13. High Risk Intermediate Risk Low Risk History Known CAD Prior MI Patient presenting with typical symptoms Chest/left arm pain Age >70yrs Diabetes Male Recent cocaine use Physical Exam Pulmonary Edema Hypotension, MR Arrythmias Manifestation of extra-cardiac vascular disease Pain reproducible on exam ECG New transient ST segment depression >1mm T wave inversions in multiple leads New T-wave changes Pathological Q waves St depression 0.5-1mm Normal or unchanged Cardiac Markers Elevated cardiac enzymes Slightly elevated Normal
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23. TIMI IIIB (94) Conservative Strategy Favored N=920 Invasive Strategy Favored N=7,018 VANQWISH (98) MATE FRISC II (99) TACTICS- TIMI 18 (01) VINO RITA-3 (02) TRUCS ISAR- COOL ICTUS (05) No difference N=2,874 Weight of the evidence
changes greater than 0.5 mm Bundle-branch block, new T-wave changes Pathological Q waves or resting ST-depression less than 1 mm in multiple lead groups Normal or unchanged ECG
Score of more than 3 is high risk
Initial troponin is negative
Intravenous NTG may be initiated at a rate of 10 mcg per min and increased by 10 mcg per min every 3 to 5 min until relief of symptoms or blood pressure response is noted. A ceiling dose of 200 mcg per min is commonly used. Systolic blood pressure generally should not be reduced to less than 110 mm Hg in previously normotensive patients or to more than 25% below the starting mean arterial blood pressure if hypertension was present
Why have we moved towards considering these two strategies. Early study Vanquish showed harm with an early invasive strategy, Then came other trials which showed benefit. So in 2002 guidelines, all NST ACS patients should be treated with an invasive approach. Then came Most recently came ICTUS which showed no difference, so guidelines in 2007 were changed to say consider either strategy based on the risk of the patient. NOTE THAT ALL THE TRIALS THAT HAVE FAVORED AN INVASIVE APPROACH SHOW AN IMPROVEMENT IN REDUCTION IN ISCHEMIA. REDUCTION IN DEATH IS INCONSISTENT IN BETWEEN THE TRIALS, however some meta analaysis show some improvement in mortality
If patient has these low risk features they can be managed medically
If elected from start to take the early invasive approach
More bleeding in prasugrel arm but overall benefit outweigh the risk
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