Current and Future Perspectives on Current and Future Perspectives on Acute Coronary SyndromesAcute Coronary Syndromes

Paul W. Armstrong MDPaul W. Armstrong MD

AMI QuebecAMI Quebec

Montreal Montreal October 1, 2010October 1, 2010

Pivotal Role of TimePivotal Role of Time

Timing of Symptom OnsetTiming of Symptom Onset Time to 1Time to 1stst Medical Contact Medical Contact Time to ReperfusionTime to Reperfusion Time as Modulator of Rx EffectTime as Modulator of Rx Effect Time as Modulator of Rx ChoiceTime as Modulator of Rx Choice Time Interaction & Risk Assessment Time Interaction & Risk Assessment

Strategic Alignment: Paramedical Program, IT & ECG, Molecular Chemistry Coronary Intervention

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Pharmacologic Reperfusion

CCU

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied

Armstrong Collen Antman Circulation 2003Armstrong Collen Antman Circulation 2003

2.4hrs2.4hrs

Reperfusion Options for STEMI PtsStep One: Assess Time and Risk

Time Since Symptoms

Time Required to

Initiate Invasive Strategy

Risk of STEMI

Risk of Lysis

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Reperfusion Relationships: Time & Myocardial Salvage, Lives Saved & Frequency Aborted MI

Armstrong ,Westerhout, Welsh, Armstrong ,Westerhout, Welsh, Circulation 2009Circulation 2009

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Efficacy vs Effectiveness …..Efficacy vs Effectiveness …..Isn’t All About Time?Isn’t All About Time?

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99 33Self presentation

to hospital 911 EMS

Infarct specific

Patient specific

Risk of STEMI

Reperfusion Choice

Strategy

STEMISTEMI NEXUS

Armstrong ,Westerhout,Welsh, Circulation 2009Armstrong ,Westerhout,Welsh, Circulation 2009

NSTE ACS: NSTE ACS: Too Great a Theraputic Burden?Too Great a Theraputic Burden?

ASAASA Anti thrombin(s)Anti thrombin(s) Clopidogrel, PrasugrelClopidogrel, Prasugrel 2B /3A2B /3A Beta Blocker Beta Blocker ACE inhibitorACE inhibitor StatinStatin Anti inflammatoryAnti inflammatory Mechanical InterventionMechanical Intervention BMS vs DESBMS vs DES

GRACE Risk ModelGRACE Risk ModelVariablesVariables Age (continuous) Age (continuous) Killip classKillip class Blood pressureBlood pressure ST deviationST deviation Cardiac arrestCardiac arrest CreatinineCreatinine Elevated CK-MB / TnElevated CK-MB / Tn Heart rateHeart rate

VariablesVariables Age (continuous) Age (continuous) Killip classKillip class Blood pressureBlood pressure ST deviationST deviation Cardiac arrestCardiac arrest CreatinineCreatinine Elevated CK-MB / TnElevated CK-MB / Tn Heart rateHeart rate

—Granger et al Archives Int Med 2003www.umassmed.edu/outcomes/grace

C-index = 0.84, validated in clinical trial + registry populations

www.statcoder.com/grace.htm

Hospital Mortality

Mehta S et al. N Engl J Med 2009

Primary Outcome* Stratified by Baseline GRACE Risk Score

TIMACS

HR 0.65(0.48-0.89)

Non ST elev’n ACS n=3031

(1/3)

*Death, MI, Stroke @ 6mo Early =14h : Delayed= 50h

High – risk ACS (NSTEMI)

Opportunities in pre-hospital cardiovascular care

Cardiac Arrest

ST elevation AMI

Seamless pre-hospital diagnosis, triage and treatment

Bystander CPR and AEDRapid ACLS responseNovel EBM therapies

Pre-hospital triage Antiplatelets

Anticoagulants

Risk assessment and

management

Welsh & Armstrong Heart 2005

Perspectives on Acute Coronary Perspectives on Acute Coronary SyndromesSyndromes

Baseline risk and its evolution Baseline risk and its evolution Lesson of subsets and disease heterogeneity Lesson of subsets and disease heterogeneity Time and its potential for deceptionTime and its potential for deception Dose: Renal function, age, body weight, sexDose: Renal function, age, body weight, sex Bleeding is bad and choice of vascular access site a key Bleeding is bad and choice of vascular access site a key

modulator modulator Guidelines are roadmaps: detours may be necessaryGuidelines are roadmaps: detours may be necessary Beware of too rapid uptake of high profile meeting Beware of too rapid uptake of high profile meeting

presentationspresentations One strategy rarely meets all clinical needsOne strategy rarely meets all clinical needs Patients are partners: helping them make an informed Patients are partners: helping them make an informed

choice is an artchoice is an art

a