risk stratification of acs patients - european society of...

Frans Van de Werf, MD, PhD

University of Leuven, Belgium

Risk Stratification of ACS Patients

Which type of ACS patients are we

talking about to day?

4/14/2011

STEMI and NSTEMI in the NRMI registry from 1990 to 2006

and % in whom a troponin assay was used to diagnose MI

Roger, V. L. et al. Trends in incidence, severity, and outcome of hospitalized myocardial infarction.

Circulation 121, 863–869 (2010)

,

Trends in incidence of hospitalized MI from 1987 to 2006 in

OlmstedCounty, MN, USA, by ST-segment elevation status

Roger, V. L. et al. Trends in incidence, severity, and outcome of hospitalized myocardial infarction.

Circulation 121, 863–869 (2010)

Age-adjusted and sex-adjusted incidence of acute MI in

KaiserPermanente, Northern California, USA,

from 1999 to 2008

Yeh, R. W. et al. Population trends in the incidence and outcomes of acute myocardial infarction. N. Engl. J.

Med. 362, 2155–2165 (2010)

Copyright ©2010 American Heart Association Roger, V. L. et al. Circulation 2010;121:863-869

30-day case fatality rates for hospitalized MI overall and by age, sex, and time period

.Long-term survival among 30-day survivors did not improve!

.Causes of death shifted from CV to non-CV in most recent

year quartile (50% non-CV)

BUT

What is a myocardial infarction nowadays ?

4/14/2011

Copyright ©2011 American College of Cardiology Foundation. Restrictions may apply.

Lim, C. C. S. et al. J Am Coll Cardiol 2011;57:653-661

Flow Diagram of

Patient Recruitment



Peak CK-MB and Troponin Values



PMI Groups



Percentage Change From Baseline of CRP,

SAA, MPO, and TNF-Alpha Levels

The classical risk models

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Risk Models and Risk Scores

GUSTO-I Model for 30-Day Mortality in STEMI

TIMI Risk Score for STEMI and NonSTEMI

GRACE Risk Model for 6 Months Outcome in

ACS (STEMI , NonSTEMI and UA)

GUSTO-I : Independent Clinical

Predictors of 30-Day Mortality*

Variable

Age, y

Systolic BP, mm Hg

Killip class

Heart rate, bpm

Location of infarction

-----------------------------------

Previous infarction

Age-by-Killip class interaction

Height, cm

Time to treatment, h

Diabetes

Weight, kg

Smoking

Choice of thrombolytic therapy

Previous bypass surgery

Hypertension

Prior cerebrovascular disease

Adjusted c2

717

550

350 (3 df)

275 (2 df)

143 (2 df)

--------------

64

29

31 (4 df)

23

21

16

22 (2 df)

15 (3 df)

16

14

10

Lee et al. Circulation 1995

*Indicates the independent

contribution of each variable

after adjustment for all other

factors in the list. The first 10

factors are significant with

P<0.00001; the next four P

<0.0001; the last two P<0.01. Sex

(P=0.043) and US enrollment

(P=0.047) were marginal

predictors.

Lee, K. L. et al. Circulation 1995;91:1659-1668

Predictors of 30 Day Mortality in

> 40 000 STEMI patients (GUSTO)

GUSTO-I : Observed 30-Day Mortality vs 30-Day

Mortality Predicted by Regression Model

Lee et al.

Circulation

1995

GRACE: Predictors of 6 Month Mortality

4/14/2011

Predictors

Age (per 10 year increase)

Medical History

• Congestive heart failure

• Hypertension

• Peripheral vascular disease

• PCI

Χ2

505.7

34.2

8.8

21.8

8.3

HR (95%CI)

1.8 (1.68 to 1.84)

1.5 (1.32 to 1.73)

1.2 (1.05 to 1.33)

1.4 (1.21 to 1.62)

0.8 (0.64 to 0.93)

GRACE: Predictors of 6 Month Mortality

Predictors

Presentation characteristics

• Pulse (per 30 bpm ↑)

