Download THE NEW SIGN GUIDELINES

THE NEW SIGN
GUIDELINES
Malcolm Metcalfe
Aberdeen Royal Infirmary
SIGN guidelines
6th February 2007
SIGN 93 - ACS
Principle recommendations
• Patients with NSTEMI at medium or high risk of early
recurrent cardiovascular events should undergo early
coronary angiography +/- intervention.
– GRACE score rather than TIMI recommended
• Patients with STEMI treated with thrombolysis should
be considered for coronary angiography +/intervention
– 4 RCTs. Eg GRACIA -1, at 1 year 12% ARR, 56%RRR
combined end point.
Risk assessment using the TIMI
score (JAMA 2000; 284: 835-)
GRACE score
www.outcomes-umassmed.org/grace
The in-hospital GRACE model was based upon data from 11,389 patients with either an STEMI
or a non-ST elevation ACS (1). This model was then validated based upon data from an
additional 3972 patients from GRACE and 12,142 patients from the GUSTO IIb trial. Eight
independent risk factors were found to account for
almost 90 percent of the prognostic information:
Killip class
Age

Class I - no evidence of HF
Killip class

Class II - findings consistent with mild to moderate
HF (S3, lung rales less than one- half way up
the
posterior lung fields, or jugular venous distension)

Class III - overt pulmonary edema

Class IV - cardiogenic shock
Systolic blood pressure
Presence of ST segment deviation
Cardiac arrest during presentation
Serum creatinine concentration
Presence of elevated serum cardiac biomarkers
Heart rate
Point scores were assigned for each predictive factor and are added together to arrive at an estimate of the risk of inhospital mortality.
Pharmacological highlights
• Clopidogrel in NSTEMI for only 3
months (saves £2M)
• All patients with established vascular
disease should be on ACEI
• Patients with MI, LVD (LVEF <40%) with
either heart failure or diabetes should
be given eplerenone
SIGN 94 - Arrhythmias
• Defibrillation in patients with VF or pulseless VT
should be administered without delay in witnessed
cardiac arrests and following 2 minutes of CPR in
unwitnessed cardiac arrests [B].
• Automated external defibrillators should be sited in
locations which have a high probability of cardiac
arrests [B].
• IV amiodarone should be considered for the
management of refractory VT/VF [A]
SIGN 94 - Arrhythmias
• In AF rate control is the recommended strategy for
asymptomatic patients [A]
• Ventricular rate in AF should be controlled with B
blockers, rate-limiting Ca antagonists or digoxin [A].
• Ablation and pacing should be considered for
patients with AF who remain severely symptomatic or
who have LV dysfunction in association with poor rate
control or intolerance of rate-limiting medication [B].
SIGN 94 - Arrhythmias
• Patients 1 month after MI with symptomatic LV
dysfunction (<35%) should be considered for ICD [A].
• Patients with NSVT (esp if inducible), LVEF < 25% or
prolonged QRS should be offered ICD [B]
• Patients with above but also NYHA III-IV and QRS
>120 should be considered for CRT-D [A]
• Patients surviving cardiac arrest in absence of
ischaemia or other treatable cause should be
considered for ICD [A]
SIGN 95
Management of CHF
• BNP and/or ECG should be used to
indicate the necessity for
echocardiography in patients with
suspected heart failure [A].
• A CXR is still recommended early in the
diagnostic pathway to investigate other
potential causes of SOB [B].
Pharmacology
• ACEIs recommended for all grades of LVSD [A]
• B Blockers recommended for all stable LVSD patients
[A]
• Patients intolerant of ACEI should be given ARB [A]
• Patients with LVSD who are still symptomatic despite
above can be considered for an ARB as additional
therapy [B]
• Digoxin should be considered as add on therapy [B]
Devices
• For patients in SR with drug refractory
symptoms due to LVSD and who are in
