1. Management of Acute Myocardial Infarction Minimal Acceptable vs Optimal Care Hussien H. Rizk, MD Cairo University

2. Background Suspicious chest pain: extremely common cause of ER visits Acute MI: the most costly cardiac cause of ER visits 5-10% of acute MI patients are missed because of errors in symptom interpretation or missed ECG diagnosis Many patients do not receive proven inexpensive effective therapy

3. Clinical proceedings of a suspected MI Symptom evaluation –Pain characteristics –Heart failure, syncope –Contraindication to SK Physical examination ECG –Quick –Interpretation correct Lab work-up –Basic [Sugar. CRT. K. CK if no ST elevation] –CXR –Specific [Clinically guided] Disposal: –Discharge –Observation –Admission –Referral Relief of symptoms –Pain –Nausea –Anxiety Aspirin –Saves as many lives as SK ACE-I –Low dose [Captopril 6.25] –Not if SBP<100 BB Thrombolysis –SK –TPA: SK sensitive or recent use Primary PCI: –Who? Where?

4. Should everybody with acute MI have: Statin? Clopedogrel? Platelet GP II b/III a inhibitor? Primary PCI?

5. Timing of Statin Therapy Initiation After ACS in Recent Clinical Studies Days Secondary prevention 06 Months 3 2 L-CAD CARE LIPID 24 Hours 10 6 8 12 184 MIRACL 4S 6 Atorvastatin Pravastatin Simvastatin PROVE IT WOSCOPS Primary prevention ACS Fluvastatin FLORIDA

6. MIRACL Study Outcome Measures Primary –Death, Non-fatal MI, Cardiac arrest –Worsening angina + evidence of myocardial ischemia. Secondary –Stroke –Revascularization. –Worsening CHF –Worsening angina without evidence of ischemia Schwartz GG et al. JAMA 2001;255:1711

7. Time Since Randomisation (Weeks) 0481216 15 10 5 0 Placebo 17.4% Atorvastatin 14.8% Risk reduction = 16% P=0.048 95% CI = 0.701–0.999 Time to first occurrence of composite endpoint of: n Death (any cause) n Non-fatal MI n Resuscitated cardiac arrest n Worsening angina with new objective evidence and urgent rehospitalisation Schwartz GG et al. JAMA 2001;255:1711-8. MIRACL: Primary Efficacy Measure Cumulative Incidence (%) Placebo 8.4% Atorvastatin 6.2% MIRACL Worsening Angina with New Objective Evidence of Ischemia Requiring Urgent Hospitalisation Risk reduction = 26% P=0.02

8. MIRACL: COST-BENEFIT Absolute risk reduction for worsening angina: 2.2% NNT = 100/2.2 = 45.5 Cost of avoiding one worsening angina event = NNT x No of Days x Daily cost (Ignoring lab tests & treating complications) = 45.5 x 120 X 36 = 196,364 LE

9. GP II b/III a inhibitors for medically treated acute coronary syndromes GUSTO 4-ACS: Abciximab, no acute revascularization. No benefit at 30D (Simoons. Lancet 2001;357:1915) or 1Y (Ottervanger et al. CIRCULATION 2003;107:437) GRAPE pilot: abciximab for acute MI: TIMI 3 flow in 20% (van der Merkhof et al. JACC 1999;33:1528) PRISM: Tirofiban reduced total mortality compared to heparin alone.

10. Tirofiban in ACS: 1.5% ARR of 30D mortality compared to heparin alone PRISM. NEJM 1998;338:1498 NNT = 67 Cost/event = LE 130,000

11. PRISM PLUS: terminated prematurely for excess mortality with tirofiban (4.6% vs 1.1% for heparin alone)

13. DANAMI-2 COST-BENEFIT 6% Absolute risk reduction NNT = 16.7 Procedure cost: LE 14,000 Cost of preventing ONE EVENT (MI) at 30D = LE 233,800

14. MINIMAL ACCEPTABLE CARE FOR MI CLINICAL TRAINING COST-EFFECTIVE ROUTINE LAB: FBS. BUN. K. CK. CXR ROUTINE Rx. SYMPTOMS. ASA. SK. BB. ACE-I NOT ROUTINE: –TPA –CLOPEDOGREL –STATIN –PLATELET GLYCOPROTEIN INHIBITORS –PRIMARY PCI