Download Patients with ST elevation acute coronary syndrome should be

SIGN CHD
In Scotland in the year ending 31 March
2006 over 10,300 patients died from
CHD and 5,800 from cerebrovascular
disease, with almost 49,000 hospital
admissions for CHD and a further
22,050 for cerebrovascular disease.
www.isdscotland.org
Coronary Heart
Disease
SIGN CHD
SIGN is a collaborative network of
healthcare professionals and SIGN
guidelines are developed by
multidisciplinary groups using a standard
methodology based on a systematic review
of the evidence.
SIGN levels of evidence
1+ +
High quality meta analyses, systematic reviews of RCTs,
or RCTs with a very low risk of bias
1+
Well conducted meta analyses, systematic reviews of RCTs,
or RCTs with a low risk of bias
1
Meta analyses, systematic reviews of RCTs,
or RCTs with a high risk of bias
2+ +
High quality systematic reviews of case-control or cohort studies
High quality case-control or cohort studies with a very low risk of confounding,
bias, or chance and a high probability that the relationship is causal
2+
Well conducted case control or cohort studies with a low risk of confounding,
bias, or chance and a moderate probability that the relationship is causal
2
Case control or cohort studies with a high risk of confounding, bias, or chance
and a significant risk that the relationship is not causal
3
Non-analytic studies, e.g. case reports, case series
4
Expert opinion
SIGN grades of recommendation
A
At least one meta analysis, systematic review, or RCT rated as 1+ + , and directly
applicable to the target population;
or
A systematic review of RCTs or a body of evidence consisting principally of
studies rated as 1+ , directly applicable to the target population, and demonstrating
overall consistency of results
B
A body of evidence including studies rated as 2+ + , directly applicable to the target
population, and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 1+ + or 1+
C
A body of evidence including studies rated as 2+ , directly applicable to the target
population and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 2+ +
D
Evidence level 3 or 4;
or
Extrapolated evidence from studies rated as 2+
SIGN Coronary Heart Disease
SIGN CHD
•
•
•
•
•
PREVENTION
STABLE ANGINA
ACUTE CORONARY SYNDROMES
ARRHYTHMIAS
CHRONIC HEART FAILURE
SIGN: Prevention
SIGN CHD: prevention
Prevention of CHD - Risk Estimation
• Individuals with symptomatic manifestations of
cardiovascular disease or diabetes should be considered
at high risk (≥ 20% risk over 10 years) of
cardiovascular events
D
• All adults over the age of 40 who have no history of
cardiovascular disease or diabetes and who are not
being treated for blood pressure or lipid reduction
should have their cardiovascular risk estimated at least
once every five years
D
SIGN CHD : prevention
Simvastatin 40 mg/day recommended as
part of the management in those patients
over age 40 with a 10 year risk of CVS
events of > 20%
A
Potential events avoided and related resources saved from
treating 435,000 asymptomatic individuals at high CVD risk
with a statin
Event
Clinical benefit
over 4.3 years
Major vascular
6,217
All cause mortality
2,303
Total
8,520
Annual bed days
saved
ASCOT-LLA/CARDS
Annual cost
savings (million)
17,050
£5.9
17,050
£5.9
Potential events and resources saved from treating 95,000
symptomatic individuals with a statin
Events
Major vascular
All cause mortality
Total
Events avoided
Annual bed days
saved
9,437
Annual cost
savings (million )
19,770
£6.8
19,770
£6.8
718
10,155
HPS
SIGN has commissioned the development of a
score to include social deprivation as a risk
variable. ASSIGN tends to classify more people
with a positive family history and who are
socially deprived as being at high risk. When
used in its own host population, it abolished a
large social gradient in future CVD victims not
identified for preventative treatment by the
Framingham score: it therefore improved
social equity. http://assign-score.com
