidemiology, Risk Stratification, Evaluation, and ManagementSlides compiled and annotated by Glenn N. Levine, MD, with thanks to many, particularly Christopher P. Cannon, MD. The content of these slides is current as of July 2004 Future revisions will be posted on the American Heart Association website (www.americanheart.org)

Slide 3 :

Non-ST-Segment Elevation Acute Coronary Syndrome Pathology, Pathophysiology, and Epidemiology Risk and Risk Stratification Initial Therapies and Management Platelets and Anti-Platelet Therapies Anti-Thrombin Studies and Recommendations Early Invasive Strategy Peri- and Post-Discharge Medications and Management

Slide 4 :

Pathology, Pathophysiology, and Epidemiology

Slide 5 :

The Vulnerable Plaque Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671. Large Lipid Core Thin, Vulnerable, Fibrous Cap

Slide 6 :

Ruptured Plaque with Occlusive Thrombus Formation Reproduced with permission from Falk E, et al. Circulation. 1998;92:657-671. Thrombus Formation

Slide 7 :

Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque Adapted with permission from Falk E, et al. Circulation. 1998;92:657-671. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 8 :

Characteristics of Unstable and Stable Plaque Thin fibrous cap Inflammatory cells FewSMCs Erodedendothelium Activatedmacrophages Thickfibrous cap Lack ofinflammatory cells Foam cells Intactendothelium MoreSMCs Adapted with permission from Libby P. Circulation. 1995;91:2844-2850. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. Unstable Stable

Slide 9 :

The Stable and Unstable Plaque Reproduced with permission from Yeghiazarians Y, Braunstein JB, Askari A, et al. Unstable angina pectoris. N Engl J Med. 2000;342:101-114.Copyright © 2000, Massachusetts Medical Society. All rights reserved.

Slide 10 :

ACS PathophysiologyPlaque Rupture, Thrombosis, and Microembolization Quiescent plaque Platelet-thrombin micro-emboli Plaque rupture Process Plaque formation InflammationMultiple factors ? Infection Plaque Rupture ? Macrophages Metalloproteinases ThrombosisPlatelet ActivationThrombin Marker CholesterolLDL C-Reactive ProteinAdhesion Molecules Interleukin 6, TNFa, sCD-40 ligand MDA Modified LDL D-dimer, Complement, Fibrinogen, Troponin, CRP, CD40L Vulnerable plaque Macrophages Foam Cells Collagen ? platelet activation TF ? Clotting Cascade Lipid core Metalloproteinases Inflammation Courtesy of David Kandzari.

Slide 11 :

Systemic and Focal Plaque Rupture by IVUS in ACS Patients Undergoing PCI Adapted from Rioufol G, et al. Circulation. 2002;106:804-808. Slide courtesy of David Kandzari. Plaque rupture at site of culprit lesion Plaque rupture elsewhere than site of culprit lesion Plaque rupture in different artery than culprit lesion % % % Analysis of 72 Arteries (n=24 TnI-positive ACS Patients) % Plaque rupture

Slide 12 :

Frequency of multiple active plaque ruptures beyond the culprit lesion. Patients (%) 80% of Patients With ?2 Plaques 0 5 10 15 20 25 30 0 1 2 3 4 5 N=24 Frequency of Multiple “Active” Plaques in Patients With ACS ACS indicates acute coronary syndrome. Adapted from Rioufol G, et al. Circulation. 2002;106:804-808. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 13 :

Slide 14 :

Atherothrombosis* is theLeading Cause of Death Worldwide1 *Atherothrombosis defined as ischemic heart disease and cerebrovascular disease. 1The World Health Report 2001. Geneva: WHO; 2001. Reprod.with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. 22.3 19.3 12.6 9.7 9 6.3 0 5 10 15 20 25 30 Atherothrombosis* Infectious Disease Cancer Injuries Pulmonary Disease AIDS Causes of Mortality (%)

Slide 15 :

