"Routine invasive" versus "selective invasive" approaches to non–ST-segment elevation acute coronary syndromes management in the post-stent/platelet inhibition era
William E. Boden, MD, FACC* ,*,1
* Division of Cardiology and the Henry Low Heart Center at Hartford Hospital, Hartford, Connecticut, USA
Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
View larger version (33K):
[in a new window]
|
Figure 1 Acute ischemia pathway. EF = ejection fraction; LV = left ventricular; Rx = treatment. Adapted from ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2000;36:970–1062. Copyright 2002 by the American College of Cardiology and American Heart Association, Inc. Permission granted for one-time use.
|
|
View larger version (15K):
[in a new window]
|
Figure 2 From the VANQWISH trial: Kaplan-Meier curves for the trial primary end points (death or MI) at one-year of follow-up. CHR = Cox hazard ratio; CI = confidence interval; MI = myocardial infarction; VANQWISH = Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital. Adapted with permission from Boden WE, O’Rourke RA, Crawford MH, et al., for the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial investigators. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med 1998;338:1785–92. Copyright © 2002, Massachusetts Medical Society. All rights reserved.
|
|
View larger version (34K):
[in a new window]
|
Figure 3 From the FRISC-II trial. Kaplan-Meier analysis of the probability of event-free survival according to strategy group during six months of follow-up for the trial primary end point of death or MI, showing significant benefit in clinical outcomes for the routine invasive strategy. CI = confidence interval; FRISC = Fragmin and fast Revascularization during InStability in Coronary artery disease; MI = myocardial infarction; RR = risk reduction. Adapted with permission from Elsevier Science (The Lancet 1999;354:708–15).
|
|
View larger version (16K):
[in a new window]
|
Figure 4 From the TACTICS TIMI-18 trial. Kaplan-Meier analysis of the probability of event-free survival for the triple composite end point of death, MI, and biomarker-positive ACS during six months of follow-up, showing a significant benefit for the routine invasive strategy. CI = confidence interval; MI = myocardial infarction; OR = odds ratio; TACTICS TIMI = Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction trial. Adapted with permission from Cannon CP, Weintraub WS, Demopoulos LA, et al., for the TACTICS–Thrombolysis in Myocardial Infarction-18 investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879–87. Copyright © 2002, Massachusetts Medical Society. All rights reserved.
|
|
View larger version (40K):
[in a new window]
|
Figure 5 Flow diagram of a proposed risk-stratification algorithm for patients with non–ST-segment elevation acute coronary syndromes. ASA = aspirin; ECG = electrocardiogram; GP IIb/IIIa = glycoprotein platelet IIb/IIIa inhibitor; Hx = history; LMWH = low-molecular-weight heparin; PCI = percutaneous coronary intervention; PE = physical exam; STTWA = ST-T-wave abnormalities; TW = T-waves; UFH = unfractionated heparin. Derived from Boden WE, McKay R. Optimal treatment of acute coronary syndromes—an evolving strategy. N Engl J Med 2001;344:1939–42.
|
|
|