NYHA III or IV with a QRS duration
>120ms - CRT should be considered
[A].
• Caveats
– benefit may be greatest for NYHA II-III
– RBBB does not appear to benefit
CARE-HF Extension Study
Effect of CRT on All-Cause
1.00
Hazard Ratio 0.60
Mortality
(95% CI 0.47 to 0.77; P<0.0001)
0.75
Survival
CRT
Medical
Therapy
0.50
0.25 Mean Follow-up 36.4 months (range 26.1 to 52.6)
CRT Deaths = 101 (24.7%) (cross-over 4.6%)
0.00 Medical Therapy Deaths = 154 (38.1%) (cross-over 23.
0
Number at risk
CRT
409
Medical therapy404
400
800
1200
Time (days)
383
372
358
331
338
298
209
178
85
63
1600
9
6
CARE-HF Extension Study
Time to Sudden Cardiac Death
1.00
0.75
CRT
P=0.006
Survival
HR 0.54 (95% CI 0.35 to 0.84) Medical
0.50
Therapy
Medical = 54 sudden deaths (13.4%)
0.25
CRT = 32 sudden deaths (7.8%)
Absolute difference = 22 (5.6%)
0.00
0 Mean Follow-up
400
800
1200 (range
1600
36.4 months
26.1 to 52.6)
Time (days)
SIGN 96 - Stable angina
•
•
•
•
•
•
•
B blockers first choice [A]
Rate-limiting Ca antgonists 2nd choice [A]
All patients should receive statin and aspirin
LMS - CABG [A]
3VD - CABG preferred [A]
Other disease either PCI or CABG [A]
B Blockers are recommended in high-risk
patients with cad undergoing non-cardiac
surgery [A]
RISK FACTORS
(SIGN 97 RISK ESTIMATION & PREVENTION
OF CORONARY DISEASE)
• Change in emphasis to embrace social
deprivation (ASSIGN)
– classical risk factors
– FH if <60 years
– SIMD (by postcode)
• Calculation will be via computer desktop
and value expressed as continuous
variable.
RISK FACTOR MANGEMENT
–
–
–
–
–
–
–
–
–
–
–
age
sex
smoking status
BP
DM
waist/Hip ratio
dietary pattern
physical activity
alcohol consumption
lipid levels
psychosocial factors (“stress”)
Framingham factors underestimate risk in
high risk individuals (eg social deprivation)
PREDICTED AND OBSERVED HEART DEATHS IN
RENFREW PAISLEY (MIDSPAN)
CVD mortality %
25
Observed
Predicted
20
15
10
5
0
1
2
3
4
5
Quintiles of Framingham risk
Is it feasible, will it do any
good?
• Whilst good evidence that deprivation
score is proportional to risk little
evidence that targeting it will gain
advantage (level D evidence)
• Makes things more complex
• Expensive
– statins £43M, better BP control £2.8M
Avoid bad habits...
TREATMENT THRESHOLD
• Individuals should be considered to be
at high risk if the chance of an initial
major vascular event is >20% over 10
years.
What level to treat to?
Absolute Reduction in LDL-Cholesterol
(mmol/l) and Absolute Reduction in Risk of
20%
Intervention/Primary
Intervention/Secondary
Intervention/Both
.Control/Primary
.Control/Secondary
.Control/Both
4S
PROSPER
LIPID
A TO Z
10%
CARE
Post-CABG
HPS
MIRACL
GREACE
LRC-CPPT
PROVE-IT
WOSCOPS
LIPS
CARDS
ASCOT
AF/Tex-CAPS
0%
Major Cardiac Event (%)
30%
Major Cardiac Event (MCE)
1
2
3
4
LDL-Cholesterol (mmol/l)
5
Adapted from Joint British
Societies’ Guidelines1
STATIN EXPENSE
• The more aggressive the policy the more
expensive the treatment.
• Benefits unclear.
• Recommendation therefore to keep to
existing standards of achieving TC <5mmol/l
(LDL <3) This however is the minimum
standard and for certain high risk patients a
more aggressive policy may be appropriate
ASPIRIN
• Despite widespread belief of benefit still
controversial.
– no dispute re secondary prevention
– more complex for primary prevention
•
•
•
•
reduces MI by 30% in males, 0% in females
increases haemorrhagic CVA by 40%
increases gi bleeding by 70%
generally no overall benefit
• however when cvs risk >15% may be of net benefit.
• Consider use for high risk individuals
ACEIs for patients with vascular disease
but not LV systolic dysfunction
• Good evidence for benefit in higher risk
patients (level A)
– PVD
– CVD
– Diabetes
• No evidence of significant benefit for
low-risk individuals
HOPE study
And finally...