RESIDENTS CAN ALWAYS START WITH ASPIRIN AND ANTI-THROMBIN AND DISCUSS PGY12 TIMING with CARDS.Įarly trials such as the VA Cooperative Study (1983) and ISIS-2 (1988) demonstrated that aspirin, which inhibits platelets through irreversible cyclooxygenase blockade, decreases mortality in UA/NSTEMI. PLACE ALL PATIENTS WITH NSTEMI ON APPROPRIATE MEDICAL THERAPY. May have benefit, but may also delay CABG if needed. Unclear if patients should be pre-treated prior to invasive strategies in first 24 hours. Prasugrel and ticagrelor more rapid onset. Ticagrelor (see PLATO Trial) has reduction in death from vascular causes or MI in 1 year compared to clopidogrel, may see bradycardia. Prasugrel has increased bleeding risk but better ichemic outcomes. Newer agents likely better based on recent studies. Certain newer trials so benefit to Ticagrelor and prasugrel, still not clear about which is best but all patients need to be on one of the 3. P2Y12 inhibitor AHA/ACC Class 1 (clopidogrel, prasugrel, ticagrelor). Aspirin Class I therapy in all ACS patients 162-325 mg (rapidly inhibits platelet activation by halting thromboxane A2 production). ACC/AHA Class 1 recommendation: anti-coagulation recommended for all patients with NSTE-ACS: Unfractionated heparin or LMWH. Medical therapy will usually include both anti-thrombin strategies and anti-platelet strategies seen below. Those without immediate need but still intermediate risk will undergo invasive strategy within 48 hours while receiving medical therapy. In addition, TACTICS-TIMI 18 was also a trial of the IIb/IIIa inhibitor tirofiban, which continues to have a limited role in NSTE-ACS, primarily as bailout therapy in patients undergoing PCI of high-risk lesions.Īngiography is preformed immediately for refractory angina, hemodynamic instability, ventricular arrythmia, or acute heart failure. It is important to note that although both the biomarker and TIMI risk stratification findings (i.e., patients with negative troponins or patients with TIMI risk score 0-2 do not benefit from an early invasive strategy) are often incorporated into routine clinical practice, the interaction between the primary outcome and these individual subgroups did not reach statistical significance however, given stark numerical differences and apparent risk-response pattern within the TIMI score group (i.e., as TIMI risk increased, benefit with early angiography increased), lack of statistical interaction likely reflects underpowered subgroups in this case rather than a spurious finding. Overall the results of TACTICS-TIMI 18 provide practical guidance for the selection of patients who are most likely to benefit from early coronary angiography and intervention in non-STEMI ACS. Importantly, patients with TIMI score 0-2 and patients with undetectable troponins (25% of the study population) did not appear to benefit from routine angiography and PCI, suggesting that it is reasonable to pursue stress testing in these low-risk patients with intervention reserved for patients with significant ischemia on functional testing. Notably there was no mortality benefit with an early invasive approach, and this strategy was associated with a 2% absolute increase in protocol-defined bleeding. This benefit was most apparent in patients presenting with ST segment changes, troponin elevation at presentation, and patients with intermediate or high TIMI risk scores (3 or greater). TACTICS-TIMI 18 demonstrated a clear reduction in major adverse cardiovascular events with an early invasive approach, driven primarily by a reduction in nonfatal MI and recurrent ischemia. Overall, 60% of patients in the early invasive arm underwent revascularization versus 36% in the conservative arm. ![]() In the conservative strategy, patients underwent coronary angiography only if noninvasive stress testing was positive or there was failure of medical therapy (prolonged angina at rest, hemodynamic instability, recurrent angina or MI). In the early invasive strategy arm, 97% of patients underwent coronary angiography a median of 22 hours (all within 48 hours) after presentation with PCI or CABG to culprit lesions. The 2001 Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy – Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) trial randomized 2220 patients to either a protocolized early invasive strategy versus a delayed selectively invasive strategy with each arm receiving the IIb/IIIa inhibitor tirofiban. Unlike patients presenting with STEMI in which there is a clear mortality benefit to emergent coronary angiography and PCI, it is less clear whether patients with non-STEMI ACS (unstable angina or non-ST segment elevation MI) also benefit from routine early angiography and intervention.
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