3.2 Million Hospital Admissions Coronary Atherosclerosis Acute Myocardial Infarction 1,153,000 Admissions 829,000 Admissions Hospitalizations in the USDue to Atherosclerotic Disease Cerebrovascular Disease 961,000 Admissions Vascular Disease Other IschemicHeart Disease 280,000 Admissions From Popovic JR, Hall MJ. Advance Data. 2001;319:1-20. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 16 :

* Based on data from the ARIC study of the National Heart, Lung, and Blood Institute, 1987-1994. Includes Americans hospitalized with definite or probable MI or fatal CHD, not including silent MIs. ACS indicates acute coronary syndrome; MI, myocardial infarction; ARIC, Atherosclerotic Risk in Communities; and CHD, coronary heart disease. From American Heart Association. Heart Disease and Stroke Statistics—2003 Update. Epidemiology of ACS in the United States Single largest cause of death 515,204 US deaths in 2000 1 in every 5 US deaths Incidence 1,100,000 Americans will have a new or recurrent coronary attack each year and about 45% will die* 550,000 new cases of angina per year Prevalence 12,900,000 with a history of MI, angina, or both Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 17 :

Risk and Risk Stratification

Slide 18 :

GUSTO IIb: Correlation of 6-Month Mortality With Baseline ECG Findings in Patients With ACS GUSTO indicates Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes; ECG, electrocardiogram; ACS, acute coronary syndrome; and STEMI, ST-segment elevation myocardial infarction.Figure adapted with permission from Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:707-713. Copyright © 1999, American Medical Association. All rights reserved. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 19 :

Braunwald Classification of Risk for Patients with Unstable Angina Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 20 :

TIMI Risk Score Age >65 years >3 CAD Risk Factors Prior Coronary Stenosis >50 % ST deviation >2 Anginal events <24 hours ASA in last 7 days Elevated Cardiac Markers (CK-MB or troponin) Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835-842. Copyright © 2000, American Medical Association. All rights reserved.

Slide 21 :

The TIMI Risk Score and Incidence of Adverse Ischemic Events in Patients with NSTE-ACS Reproduced with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA.. 2000;284:835-842. Copyright © 2000, American Medical Association. All rights reserved. 4.7 8.3 13.2 19.9 26.2 40.9 0 10 20 30 40 50 0/1 2 3 4 5 6/7 Number of Risk Factors Death, MI, or Urgent Revascularization (%)

Slide 22 :

Troponin I Levels and Mortality in Patients with NSTE-ACS 0 2 4 6 8 0- <0.4 0.4- <1.0 1.0- <2.0 2.0- <5.0 5.0- <9.0 >9.0 % Mortality at 42 Days Adapted with permission from Antman EA, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996;335:1342-1349. Copyright © 1996, Massachusetts Medical Society. All rights reserved. Troponin I Level

Slide 23 :

Prognostic Value of Troponin T or I in ACS: A Meta-Analysis 1.9 6.7 6.4 20.8 0 5 10 15 20 25 Death Death/MI % RR 3.9(2.9-5.3) RR 3.8(2.6-5.5) Figure reproduced with permission from Heidenreich PA, Alloggiamento T, Melsop K, et al. The prognostic value of troponin in patients with non-ST elevation acute coronary syndrome: a meta-analysis. J Am Coll Cardiol. 2001;38:478-485. Slide modified with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 24 :

B-type Natriuretic Peptide (BNP) and Mortality in ACS Patients Figure reproduced with permission from de Lemos JA, Morrow DA, Bentley JH, et al. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndrome. N Engl J Med. 2001;345:1014-1021.Copyright © 2001, Massachusetts Medical Society. All rights reserved. Slide modified with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. 0 2 4 6 8 10 Mortality (%) 0 50 100 150 200 250 300 Days After Randomization P<.001 Quartile 4(n=630) Quartile 3(n=632) Quartile 2(n=632) Quartile 1(n=631)

Slide 25 :