Heart 2007;93:172-176
SIGN: chronic stable angina
SIGN CHD: Stable Angina
• Patients with left main stem disease should undergo coronary
artery bypass grafting to improve coronary heart disease
prognosis
A
• Patients with triple vessel disease should be considered for
coronary artery bypass grafting to improve coronary heart disease
prognosis but where unsuitable be offered percutaneous coronary
intervention
A
• Patients with single or double vessel disease where optimal medical
therapy fails to control symptoms should be offered percutaneous
intevention or where unsuitable, be considered for coronary
bypass surgery
A
SIGN: acute coronary syndromes
SIGN CHD: ACS
• Patients with ST elevation acute coronary syndrome should be
treated immediately with primary percutaneous coronary
intervention
A
• Where primary percutaneous coronary intervention cannot be
provided within 90 minutes of diagnosis, patients with ST elevation
acute coronary syndrome should receive immediate thrombolytic
therapy
D
•
Patients with ST elevation acute coronary syndrome within 6
hours of symptoms who fail to reperfuse following thrombolysis
should be considered for rescue percutaneous coronary
intervention
B
SIGN CHD: ACS
• A
• ABA
In addition to long term aspirin,
clopidogrel therapy should be continued
for three months in patients with nonST elevation acute coronary syndromes
B
SIGN: Arrhythmias
SIGN CHD: arrhythmias
• Patients with impaired LV ejection fraction in NYHA
Class I – III after previous myocardial infarction
should be considered for ICD therapy
A
• Patients with spontaneous non-sustained ventricular
tachycardia, severely depressed ejection fraction
(<0.25) or prolonged QRS duration (>0.12 sec) should
be prioritized for ICD implantation
B
SIGN Heart Failure
SIGN CHD : heart failure
BNP should be checked prior to
commencing therapy for suspected heart
failure
A
SIGN CHD: Heart failure
Heart Failure - Interventional procedures
In patients in sinus rhythm with drug
refractory symptoms of heart failure due to left
ventricular systolic function (LVEF < 35%) and
who are in NYHA Class III and IV and who
have a QRS duration of > 120 m/s, cardiac
resynchronisation therapy (CRT) should be
considered
A
SIGN CHD: Heart failure
Heart Failure - Discharge planning
• Comprehensive discharge planning to ensure links with
post discharge services should be available to all those
with symptomatic heart failure. A nurse-led, home
based element should be included
A
• Telephone follow-up by specialised heart failure nurses
should be considered for patients with stable heart
failure. Nurses should have the ability to alter diuretic
dose, telephone schedules and recommend
emergency/non-scheduled medical contact
A
SIGN CHD
What are the potential clinical events avoided by implementation?
SIGN CHD implementation
benefits
7,229
Bed
days
saved
per
year
17,052
Saving
s per
year
(£
million)
5.9
718
9,437
19,770
6.8
950
2,761
9,108
2.5
750
2,672
5,414
2.0
5,096
22,099
51,344
17.2
Acute Coronary
Syndromes
guideline
896
2,176
2,394
1.2
Arrhythmia and
Heart Failure
guidelines
1,232
2,851
7,074
2.3
Total events
7,224
27,126
60,812
20.7
Recommendati
on by guideline
Mortality
avoided
over 5
years
Events
avoide
d over
5 years
2,678
Statins –
secondary
prevention
Antihypertensive
drugs
Statins –
primary
prevention
Prevention other
Prevention - total
Estimated annual cost of implementing key recommendations
by guideline
Cost (£ million)
Year 1
Year 6
ACS
5 (5)
5 (5)
Arrhythmias
4 (5)
4 (5)
Heart Failure
7 (7)
7 (7)
Prevention
25 (27)
54 (62)
Total
41 (44)
70 (79)
SIGN CHD
The recommendations on statins and
hypertension account for over 90% of the
costs and the savings
SIGN CHD
Over the next five years, it is estimated
that over 7,200 premature deaths from
CVD and over 27,000 vascular events
could be avoided. This is equivalent to a
9% reduction from the current CVD
mortality rate and an 8% reduction from
the current CVD event rate.