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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.

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Presentation on theme: "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."— Presentation transcript:

1 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) Eduard van den Berg, cardio.nl1

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6 GRACE score best score for ACS at the moment Eduard van den Berg, cardio.nl

7 Eduard van den Berg, cardio.nl7 Mortality after Acute Coronary Syndromes Cumulative: 13.6% Blue 10.6% Green 11.6% Red

8 Do we need risk scoring ? Eduard van den Berg, cardio.nl8 Risk scoring leeds to lower mortality

9 Eduard van den Berg, cardio.nl9 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

10 Eduard van den Berg, cardio.nl10 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

11 Eduard van den Berg, cardio.nl11 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- CCS class in last 6/52 – Signs of CCF- ST depression on ECG GRACE – Age- Heart rate and systolic BP – Creatinine- CCF (Killip class) – Cardiac arrest at admission – Elevated cardiac markers- ST segment deviation

12 Eduard van den Berg, cardio.nl12 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- CCS class in last 6/52 – Signs of CCF- ST depression on ECG GRACE – Age- Heart rate and systolic BP – Creatinine- CCF (Killip class) – Cardiac arrest at admission – Elevated cardiac markers- ST segment deviation

13 Eduard van den Berg, cardio.nl13 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

14 How was GRACE introduced ? Eduard van den Berg, cardio.nl14 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

15 Eduard van den Berg, cardio.nl15 Missed Opportunities for Reperfusion ST ↑ or LBBB, <12 hrs from onset, no contraindications ANC (%) US (%) AB (%) EUR (%) n PCI alone Lytic alone Both Neither AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States Eagle KA et al. Lancet 2002;359:373-7.

16 Eduard van den Berg, cardio.nl16 Independent Predictors of No Reperfusion Variable OR (95% CI) Prior CABG 2.28 ( ) History of diabetes 1.46 ( ) History of congestive heart failure 2.92 ( ) Presentation without chest pain 2.23 ( ) *Age  75 years 2.37 ( ) *As compared to the <55 years age group Eagle KA et al. Lancet 2002;359:373-7.

17 Eduard van den Berg, cardio.nl17 ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil Geographical Variation: Admission to Hospitals with/without Access to Cath Lab

18 Eduard van den Berg, cardio.nl18 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:

19 Eduard van den Berg, cardio.nl19 Geographic Practice Variation Budaj A et al. Am Heart J 2003;146:

20 Eduard van den Berg, cardio.nl20 Incidence of Major Bleeding Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.

21 Eduard van den Berg, cardio.nl21 ** **P<0.001 In-Hospital Mortality Rates ** Moscucci Met al.Eur Heart J 2003;24: Moscucci M et al.Eur Heart J 2003;24:

22 Eduard van den Berg, cardio.nl22 Hospital Outcomes of ACS Patients Stratified by Statin Use Outcome Prior statins Prior & Hospital Hospital Statins Only Statin Only Death1.39 (0.91,2.14) 0.20 (0.16,0.25)0.38 (0.30,0.48) Recurrent MI0.69 (0.43,1.11) 0.90 (0.75,1.07)1.22 (1.08,1.37) Stroke1.08 (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:

23 Eduard van den Berg, cardio.nl23 At Admission Risk Model

24 Eduard van den Berg, cardio.nl24 At Discharge Risk Model

25 Eduard van den Berg, cardio.nl25 GRACE PDA Software

26 Eduard van den Berg, cardio.nl26 Manuscript Status

27 Eduard van den Berg, cardio.nl27 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

28 Eduard van den Berg, cardio.nl28 Guide to GRACE manuscripts (1999 to 2006)

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30 Bleeding Risk Score Eduard van den Berg, cardio.nl30 C an R apid risk stratification of U nstable angina patients S uppress AD verse outcomes with E arl implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE)

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