Figure reproduced with permission from Lindahl B, Toss H, Siegbahn A, et al. Markers of myocardial damage and inflammation in relation to long-term mortality in unstable coronary artery disease. FRISC Study Group. Fragmin during Instability in Coronary Artery Disease. N Engl J Med. 2000;343:1139-1147. Copyright © 2000, Massachusetts Medical Society. All rights reserved. Slide modified with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. Predictive Value of hs-CRP for Mortality from ACS in FRISC Substudy Cumulative Probability of Death (%) Months CRP 2-10mg/l (n=294) 20 10 0 0 6 12 18 24 30 36 42 48 CRP >10mg/l (n=309) CRP <2mg/l (n=314)

Slide 26 :

Initial Therapies and Management

Slide 27 :

ACC/AHA Class I Recommendations for Initial Management and Anti-Ischemic Therapy Bed rest Continuous ECG Monitoring Supplemental O2 to maintain SaO2 >90% NTG (IV or PO as dictated clinically) Beta-blockers (PO and/or IV) IV Morphine prn pain, anxiety, and/or CHF IABP for hemodynamic instability ACEI for persistent hypertension in patients with LV systolic dysfunction or CHF Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 28 :

Platelets and Anti-Platelet Therapies

Slide 29 :

Pathogenesis of Acute Coronary Syndromes:The integral role of platelets Plaque Fissure or Rupture Platelet Aggregation Platelet Activation Platelet Adhesion Thrombotic Occlusion

Slide 30 :

Adhesion The Role of Platelets in Atherothrombosis Aggregation 3 Reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. 1 Activation 2

Slide 31 :

Ticlopidine Clopidogrel Heparin LMW Heparin Direct Thrombin Inhibitors Aspirin IIb/IIIa receptors fibrin The Platelet GP IIb/IIIa inhibitors

Slide 32 :

Platelet Inhibition With GP IIb/IIIa Inhibitors Reproduced with permission from Yeghiazarians Y, Braunstein JB, Askari A, et al. Unstable angina pectoris. N Engl J Med. 2000;342:101-114. Copyright © 2000, Massachusetts Medical Society. All rights reserved.

Slide 33 :

placebo aspirin heparin ASA+hep 0 2 4 6 8 10 12 % Developing MI Treatment Treatment of Unstable Angina Results of a study from the Montreal Heart Institute Data from Theroux P, Quimet H, McCans J, et al. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med. 1988;319:1105-1111.

Slide 34 :

Reproduced with permission from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502. Copyright © 2001, Massachusetts Medical Society. All rights reserved. 2 4 6 8 10 12 14 % With Event Clopidogrel + Aspirin 3 6 9 Placebo + Aspirin Follow-up (months) P=.00009 0 12 20% RRR The Primary Composite End Point in the CURE Trial

Slide 35 :

CURE Bleeding Complications Data from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.

Slide 36 :

CURE: Primary End Point in Subgroups Data from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.

Slide 37 :

CURE Secondary End Points Data from Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502.

Slide 38 :

2 Days 7 Days 30 Days RR=43% P=0.006 8.3 4.9 RR=30% P=0.03 11.9 8.7 % Patients RR=66% P=0.01 2.6 0.9 PRISM-PLUS: MI/Death Event Rates Data from PRISM-PLUS Study Investigators. N Engl J Med. 1998;338:1488-1497.

Slide 39 :

PURSUIT Primary End Point Reproduced with permission from the PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998;339:436-443. Copyright © 1998, Massachusetts Medical Society. All rights reserved.

Slide 40 :

PURSUIT Primary Composite End Point % With Death or MI 0 2 4 6 8 10 12 14 16 Integrilin 9.1% 7.6% 11.6% 10.1% 15.7% 14.2% (n=79) (n=66) (n=118) (n=103) Not powered for statistical analysis 96 Hrs 7 Days 30 Days Placebo Reproduced with permission from the PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998;339:436-443. Copyright © 1998, Massachusetts Medical Society. All rights reserved. P=0.01 P=0.02 P=0.04

Slide 41 :

Subgroup Analyses from the PURSUIT Study Reproduced with permission from the PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. Platelet glycoprotein IIb/IIIa in unstable angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998;339:436-443. Copyright © 1998, Massachusetts Medical Society. All rights reserved.