• Systolic blood pressure (20 mmHg ↓)

• Killip class

• Initial serum creatinine (per 88 µmol/l ↑)

• Initial cardiac markers or enzymes

• Cardiac arrest

Findings on electrocardiography

• ST segment deviation

• LBBB

• No of leads with ST segment deviation

Χ2

44.3

152

142.8

135.3

63.0

58.5

46.8

10.0

20.1

HR (95%CI)

1.2 (1.16 to 1.31)

1.2 (1.22 to 1.30)

1.5 (1.41 to 1.62)

1.2 (1.19 to 1.29)

1.6 (1.42 to 1.78)

2.6 (2.00 to 3.32)

1.6 (1.41 to 1.88)

1.3 (1.10 to 1.60)

1.2 (1.10 to 1.33)

Simplified GRACE Risk Model for

Death in ACS at 6 Months

Simplified GRACE Risk Model for

Death/MI in ACS at 6 Months

GRACE Risk Nomogram for Death

at 6 Months (simplified model)

GRACE Risk Nomogram for Death/MI

at 6 Months (simplified model)

GRACE Risk Nomogram for Death

at 6 Months (Simplified Model)

GRACE Risk Nomogram for Death/MI

at 6 Months (Simplified Model)

27

GRACE PDA Software

TIMI Risk Score: Independent Predictors of

30-Day Mortality in InTIME-II

Morrow et al.

Circulation

2000

TIMI Risk Score for STEMI

Morrow et al.

Circulation

2000

TIMI Risk Score for UA/Non-STEMI

TIMI Risk Score and all-cause mortality, MI, and severe recurrent ischemia

calculated for enoxaparin and UFH in TIMI11B and ESSENCE

Antman, E. M. et al. JAMA 2000;284:835-842

A recent case:Women, 66 y, chest pain, troponins negative, cholesterol : 266 mg/dl

ST segment depression in II, III, aVF and V6

enrolled in a NSTE-ACS study, coronary angiography: negative!

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Event rates after an ACS

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Cumulative death rates in 3721 ACS patients

from UK and Belgium at ± 5 year (GRACE)

0

5

10

15

20

25

STEMI Non-STEMI UA

% CV

CV

CV

n=1403 n=1107 n=850

65% after

discharge

83% after

discharge

95% after

discharge

14%

16%

13%

19%

TOTAL

22%

TOTAL

17%

TOTAL

Fox K et al. Eur Heart J 2010

Who Can/Should Use

the Risk Models/Scores ?

Risk models/scores can/should be used by clinicians to :

for triage decisions

To determine risk of an adverse event or

co-morbidity

to delineate treatment options

Risk models/scores can/should be used by guidelines committees to :

to determine relative treatment benefit/harm of certain therapies in different risk categories

Do (Good !) Clinicians Really need these

Risk Models/ Scores ?

78-year-old female patient with 6 mm ST-

segment elevation in anterior leads, history

of hypertension, type 2 DM, renal failure

(serum creatinine of 1.8 mg/dl), never

smoked, Killip class II on admission

vs

42-year-old male patient with 1 mm ST-

segment elevation in inferior leads, no

hypertension, no DM, heavy smoker (1.5

packet /day), Killip class I on admission

Estimated

30 day mortality

20% or 30%

Estimated

30 day mortality

1% or 2%

Do Guidelines Committees Use

these Risk Models/Scores?

Yes,to a certain extent but the usual

conclusion is that there is

“uncertainty” and that new

prospective and randomized studies

are needed in specific risk categories

such as eg the elderly, diabetics,

renal failure , hypertensive pts etc

Conclusions Risk models/scores for cardiac risk stratification in

ACS patients perform well in populations similar to the one from which they were obtained

Risk models/scores for mortality alone provide better discrimination than those for a composite endpoint

Risk models/scores tend to underestimate the risk in patients who did not participate in randomizedtrials

Risk models/scores for longterm outcome are lacking

The usefulness of these risk models/scores in daily clinical practice has not been demonstrated

risk stratification of acs patients - european society of...

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