Percutaneus coronary intervention in Non ST elevation myocardial infarction

PCI IN NSTEMI

Dr R Barik/Prof A.N Patnaik/Dr N Lalita

NIMS,Hyderabad

PCI IN NSTEMI-INCOMPLETE WHITE THROMBUS

Dedicated to AHA /ACC/SCAI 2012- guidelines

NSTEMI:An ACS

Chest pain of at crescendo/at rest/worsening for at least 30 minutes and <48-72 hrs

ECG: ST-depression of >0.1 mV in at least 2 or transient ST-segment elevation >0.1 mV in at least 2 leads for less than 30 minutes) and/or T-wave changes (inversion of >0.15 mV in at least two contiguous leads)

Biomarker: cardiac troponin T >0.01 μg/L



Bird’s eye view…………..Hamm Lancet 358:1533,2001Bird’s eye view…………..Hamm Lancet 358:1533,2001


Fibrinolysis: Red vs. White thrombusSTEMI The GUSTO investigators. N Engl J Med 1993; 329:673.

GUSTO- J Am Coll Cardiol 1995; 25:10S.

Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994; 343:311.Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348:771.Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA 1993; 270:1211

18-30 DEATH REDUCTION FOR EACH 1000 TLT GIVEN

NSTEMINO

TIMI IIIB, ISIS-2, and GISSI 1 trials. Ameta-analysis of fibrinolytic therapy in UA/NSTEMI patients showed no benefit

of fibrinolysis versus standard therapy (FTT Collaborative-1994). Fibrinolytic agents had no significant beneficial effect and actually increased the

risk of MI. Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol.

2004.AHA/ACC TASK FORCE 2007


White= platelet plug±lilttle red thrombusLEAST respond to fibrinolytic therapy

Jang IK et al. Differential sensitivity of erythrocyte-rich and platelet-rich arterial thrombi to lysis with recombinant tissue-type plasminogen activator. A possible explanation for resistance to coronary thrombolysis. Circulation 1989


ACC/AHA guidelines ,1999/2002/2004/2007...Co

ntd


Two issues better clarified

Definitions of UA and NSTEMIDefinitions of early invasive and early

conservative strategies


A perfect SANDWITCH


IMISCABLE

Causes are many


Phenotype of deception

• Two thirds of ACS of are USA/NSTEMI• F>M ,F= 30% to 45% NSTEMI=25% to 30% AND STEMI =20% of Older>YOUNGER Prior MI/CSA/DM/Revasc/CVA/PAD/CKD 80% of patients with UA/NSTEMI have HX of CAD-higher

syntax score IRA is not occluded in 60 to 85 percent cases 9 to 14 % of NSTEMI : normal vessels or no vessel with ≥50 to

60 percent stenosis (CRUSADE registry)

Contd...

• Risk is highest at presentation fades but at 6 months cumulative mortality >STEMI

• Early mortality risk is: 3% and 5%=STEMI• F/U is worse than STEMI• Recurrence/older age• CAD/ prior MI/DM/ diabetes/CKD/CVA/PAD+• 50% higher risk with comorbities• >Killip's II mortality = STEMI


PROGNOSIS: Fire under ash Similar to that with an STEMI Worse than USA 70% Non occlusive benefit is diluted by >50% TVD recurrent ischemia> STEMI (35 versus 23 percent at one year

in (GUSTO-IIb) Significant amount of myocardium often remains at risk AW ischemia is dangerous (SPRINT registry)


Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399

A big fall(patient) for Small rise(Tn)

Small rise in biomarkers most of the reveals a big damage related to the likelihood of severe TVD, an unstable plaque with thrombus and downstream microembolization, and impairment of coronary flow; these factors are all associated with an increased risk for reinfarction and death


1.FRISC II and TACTICS-TIMI 182. Ricciardi MJ, Wu E, Davidson CJ, et al. Visualization of discrete microinfarction after percutaneous coronary intervention associated with mild creatine kinase-MB elevation. Circulation 2001

NTEMI Paradox?

