ACS Guidelines

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ACS Guidelines
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Revising ACS Guidelines

• Take account of revised diagnosis
• In-patient assessment of all myocardial
  infarction (unless serious co-morbidity)
• any troponin rise in context of definite or
  probable ACS
• Increasing awareness of prognosis NSTEMI
• Take account of new data
• Improved risk scoring
• Allow for changing hospital facilities
• DGH cath lab facilites improved functional
  imaging capability

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Mortality after Acute Coronary Syndromes
MINAP 2008
Cumulative 13.6 Blue 10.6 Green 11.6 Red
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Do we need risk scoring ?

• Canadian ACS Registry II
• 36 hospitals 2358 patients
• Referral rate for LHC 64.7
• 62.5 of higher risk and 66.9 of lower risk
• Lower mortality rates in those referred

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Do we need 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

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ACS Risk Scoring

• TIMI
• Age - Use of aspirin
• Risk Factors - Known CAD
• gt 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

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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

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Risk Scoring at admission
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Thresholds of Risk
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ACS Guidance

• CAG discussion Jan and April
• General agreement/minor differences of emphasis
• TIMI vs GRACE
• Intermediate vs High risk
• Role of troponin

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ACS Guidance

• CAG discussion Jan and April
• General agreement/minor differences of emphasis
• TIMI vs GRACE
• Intermediate vs High risk
• Role of troponin

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ACS Guidance

• CAG discussion Jan and April
• General agreement/minor differences of emphasis
• TIMI vs GRACE
• Intermediate vs High risk
• Role of troponin
• Compromise
• Local unit modification appropriate, eg TIMI in
  A/E
• Commonality treatment and referral principles
• Audit

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Key changes

• Use of risk score
• Emphasis on paired troponin testing
• Intermediate risk group
• In-patient investigation
• Functional testing/imaging or diagnostic imaging
  according to local availability/preference
• Recommended target timescales for intervention

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ACS guidance Pg 2
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ACS Audit

• MINAP
• Secondary prevention
• Clopidogrel prescribing
• Network
• Audit against guidelines
• Case note review against positive troponin result
  clear diagnosis of MI? appropriate use of
  troponin
• Definite ACS use of GRACE score, referred,
  revascularised, clinical outcome at 6 months (cf
  GRACE)
• Time scales for investigation and treatment
• Standard of 72 h

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Discharge Risk score An Audit Standard ?
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DISCUSSION