Management of Acute Myocardial Infarction Minimal Acceptable vs Optimal Care Hussien H. Rizk, MD...
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Transcript of Management of Acute Myocardial Infarction Minimal Acceptable vs Optimal Care Hussien H. Rizk, MD...
Management of Acute Myocardial Infarction
Minimal Acceptable vs Optimal Care
Hussien H. Rizk, MDCairo University
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
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?
Should everybody with acute MI have:
• Statin?• Clopedogrel?
• Platelet GP II b/III a inhibitor?
• Primary PCI?
Timing of Statin Therapy Initiation After ACS in Recent Clinical Studies
Days
Secondary prevention
0 6Months
32
L-CAD CARE
LIPID
24Hours
10 6 8 1212 18 4
MIRACL
4S
6
Atorvastatin
Pravastatin
Simvastatin
PROVE IT
WOSCOPS
Primary prevention
ACS
Fluvastatin
FLORIDA
MIRACLStudy 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
Time Since Randomisation (Weeks)
0 4 8 12 16
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: Death (any cause) Non-fatal MI Resuscitated cardiac arrest 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
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
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.
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
• PRISM PLUS: terminated prematurely for excess mortality with tirofiban (4.6% vs 1.1% for heparin alone)
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