Stanford ACS Guidelines 2003

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Stanford ACS Guidelines 2003

• David P. Lee, M.D.
• John S. Schroeder, M.D.
• Donald Schreiber, M.D.
• Division of Cardiovascular Medicine and
  Department of Emergency Medicine

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Acute Coronary Syndromes

• Within the guidelines, ACS is defined as
• Unstable angina
• Non-ST-elevation MI
• These guidelines do NOT apply to acute
  ST-elevation MI

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Acute Coronary Syndromes

• Based upon recent clinical data, these guidelines
  reflect new management strategies in ACS
• Any questions or comments may be directed to any
  of the authors

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ESSENCE
Time to First Triple Endpoint (Death/MI/RA)
40
35
30
25
20
Cumulative event rate ()
15
10
5
0
0
2
4
6
8
10
12
14
Months
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Cardiac Events at 6 Months
P value
INV ()
CONS ()
RR
No. Pts 1o Endpoint Death/MI Death MI Rehosp
ACS
1114 15.9 7.3 3.3 4.8 11.0
1106 19.4 9.5 3.5 6.9 13.7
0.78 0.74 0.93 0.67 0.78
0.025 lt0.05 0.74 0.029 0.054
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Primary Endpoint
Death, MI, Rehosp for ACS at 6 Months
20
16
Patients
12
8
4
0
0
1
2
3
4
5
6
Time (months)
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TIMI Risk Score 6 month results
RR0.55 CI (0.33, 0.91)
CONS
INV
RR0.75 CI (0.57, 1.00)
Death/MI/ACS Rehosp ()
TIMI Risk Score
of Pts 25 60 15
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Outcomes
Plac Clop
RR CI p
Patients 6303 6303 6259
1st Co-Primary 11.41 11.41 9.30 0.80 0.72-0.90 lt 0.001
CV Death CV Death 5.47 5.08 0.93 0.79-1.08
MI MI 6.65 5.18 0.77 0.67-0.89
Stroke Stroke 1.38 1.20 0.86 0.63-1.18
Non CV death Non CV death 0.71 0.66 0.91 0.60-1.39
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Cumulative Hazard Rates for CV Death/MI/Stroke
Placebo
Clopidogrel
Cumulative Hazard Rates
P lt 0.001
0
3
6
9
12
Months of Follow-up
N
6303 6259
5780 5866
4664 4779
3600 3644
2388 2418
Plac Clop
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Acute Coronary Syndromes

• Data from several recent trials suggest
• Unfractionated heparin should be replaced by low
• molecular weight heparin (enoxaparin) ESSENCE
• In higher-risk patients, early (upstream) use
  of a platelet glycoprotein IIb/IIIa receptor
  inhibitor should be strongly considered as well
  as early angiography (within 24 hours of
  hospitalization) TACTICS/TIMI-18
• Clopidogrel should be considered for early
  therapy CURE/OASIS-4
• An HMG-co-A-reductase inhibitor (statin) should
  be initiated during hospitalization MIRACL

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TIMI Risk Score for UA / NSTEMI
HISTORICAL
POINTS
RISK OF CARDIAC EVENTS () BY 14 DAYS IN TIMI 11B
Age ?? 65
1
RISK SCORE
DEATH OR MI
DEATH, MI OR URGENT REVASC
? 3 CAD risk factors (FHx, HTN, ? chol, DM,
active smoker)
1
0/1 2 3 4 5 6/7
3 3 5 7 12 19
5 8 13 20 26 41
Known CAD (stenosis ? 50)
1
ASA use in past 7 days
1
PRESENTATION
Recent (?24H) severe angina
1
? cardiac markers
1
ST deviation ? 0.5 mm
1
RISK SCORE Total Points (0 - 7)
Entry criteriaUA or NSTEMI defined as ischemic
pain at rest within past 24H, with evidence of
CAD (ST segment deviation or marker)
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Antman et al JAMA 2000 284 835 - 842
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ACS ALGORITHM in ED
Chest pain
Suspicious for cardiac?
Yes
No
Low
High
Risk
OPT f/u
ASA Clopidogrel /- Enoxaparin
ASA Clopidogrel Enoxaparin Tirofiban EARLY CATH
(lt24h)
Fxn test If , CATH
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TIMI risk scoregt 2, active ECG changes,
refractory pain, marker
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Acute Coronary Syndromes

• Notes about the ACS algorithm
• IV NTG and beta-blocker encouraged
• OK to give enoxaparin before catheterization
• If surgery is anticipated, hold clopidogrel
• Early catheterization encouraged in higher-risk
  patients
• 5. If IIb/IIIa used on the floor, may use
  either tirofiban or eptifibatide

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Acute Coronary Syndromes

• Notes about the ACS algorithm
• 7. If IIb/IIIa used, reduce enoxaparin dose to
  0.75 mg/kg SQ BID
• For patients with CrCllt30 or creatinine gt2.0,
  give unfractionated heparin and adjust to ½ dose
  IIb/IIIa
• No dosing adjustment necessary for obesity
• Statin use should be started on day 1

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Acute Coronary Syndromes Dosing

• ASA 325 mg chewable
• 81 mg if already on ACE-inhibitor
• Clopidogrel 300 mg po load, then 75 mg QD
• Enoxaparin 1 mg/kg SQ BID
• 0.75 mg/kg SQ BID if IIb/IIIa used
• Tirofiban 0.40 mcg/kg/min IV x 30 minutes,
  then 0.10 mcg/kg/min
• (In Acute MIs use 10mcg/kg IVB over 3
  minutes, then 0.15mcg/kg/min)
• Eptifibatide 180 mcg IV bolus, then 2.0
  mcg/kg/min

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