Crusade

Grace

ESTRATEGIA INVASIVA en SCASEST

ESTRATEGIA INVASIVA en SCASEST

ACTP vs CIRUGÍA

TRATAMIENTO ANTITROMBÓTICO en SCASEST

Before angiography it may not be clear what the true diagnosis is

• The ACCOAST-PCI study shows that there is no downside in

waiting to provide prasugrel until after coronary angiography in

patients who will need dual antiplatelet therapy for stenting1. 32%

of patients in ACCOAST did not go to PCI (but CABG or MM) →

not in-label for prasugrel)2

1. Montalescot et al. J Am Coll Cardiol. 2014 Dec 23;64(24):2563-712. Montalescot et al. N Engl J Med. 2013 Sep 12;369(11):999-1010

Why is it important to confirm the diagnosis NSTE-ACS before initiating any DAPT?

• Myocarditis• Takatsubo• Arrhythmias• Acute heart failure• Aortic dissection• Pulmonary embolism• Chemotherapy

• Infection/Sepsis• Circulatory shock• COPD exacerbation• Pneumonia• CO intoxication• …….• …….

There are many other causes of myocardial injury with/without CAD

Pretreatment not beneficial or even harmful

NSTE-ACS patient receiving DES: What do the trials show?

• BASKET-PROVE trial1: Compared with BMS, use of DES in NSTE-ACS patients undergoing stent implantation in large vessels was associated with a reduction in both TVR and the combined endpoint consisting of cardiovascular death/MI. Thus, DES use improves both efficacy and safety. These findings support the use of DES in NSTE-ACS patients.

• Prasugrel: TRITON-NSTE DES subgroup: Statistical significant 65% RRR in definite stent thrombosis vs. clopidogrel (p=0.0001)2,3

• Ticagrelor: PLATO-NSTE DES subgroup: Non-significant 31% RRR in definite stent thrombosis vs. clopidogrel (p=0.2304)4,5

1. Pedersen et al. EuroIntervention. 2014 May;10(1):58-642. Adapted from Wiviott SD et al, Lancet (2008);371:1353-1363 3. Data on file Daiichi Sankyo, Ltd. and Eli Lilly and Company4. Advisory Committee Briefing Document Drug Substance Ticagrelor Date 23 June 20105. Adapted from Cannon CP et al, Lancet (2010);375: 283-293

Take home messages

1. Identificación de los criterios primarios o secundarios de riesgo elevado para la indicación de una estrategia invasiva precoz < 24 horas: aumento de la troponina; cambios dinámicos del segmento ST o la onda T (sintomáticos o silenciosos) .

• Orientación a la UCI• Traslado al laboratorio de cateterismo para coronariografía ± angioplastia

en las 24 horas.

2. SCASEST es una urgencia médica.

3. La realización de anamnesis, exploración y ECG permite el diagnóstico inicial.

4. La estratificación del riesgo es indispensable para decidir la estrategia a seguir.

5. En SCASEST de alto riesgo se recomienda la realización de cateterismo en las primeras 24 horas.

6. Es más inconveniente seguir el camino de enviar al paciente a UCI y después cateterismo a las 24 horas.