High sensitive TnT increases NSTEMI incidences but better care reduces fatality

How frequently you Dx NSTEMI

SHOCK: 20% of all cardiogenic shock The Global Use of Strategies to Open Occluded Coronary

Arteries (GUSTO)-II and PURSUIT:5% but > 60% mortality PURSUIT, TIMI IIIB Investigators,PRISM,PRISM-PLUS>10%

Risk scores for NSTEMI/USAPCI vs. Medical Rx PCI vs. CABG Bleeding risk

Thrombolysis In Myocardial Infarction (TIMI) Global Registry of Acute Coronary Events (GRACE)Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT

SYNTAX TIMI Mehran R et al.2007


Basis of risk score for PCI


TIMI RISK cut off for PCITRIALS PCI INDICATION±IIB-IIIA inhibitors

TACTICS-TIMI 18 score ≥3

PRISM-PLUS score ≥4

TIMI 11B and ESSENCE score ≥4 and 5


Grace risk for PCI


Right person to talk right way


Syntax after CAG......Ya!Ya!STEPS ANTIPLATLETS IIB-IIIA inhibitor ANTICOGULATION

ICCU ASA to all No to Abciximab LMW/Fondaparinaux/Bivaluridin

PREPARATION ON for PCI

+1 antiplatlets but No Prasugrel

No to Abciximab -do-

CAG DONE,PCI ON

Now you can give Prasugrel if patient is on only aspirin But Ticagrelor is best

Abciximab is congratulated

-do- but bivaluridin is prefered

CAG +CABG No antiplatlets except Aspirin

No AB Heparin


With rising risk

LMWH :ESSENCE: Efficacy and Safety of SC Enoxaparin in USA & Non-Q-Wave MI, TIMI 11B:TLT in MI

GP IIb/IIIa inhibition (TIMI Risk Score for UA/NSTEMI in PRISM-PLUS)

Invasive strategy: Comparaison 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;344:1879–87)

are found more beneficial


Supporting trial


PCI is HARMFUL Timelines Trials Comments

Old (TIMI IIB andVANQWISH)

Harmful in comparison to CABG


Early angioplastyTIMINGS TRIALS REUSLTS

EARLY VS LATE

Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-COOL) 2003

Results of PTCA/Angio is better than done later(4days)

TIMACS(Timing of Intervention in Acute-Coronary Syndromes )-2009

GRACE risk score>140Compared early (median = 14 hours after randomization) with later (median = 50 hours) reduction of the primary endpoint (death, MI, and stroke) in the group as a whole but a significant reduction in the primary endpoint in patients with28% reduction of the secondary endpoint of death, MI, and refractory ischemia with earlier angiography


EARLIER (but <STEMI) is better

6 to 24 h is better than 48 to 96 h interervals

ESAR-COOL: Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomizedcontrolled trial. JAMA. 2003;290:1593–9FRISC II TACTICS-TIMI 18


But .........

Significant renal dysfunction is Poison

Szummer K et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-system for enhancement and development of evidence based care in Heart Disease evaluated According to recommended therapies (SWEDEHEART). Circulation 2009;120:851-8



ANTIPLATLETSCONSERVATIVE INVASIVE

TICA>>>CLOPI>>>>PRASUHigh risk:IIB-IIIA Inhibitor,avoid abciximab

TICA>>>>PRASU>>>CLOPINo IIB-IIIA Inhibitor with BivalurudinHigh risk:IIB-IIIA Inhibitor addAbciximab prefered >eftifibatibe>tirofiban


ANTICOAGULANTSAHA ESC

1. invasive strategy : enoxaparin, unfractionated heparin (UFH), or bivalirudin(prefered with bleeding risk)

2. Urgent (immediate angiography), bivalirudin or UFH is preferred

3. Conservative:enoxaparin, fondaparinux, or UFH,1and 1 prefered

1. invasive strategy : enoxaparin, unfractionated heparin (UFH), or bivalirudin

2. persistent angina, hemodynamic instability, or refractory arrhythmias, for whom UFH or bivalirudin is preferred

