who can be discharged without angiography?
TRANSCRIPT
DGH management of acute coronary syndromes
Who can be discharged without angiography ?
Dr Conrad MurphySt Richard’s Hospital Chichester
Prognosis of ACS
Terkelsen EHJ 2005
6 weeks
Who is likely to benefit from pre-discharge angiography ?
Low Moderate High
Risk of Early Ischaemic Event
Marked ST changeOn going angina
Heamodynamic instabilityMajor Arrhythmia
Angiogram Mandatory
Completed Infarction
‘Q wave MI’
Angiogram Not Necessary
Incomplete MINon-Q infarct
Stable Patient
Fully Ambulant
But Trop +ve
In-patient Angiogram Desirable
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
Conservative Invasive
VANQWISH
MATE
FRISC II
TACTICS-TIMI 18
VINO
RITA-3
TRUCS
ISAR-COOL
ICTUS
The benefits of pre-discharge angiography & intervention
• The trial evidence• Readmissions• Non-fatal MI• Mortality• QOL
• Other benefits• Investigation
‘upfront’• Simplify follow up• Back to work• Happy patient• ‘On-Guideline’
The downside of pre-discharge angiography & intervention (UK)
• May destabilise otherwise stable patient
• Other procedural and therapy complications
• Bed blocking while waiting for transfer
2003 2004
Beds BlockedEachDay
0
1
2
3
4
5
6
7
8
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Non-STEMI Audit25% >80yrs oldFor under 80’sMean age 69yrsTransfer rate=24%(urgent PCI slots available)
Readmission rate= 8%Mortality 3% at 3/12
Who is likely to benefit from pre-discharge angiography ?
Low Moderate High
Marked ST changeOn going angina
Heamodynamic instabilityMajor Arrhythmia
Multiple ACS Risk Factors
Completed Infarction
‘Q wave MI’
Incomplete MINon-Q infarct
Stable Patient
Fully Ambulant
But Trop +ve
Risk of Early Ischaemic Event
Further Risk
Stratification ?Angiography
Most cases ‘ESC 2002’
Who to transfer; Grace data
Age 0-100
CCF 24
Previous MI 14
Heart Rate 0-43
BP 0-24
ST depression 11
CRF 1-20
Enzymes up 15
No in-hosp PCI 14
45 maleNon- STEMIST depressionBP ok
85 male Non-STEMIPrev MI, CRF
Eagle et al JAMA 2004
Who to transfer; TIMI score (Non-STEMI)
0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6
0
20
40
60
80
100
120
Event rate at 14 daysEventRatePost MI %
% of MI population
TIMI score
TIMI scoringAgeCAD risk FactorsKnown CADAspirin useRecent severe APElevated MarkersST deviationScore 0-7
Exercise testing in risk stratification
Who does not need pre-discharge angiography after ACS ?
• Not candidate for intervention
• Completed MI
• Lower risk non-Q MI– Stable– No high risk features– Good Ex Test; other risk stratification– Not disadvantaged by delayed investigation– Regional centre lead
Conclusion
• The move to angiogram based risk stratification and treatment is irresistible and preferable
• Cost effectiveness will be lost if long transfer times persist
• limitations of a ‘lesion based’ approach
What to do next
Occlusion & Infarct
Occlusion
Stable severe stenosis
Resolution