DGH management of acute coronary syndromes

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DGH management of acute coronary syndromes

• Who can be discharged without angiography ?
• Dr Conrad Murphy
• St Richards Hospital Chichester

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Prognosis of ACS
Terkelsen EHJ 2005
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Who is likely to benefit from pre-discharge
angiography ?
Risk of Early Ischaemic Event
Low Moderate
High
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Invasive vs Conservative Strategy for UA/NSTEMI
ISAR-COOL
RITA-3
VANQWISH
ICTUS
VINO
MATE
TRUCS
TIMI IIIB
TACTICS-TIMI 18
FRISC II
Conservative
Invasive
UA indicates unstable angina, NSTEMI,
nonST-segment myocardial infarction ISAR,
Intracoronary Stenting and Antithrombic Regimen
Trial RITA, Randomized Intervention Treatment of
Angina VANQWISH, Veterans Affairs Non-Q-Wave
Infarction Strategies in Hospital study MATE,
Medicine vs Angioplasty for Thrombolytic
Exclusions trial TACTICS-TIMI18, Treat Angina
with Aggrastat and Determine Cost of Therapy
with Invasive or Conservative Strategy and
FRISC, Fragmin during InStability in Coronary
artery disease.
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The benefits of pre-discharge angiography
intervention

• Other benefits
• Investigation upfront
• Simplify follow up
• Back to work
• Happy patient
• On-Guideline

• The trial evidence
• Readmissions
• Non-fatal MI
• Mortality
• QOL

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The downside of pre-discharge angiography
intervention (UK)

• May destabilise otherwise stable patient
• Other procedural and therapy complications
• Bed blocking while waiting for transfer

Beds Blocked Each Day
2003 2004
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Who is likely to benefit from pre-discharge
angiography ?
Risk of Early Ischaemic Event
Low Moderate
High
Angiography
Most cases ESC 2002
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Who to transfer Grace data
Age 0-100
CCF 24
Previous MI 14
Heart Rate 0-43
BP 0-24
ST depression 11
CRF 1-20
Enzymes up 15
No in-hosp PCI 14
Eagle et al JAMA 2004
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Who to transfer TIMI score (Non-STEMI)
of MI population
Event rate at 14 days
Event Rate Post MI
TIMI scoring Age CAD risk Factors Known
CAD Aspirin use Recent severe AP Elevated
Markers ST deviation Score 0-7
TIMI score
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Exercise testing in risk stratification
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Who does not need pre-discharge angiography after
ACS ?

• Not candidate for intervention
• Completed MI
• Lower risk non-Q MI
• Stable
• No high risk features
• Good Ex Test other risk stratification
• Not disadvantaged by delayed investigation
• Regional centre lead

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Conclusion

• The move to angiogram based risk stratification
  and treatment is irresistible and preferable
• Cost effectiveness will be lost if long transfer
  times persist
• limitations of a lesion based approach

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What to do next