Slide 42 :

Meta-Analysis of IV GP IIb/IIIa Inhibitors in NSTE-ACS: Death or MI at 30 Days PRISM 7.1% 5.8%* 0.80 0.60-1.06 PRISM-PLUS 12.0% 8.7% 0.70 0.50-0.98 13.6%* 1.17 0.80-1.70 PARAGON-A 11.7% 10.3% 0.87 0.58-1.29 12.3% 1.06 0.72-1.55 PURSUIT 15.7% 13.4% 0.83 0.70-0.99 14.2% 0.89 0.79-1.00 PARAGON-B 11.4% 10.6% 0.92 0.77-1.09 GUSTO-IV 8.0% (24h) 8.2% 1.02 0.83-1.24 (48h) 9.1% 1.15 0.94-1.39 Overall 11.8% 10.8%t 0.91 0.85-0.98 Odds Ratio Placebo IV Gp IIb/IIIa 95% CI Placebo Better Gp IIb/IIIa Better 0 1.0 2.0 Study P=.015 * Without heparin. † With/without heparin. (l), Low dose; (h), High-dose. Adapted with permission from Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndrome: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-198. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 43 :

GP IIb/IIIa Inhibitor NSTE-ACS Studies Analysis Risk-Adjusted Mortality at 30 Days Data from (1) Peterson ED, Pollack CV Jr, Roe MT, et al. Early use of glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute myocardial infarction: observations from the National Registry of Myocardial Infarction 4. J Am Coll Cardiol. 2003;42:45-53 and (2) Boersma E, Harrington RA, Moliterno DJ, et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndrome: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-198. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. 0.5 2.0 1.0 NRMI1 Boersma2 0.83-1.01 0.91 0.79-0.97 0.88 95% CI Odds Ratio Odds Ratio for Mortality at 30 Days GP IIb/IIIa Inhibitor Favored (aspirin + heparin) Control Arm Favored (aspirin + heparin)

Slide 44 :

GP IIb/IIIa Therapy and Mortality (30 day) in Diabetics with NSTE-ACS 0.5 1.0 1.5 2.0 0 PARAGON A PARAGON B Pooled Relative Risk of Death (versus placebo Rx) GUSTO IV PRISM-PLUS PRISM PURSUIT Mortality: 6.2% vs. 4.6% OR=0.74 CI=0.59-0.92 P=0.007 Adapted with permission from Roffi M, et al. Circulation. 2001;104:2767-2771.

Slide 45 :

GP IIb/IIIa Dosing and Administration for Up-Front Therapy in Patients with NSTE-ACS Dosing: Integrilin: 180 mcg/kg bolus (over 1-2 min), then 2 mcg/kg/min continuous infusion Aggrastat: Initial 0.4 mcg/kg/min for 30 min, then continuous infusion at 0.1 mcg/kg/min Always also treat with ASA and some form of heparin (UFH or LMWH) Patients most commonly treated 2-4 days Follow platelet count qD and D/C for significant fall Adjust doses for renal insufficiency: Integrilin: For creatinine 2-4 mg/dL, decrease infusion to 1 mcg/kg/min; avoid if creatinine >4 mg/dL Aggrastat: For CrCl < 30 mL/min, cut all doses in 1/2

Slide 46 :

ACC/AHA Recommendations for Antiplatelet Therapy in Patients with NSTE-ACS Class I ASA Clopidogrel if ASA-allergic or intolerant Clopidogrel in addition to ASA if early invasive approach not planned Clopidogrel should be withheld for 5-7 days if CABG planned GP IIb/IIIa inhibitor if cardiac cath and PCI planned Class IIa GP IIb/IIIa inhibitor in patients with high-risk features if invasive strategy not planned GP IIb/IIIa inhibitor in patients receiving clopidogrel if cardiac cath and PCI planned Class IIb GP IIb/IIIa inhibitor in patients without high-risk features and PCI not planned Class III Abciximab in patients in whom PCI is not planned Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 47 :

