ACS guidelines Pre-program
To understand the ACS guidelines it is necessary to
know mortality risk if you do nothing and bleeding
risk for different kinds of treatment.
We make therefore use of the
GRACE score (mortality )
CRUSADE score (bleeding)
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GRACE score best score for ACS
at the moment
050212
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Mortality after Acute Coronary Syndromes
8
7
6
STE MI
Trop 0 - 0.25
Trop 0.25 - 1.0
5
4
3
2
1
0
0 - 10
days
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11 - 30
days
31 - 90 90 - 180
days
days
>180
days
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Cumulative:
13.6% Blue
10.6% Green
11.6% Red
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Do we need risk scoring ?
Risk scoring leeds to lower mortality
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Evolving ACS Guidelines
• Revised diagnosis
– IAP to NSTEMI
– Troponin and HS-Troponin
– Increasing awareness of prognosis NSTEMI
• Take account of new data
– Improved risk scoring
• Allow for improved hospital facilities
– cath lab facilites; functional imaging
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Why another risk scoring ?
• Commonest reason for non-referral
– Patients “not at high enough risk”
• Analysis of records of those not referred
– 59.1% at intermediate or high risk according to
baseline TIMI risk score
• Over reliance on one or two key risk factors
– ECG and Tn
– Under use of other variables : age, CCF, renal function
• Decrease of bed capacity
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ACS Risk Scoring
• TIMI
–
–
–
–
Age
- Use of aspirin
Risk Factors
- Known CAD
> 1 episode rest pain - ST segment deviation
Cardiac risk markers
• PURSUIT
– Age, Sex
– Signs of CCF
- CCS class in last 6/52
- ST depression on ECG
• GRACE
–
–
–
–
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Age
- Heart rate and systolic BP
Creatinine
- CCF (Killip class)
Cardiac arrest at admission
Elevated cardiac markers - ST segment deviation
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ACS Risk Scoring
• TIMI
–
–
–
–
Age
- Use of aspirin
Risk Factors
- Known CAD
> 1 episode rest pain - ST segment deviation
Cardiac risk markers
• PURSUIT
– Age, Sex
– Signs of CCF
- CCS class in last 6/52
- ST depression on ECG
• GRACE
–
–
–
–
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Age
- Heart rate and systolic BP
Creatinine
- CCF (Killip class)
Cardiac arrest at admission
Elevated cardiac markers - ST segment deviation
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ACS Risk Scores
• Balance between complexity and utility
• Score that include continuous variables more
powerful but more complex to compute
– Simple PC/PDA programmes now available
• Objective data more robust
•GRACE most powerful and
has most objective data
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How was GRACE introduced ?
Practice variation and missed opportunities for
reperfusion in ST-segment-elevation myocardial
infarction: findings from the Global Registry of
Acute Coronary Events (GRACE)
Kim A. Eagle, Shaun G. Goodman, Álvaro Avezum,
Andrzej Budaj, Cynthia M. Sullivan, José López-Sendón,
for the GRACE Investigators
Lancet 2002;359:373-77
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Missed Opportunities for Reperfusion
ST ↑ or LBBB, <12 hrs from onset, no contraindications
n
PCI alone
Lytic alone
Both
Neither
ANC (%)
269
US (%)
327
AB (%)
EUR (%)
339
739
1.1
66.9
2.2
29.7
17.7
30.6
18.7
33.0
13.9
53.1
5.0
28.0
16.2
49.4
4.9
29.5
AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States
Eagle KA et al. Lancet 2002;359:373-7.
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Independent Predictors of No Reperfusion
Variable
OR (95% CI)
Prior CABG
History of diabetes
History of congestive heart failure
Presentation without chest pain
*Age 75 years
2.28 (1.35 - 3.87)
1.46 (1.11 -1.94)
2.92 (1.84 - 4.67)
2.23 (2.13 - 4.89)
2.37 (1.82 - 3.08)
*As compared to the <55 years age group
Eagle KA et al. Lancet 2002;359:373-7.
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Geographical Variation:
Admission to Hospitals
with/without Access to Cath Lab
100
Cath lab
80
82
78
80
Patients (%)
No cath lab
61
60
39
40
20
22
18
20
0
USA
Europe
ANC
AB
ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil
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Global patterns of use of antithrombotic and
antiplatelet therapies in patients with acute coronary
syndromes: Insights from the Global Registry of Acute
Coronary Events (GRACE)
Andrzej Budaj, David Brieger, Ph Gabriel Steg, Shaun G. Goodman,
Omar H. Dabbous, Keith A. A. Fox, Álvaro Avezum, Christopher P. Cannon,
Tomasz Mazurek, Marcus D. Flather, and
Frans Van De Werf, for the GRACE Investigators
Am Heart J 2003;146:999-1006.
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Geographic Practice Variation
100
92 92 91 95
United States
Australia/New Zealand/Canada
Patients (%)
80
Europe
65
Argentina/Brazil
58
60
40
37
39
33
30
24
20
17
15
8
9
13
0
PCI
GP IIb/IIIa
LMWH
ASA
Budaj A et al. Am Heart J 2003;146:999-1006.
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Incidence of Major Bleeding
Patients (%)
9
6
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
8.3
3.9
3
2.4
2.9
0
Major bleed
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
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In-Hospital Mortality Rates
50
No Major Bleed
Major Bleed
Patients (%)
40
30
**
18.6
20
10
5.1
**16.1
**
**
15.3
5.3
3.0
22.8
7.0
0
Overall
Unstable Angina
NSTEMI
STEMI
Moscucci M et al.Eur Heart J 2003;24:1815-23.
**P<0.001
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Hospital Outcomes of ACS Patients Stratified by Statin Use
Outcome
Prior statins
Only
Prior & Hospital
Statin
Hospital Statins
Only
Death
1.39 (0.91,2.14)
0.20 (0.16,0.25)
0.38 (0.30,0.48)
Recurrent MI 0.69 (0.43,1.11)
0.90 (0.75,1.07)
1.22 (1.08,1.37)
Stroke
1.08 (0.43,2.73)
0.68 (0.42, 1.12)
0.80 (0.57, 1.14)
Composite
1.02 (0.74,1.41)
0.66 (0.56,0.77)
0.87 (0.78,0.97)
*Compared to patients never receiving statins
Ann. Intern Med. 2004;140:856-866.
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At Admission Risk Model
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At Discharge Risk Model
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GRACE PDA Software
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Manuscript Status
66
Published/in press
Submitted/being
revised
12
7
Edit/write assistance
Top priority
independent
8
16
Unprioritized
0
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40
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80
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Unique Features of
GRACE
• Multi-national perspective
• Full spectrum of coronary syndromes
• Increased data on demographics,
presentation, management and outcome
• Regular audits of data quality
• Feedback to participating sites
• Long follow-up
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Guide to GRACE manuscripts (1999 to 2006)
http://www.outcomes-umassmed.org/grace/guide_to_grace_manuscripts.aspx
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Bleeding Risk Score
Can Rapid risk stratification of Unstable angina patients Suppress
ADverse outcomes with Earl implementation of the
American College of Cardiology/American Heart Association
guidelines
(CRUSADE)
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http://www.crusadebleedingscore.org
http://www.ahjonline.com/article/S0002-8703(08)00384-0/abstract
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