14th Vietnam National Congress of Cardiology Da Nang, Vietnam October 11-14, 2014 Acute Coronary Syndromes Reperfusion Strategies Gregory W Barsness, MD, FACC, FAHA, FSCAI Director, Mayo Clinic Cardiac Intensive Care Unit Director, Mayo Clinic EECP Laboratory ©2013 MFMER | slide-1 Disclosures No pertinent financial conflicts Off-label Usage: DES in ACS ©2013 MFMER | slide-2 ACS Epidemiology Proportion of STEMI vs NSTE-ACS > million ED visits for chest pain 1.57 million admissions for ACS (1 MI every 44 seconds in US) ~ 70% of all acute MI are NSTEMI 100 NSTEMI STEMI Percent 80 60 40 20 1999 2000 2001 2002 2003 2004 2005 Year Chan, et al Circ 2009;119 2013 AHA Heart and Stroke Statistics, cardiosource.org ©2013 MFMER | slide-3 All-Cause Mortality in STEMI vs NSTEMI 4606 AMI Pts Undergoing Angiography 70 Mortality (%) 60 NSTEMI 50 40 30 STEMI 20 10 0 Years Chan, et al Circ 2009;119 ©2013 MFMER | slide-4 Therapy in NSTE-ACS is Complex Anticoagulants: UFH LMWH Fondaparinux Bivalirudin Antiplatelets: ASA Clopidogrel Prasugrel (dose) (dose) Ticagrelor IV antiplatelets: None Abciximab Eptifibatide/Tirofiban Cath strategy: Early Delayed Never 144 Different Combinations with different effects on bleeding and thrombosis risk! ©2013 MFMER | slide-5 Guideline Adherence and Outcome In-hosp mortality (%) 5.95 5.16 Adjusted Unadjusted 6.33 5.07 4.97 4.63 4.16 4.17 Every 10%  in guidelines adherence 11%  in mortality =75% Hospital composite quality quartiles Peterson, et al ACC 2004 ©2013 MFMER | slide-6 Early-Invasive vs Delayed-Invasive (Ischemia-Guided) Strategy ISAR-COOL ICTUS VANQWISH (1998) (2005) MATE TIMI III-B RITA-3 (2002) TRUCS (1994) VINO TACTICS25% Relative Mortality Risk Reduction TIMI 18 Over Years! FRISC II (2001) (1999) Weight of the evidence Favors “Conservative” n=920 No difference n=2,874 Favors Early Invasive n=7,018 ©2013 MFMER | slide-7 Timing of Intervention in ACS (TIMACS) Early (36) Kaplan-Meier Cumulative Risk of the Death, MI or Stroke Stratified by Baseline GRACE Risk Score: Low (≤140) vs High Risk (>140) 0.25 Delayed Cumulative Hazard High Risk Early Early Delayed Low-toIntermendiate Risk 0.00 Early intervention (med 14 hrs) 90 Days 180 Delayed intervention (med 50 hrs) Mehta SR et al NEJM 2009;360:2165-2175 ©2013 MFMER | slide-11 Timing of Intervention in ACS (TIMACS) Early (36) Kaplan-Meier Cumulative Risk of the Death, MI or Stroke Stratified by Baseline GRACE Risk Score: Low (≤140) vs High Risk (>140) 0.25 Delayed Cumulative Hazard High Risk Early I IIa IIb III 0.00 Early intervention (med 14 hrs) 90 Days 180 Delayed intervention (med 50 hrs) Mehta SR et al NEJM 2009;360:2165-2175 ©2013 MFMER | slide-12 ABOARD Immediate vs Delay Angio in High-Risk ACS Peak Troponin I * 30-Day MACE 30-Day Major Bleeding 16 13.7 14 12 10.2 10 6.8 4 2.1 1.7 Immediate (Mean 70 Min) *Primary Endpoint n=352 All p=NS Delayed (Mean 21 Hrs) Montalescot, et al JAMA 2009;302:947 ©2013 MFMER | slide-13 STEMI Management Algorithm Www www.cardiosource.org ©2013 MFMER | slide-20 35-Day Mortality Reduction with Thrombolysis 58,600 Patients – Trials 30 Mortality (%) P