Contraindications to GP IIb/IIIa Rx Active or recent bleeding (4-6 weeks) Severe hypertension (SBP >180-200 mm Hg; DBP >110 mm Hg) Any hemorrhagic CVA (+/- intracranial neoplasm, AVM, or aneurysm) Any CVA within 30 days–2 years Major surgery or trauma within 4-6 weeks Thrombocytopenia ( <100,000/mm3 ) Bleeding diathesis/warfarin with elevated INR (Doses must be avoided with renal insufficiency or failure)

Slide 48 :

Antithrombin Therapy Studies and Recommendations

Slide 49 :

RR: Death/MI ASA Alone 68/655=10.4% Heparin + ASA 55/698=7.9% 0.1 1 10 Summary Relative Risk 0.67 (0.44-0.1.02) Theroux RISC Cohen 1990 ATACS Holdright Gurfinkel Comparison of Heparin + ASA vs ASA Alone ASA indicates acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic Therapy in Acute Company Syndromes; RR, relative risk; and MI, myocardial infarction. Data from Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: a meta-analysis. JAMA. 1996;276:811-815. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 50 :

ESSENCE Results 30% 25% 20% 15% 10% 0 9 13 Days After Randomization 17 21 5 5% 25 29 Unfractionated Heparin Enoxaparin (Lovenox) Death, MI or Recurrent Angina P = 0.02 Risk Reduction 16.2% Adapted with permission from Cohen M, Demers C, Gurfinkel EP, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med. 1997;337:447-452. Copyright © 1997, Massachusetts Medical Society. All rights reserved.

Slide :

Slide 52 :

Guidelines for the Use of Enoxaparin in Patients with NSTE-ACS 1 mg/kg SQ q12 hours (actual body weight) An initial 30 mg IV dose can be considered Adjust dosing if CrCl <30 cc/min 1 mg/kg SQ q24 hours Do not follow PTT; do not adjust based on PTT Stop if platelets ? by 50% or below 100,000/mm3 If patient to undergo PCI: 0-8 hours since last SQ dose: no additional antithrombin therapy 8-12 hours since last SQ dose: 0.3 mg/kg IV immediately prior to PCI

Slide 53 :

ACC/AHA Recommendations for Antithrombin Therapy in Patients with NSTE-ACS Class I Anticoagulation with subcutaneous LMWH or intravenous UFH should be added to antiplatelet therapy Dose of UFH 60-70 U/kg (max 5000) IV followed by infusion of 12-15 U/kg/hr (initial max 1000 U/hr) titrated to aPTT 1.5-2.5 times control Dose of enoxaparin 1 mg/kg subcutaneously q12 hr; the first dose may be preceded by a 30-mg IV bolus Class IIa Enoxaparin is preferable to UFH as an anticoagulant unless CABG is planned within 24 hours Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 54 :

Early Invasive Strategy Studies and Recommendations in Patients with NSTE-ACS

Slide 55 :

Months 4% 20% 16% 12% 8% TACTICS 1 2 3 4 5 6 15.9% 19.4% Initial Medical Rx Early Cath + PTCA Adapted with permission from Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879-1887. Copyright © 2001, Massachusetts Medical Society. All rights reserved.

Slide 56 :

TACTICS Trial Results Based on Troponin Negative Troponin Positive Troponin 5% 10% 15% 20% 25% P=NS P<0.001 Adapted with permission from Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879-1887. Copyright © 2001, Massachusetts Medical Society. All rights reserved.

Slide 57 :

TnT indicates troponin T; and ST, ST segment. Data from (1) Morrow DA, et al. JAMA. 2001;286:2405-2412 and (2) Cannon CP, et al. N Engl J Med. 2001;344:1879-1887. Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org. Benefit of Invasive Strategy by Troponin and ST Changes Death, MI, or Rehospitalization for ACS at 6 Months 12.4 25.0* 16.0 15.3* 0 5 10 15 20 25 30 TnT – TnT + CV Events (%) P=NS 15.1 24.5* 16.6 16.4* 0 5 10 15 20 25 30 No ST change ST change P=NS P<.001 P<.001 Conservative Invasive

Slide 58 :

The Primary Composite Ischemic End Point in RITA-3 Reproduced with permission from Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised Intervention Trial of Unstable Angina. Lancet. 2002;360:743-751.