3. Conservative: fondaparinux prefred over LMW


Coronary angiogram analysisAMI DISEASE PATTERN CORONARY AND EXTRA CARDIACS

NSTEMI Eccentric/fissure/erosion/Collaterals/calficTVD : >50% stenosis is 34%DVD:28%SVD: 26%Mild CAD: <50% stenois is 13%(excellent prognosis on short term)LMCA: 10% ( >50%) Women :less extensive NSTEMI :extensive disease >NSTEMIHigh SYNTAX More carotid/RAS/PAD

STEMI Single culprit


TACTICS–TIMI 18 trial/Other 16 registries



Femoral Vs. Radial Approach


RIVAL: non superiorACUITY: Radial is superior




Thrombus Aspiration During PCI in NSTEMI

STEMI NSTEMI

TAPAS –Class I Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Non-ST-elevation Myocardial Infarction Study (TAPAS II)Phase IV results of 580 patient waited


Drug-eluting stents are better


Kandzari DE et al. Frequency, predictors, and outcomes of drug-eluting stent utilization in patients with high-risk in NSTEMI. Am J Cardiol 2005; 96:750.

Mauri L, Silbaugh TS, Garg P, et al. Drug-eluting or bare-metal stents for acute myocardial infarction. N Engl J Med 2008; 359:1330.

Culprit vs. +by critical stander(s)

Decision lies with operator


1.ACUITY(Acute Catheterization and Urgent Intervention Triage Strategy ) trial:favours2. Shishehbor MH, Lauer MS, Singh IM, et al. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol 2007; 49:849.3. ESC Guidelines for NSTEMI 2011-advise to improve decision using FFR/IVUS

4.PRAMI(Preventive Angioplasty in Myocardial Infarction) invstigator for STEMI

CABG vs.PCI:TVD/LMCA/LAD/LVDPRE DES ERA DES era/SYNTAX era

ERACI II ,AWESOME favour CABG SYNTAX favours CABG is better



Major bleeding


Diabetes a close friend

• 20%-30% of NSTEMI • Independent predictor of CVE at 1 year• Ulcerated plaque/more thrombus/diffuse• PCI is not welcomed# unless SVD• DES+Abciximab better(EAST)• PCI<<<<<<CABG benifit(BARI)/EAST/NHLBI

registry#Kip KE et al.Coronary angioplasty in diabetic patients: the National Heart, Lung,and Blood Institute

Percutaneous Transluminal Coronary Angioplasty Registry. Circulation. 1996;94:1818 –25.PCI IN NSTEMI-INCOMPLETE WHITE

THROMBUS

DM/PCI

• PCI is reasonable with SVD and inducible ischemia(Level of Evidence: IB)

• BETER use insulin (DIGAMI)

Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison ofearly invasive and conservative strategies in patients with unstablecoronary syndromes treated with the glycoprotein IIb/IIIa inhibitortirofiban. N Engl J Med. 2001;344:1879–87



Elderly and PCI:Go aheadEVIDENCE RESULTS

(FRISC-II, TACTICS, RITA-3, VINO, and MATE –Meta analysis before 1996

Older UA/NSTEMI patients face increased early procedural risks with revascularization relative to younger patients, yet the overallbenefits from invasive strategies are equal to or perhaps greater in older adults and are

recommended. (Level of Evidence: IB)

Predictors of operative death (LV dysfunction, previous CABG, peripheral vascular disease, and diabetes) were similar to those in younger patients

FRISC II

TACTIS TIMI 18

Cleveland clinic review(contemporary review)


Renal dysfunction and NSTEMI

Benefit of early invasive Rx is lost if proper timing and precaution is not opted

Szummer K, Lundman P, Jacobson SH, et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies

(SWEDEHEART).Circulation. 2009;120:851– 8


TIMING OF DISCHARGE

• Not well defined• early angiography/revascularization/stent facilities

earlier discharge• Antithrombotic/anticoagulation delays • Radial access helps go early

• Easy trial: Proves same day discharge by TRA PCI of 1000 patient with bolus dose of abcixmab only is noninferior to overnight stay with 12 infusion


NSTEMI PCI-2012 Guide



Health & Medicine

Percutaneus coronary intervention in Non ST elevation myocardial infarction