Slide 59 :

Meta-Analysis of Trials of Early Cardiac Cath and Revascularization Versus Initial Medical Therapy Alone in Patients with NSTE-ACS Reproduced with permission from Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomised Intervention Trial of unstable Angina. Lancet. 2002;360:743-751.

Slide 60 :

Invasive vs Conservative Strategy for UA/NSTEMI UA indicates unstable angina, NSTEMI, non–ST-segment myocardial infarction; ISAR, Intracoronary Stenting and Antithrombic Regimen Trial; RITA, Randomized Intervention Treatment of Angina; VANQWISH, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital study; MATE, Medicine vs Angioplasty for Thrombolytic Exclusions trial; TACTICS-TIMI18, Treat Angina with Aggrastat® and Determine Cost of Therapy with Invasive or Conservative Strategy; and FRISC, Fragmin during InStability in Coronary artery disease. TIMI IIIB 2003 Conservative Invasive VANQWISH MATE FRISC II TACTICS-TIMI 18 VINO RITA-3 TRUCS ISAR-COOL Slide reproduced with permission from Cannon CP. Atherothrombosis slide compendium. Available at: www.theheart.org.

Slide 61 :

ACC/AHA Class I Recommendations for Invasive and Medical Strategies in Patients with NSTE-ACS Class I An early invasive strategy in patients with any high-risk indicators: Recurrent angina/ischemia at rest or with low-level activities Elevated troponin New or presumed new ST-segment depression Recurrent angina/ischemia with CHF Sx and S3 gallop, pulmonary edema, worsening rales, or new or worsening MR High-risk findings on noninvasive stress testing Depressed LVEF (<40%) Hemodynamic instability Sustained ventricular tachycardia PCI with 6 months or prior CABG In the absence of any of the above high-risk indicators, either an early conservative or an early invasive strategy Available at www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 62 :

Peri- and Post-Discharge Therapies and Risk Modification

Slide 63 :

MIRACL: Acute Statin Rx Cumulative Events 5% 10% 15% Time Since Randomization (weeks) 4 8 12 16 RR=0.84 P=0.048 Adapted with permission from Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA. 2001;285:1711-1718. Copyright © 2001, American Medical Association. All rights reserved.

Slide :

Slide 65 :

ACC/AHA Class I Recommendations for Long-Term Medical Therapy in Patients with NSTE-ACS Class I Aspirin 75-325 mg qD Clopidogrel 75 mg qD when ASA is not tolerated because of hypersensitivity or GI intolerance Combined ASA + clopidogrel for 9 months after NSTE-ACS Beta blockers unless contraindicated Lipid-lower agents and diet if LDL > 100-130 mg/dL ACEI for patients with CHF, LV dysfunction (EF <40%), hypertension, or diabetes Available at: www.acc.org/clinical/guidelines/unstable/unstable.pdf.

Slide 66 :

ACC/AHA Class I Recommendations for Long-Term Risk Factor Modification in Patients with NSTE-ACS Class I Specific instruction on smoking cessation Specific instruction on optimal weight, diet, and daily exercise Lipid-lowering therapy (statin) for LDL >100-130 mg/dL A fibrate or niacin if HDL <40 mg/dL occurring as an isolated findi

There is no comments now for this Slide.

Post a comment

Post Comment on Twitter Post Comment on SlideWorld

Comments:

Subscribe to follow-up comments

	SlidesOnline 1 Years ago. Category: other

Tags:	other

726 Views, 0 favourite
Pathology , Pathophysiology, and Epidemiology. Risk and Risk Stratification Pathology , Pathophy more Pathology , Pathophysiology, and Epidemiology. Risk and Risk Stratification Pathology , Pathophysiology, and Epidemiology. The Vulnerable Plaque less

SWINE Flu

Why do women live longer then men? Humor

History of Medicine

Yoga and Medicine

How to be a Successful Interventional Fellow size 50 MB

Cardiac Pathology

Hypertension: New Concepts, Guidelines, and Clinical Management

Diabetes Pathology