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Mr Yonathan Hasin
This clinical seminar discussed the special considerations to be undertaken when treating patients who present with acute coronary syndrome (ACS) along with high bleeding risk, renal impairment, old age and concomitant arterial disease.
Antithrombotic treatment has become a mandatory milestone in the treatment of acute coronary syndrome. The introduction and development of this treatment resulted in a reduction of the risk of ACS but at the price of increased risk of bleeding. Reports from randomized clinical trials (RCT) indicate that major bleeding occurs in 1.5 - 19% of the patients. This major difference may be explained by the specific definitions of bleeding adopted by the different RCT. For example the Gusto definition relies more on clinical parameters while the TIMI definition relies more on reduction in blood count. There is obviously a need for unified objective standardized definition to be used by all. A recent initiative yielded the BARC and the ISTH definitions which are still under discussion. The more common bleeding sites are gastro intestinal, vascular access retroperitoneal and genito-urinary (Grace registry). Less common but of major importance are intracranial, intraocular, lungs and pericardial space. It also differs in different registries and is dependent on the severity of ACS, i.e. Grace Registry report. From RCT and registries, information has been accumulated about clinical features that increase the risk of bleeding. These include old age, female gender, reduced weight, renal insufficient, previous HX of bleeding, severity of ACS (STEMI > NSTEMI) pharmacotherapy (use of IIBIIIAi ) and invasive approach all contribute to bleeding. While treating ACS patients, it is advisable to take these into account. Indeed routine of the bleeding score is recommended. Dr. Lettino continued by showing multitude of data supporting the correlation between bleeding and early in late outcome of patients presenting with ACS. This very important phenomenon has driven the community to identify patients prone to bleed. By identifying patients at risk, proper precautions can be taken to avoid bleeding including avoidance of anticoagulant overdose, using medications that have been shown to reduce bleeding (fondaparinox Vs enoxaparine or bivalirudin Vs heparine + IIBIIIAi – similarly choice of the proper antiplatlet drugs i.e. clopidogrel Vs Persogrel). The access site should be considered: prefer radial approach for the high risk patients. Measures to protect the gastric mucosa should be applied in patients prone to GI bleed. Concomitant use of omeprasol and clopidogrel is no longer an issue especially if the drugs are taken few hours apart. It is important to realize that patients prone to bleeding are also the patients with an increased risk from their ACS. These are the patients who are most likely to benefit from meticulous adherence to guideline recommended remedies (including anticoagulation and coronary intervention) along with special care and precaution to minimize bleeding.
Professor Swan summarized the importance of renal impairment (RI) in patients with ACS. It should be stated upfront that estimated glomerular filtration rate (GFR) is the best way of assessing renal function. The most popular formula is the Cockcroft - Gault (CG) which appeared to be superior for the prediction of early and late outcomes as shown in the Crusade registry. Renal function deteriorates with aging and a recent Swedish report indicated that RI can be shown in 60% of patients >80 y.o. Analysis of cumulative data from different thrombolytic studies shows that RI (CrCl<70ml/min) is associated with a significant mortality by 30 and 180 day (OR=0.8). Similar results have also been shown by studies looking at NSTE ACS patients. The reasons for the increased risk of these patents can partly be explained by the increased prevalence of extensive coronary artery disease in patients with RI. Therefore, eGFR should be included in the estimation of risk of ACS patients. It has been shown to improve function of the TIMI risk score and has been incorporated into the Grace risk score. Prof. Swan went on to discuss the gender perspective of RI. She indicated that women with RI are at a higher risk than men. In conclusion, RI is associated with increased risk of early and late mortality of ACS patients. This is partially explained by associated conditions such as diabetes mellitus, hypertension and more extensive CAD. Additive risk is acute renal injury caused by acute heart failure and contrast nephropathy. Of contributing importance to the worst outcome of these patients is a policy of therapeutic nihilism with under treatment with guideline medication and intervention.
Dr. Bueno dedicated his lecture to very old patients with ACS. In recent years, the population is aging and the age of patients with ACS is gradually increasing. There is a paucity of knowledge about the very old since they were often excluded from randomized clinical trials. It can still be stated that the clinical presentation is similar to the younger age group even though there is an increased prevalence of shortness of breath, more extensive coronary artery disease, more comorbidities including increased bleeding risk and renal insufficiency. There are no special guidelines recommendations for medical treatment in the old age. Nevertheless, precautions should be used with the dosages and the type of medications, expecting oversensitivity and need to reduce doses. Special consideration should be taken to the IIBIIIAi inhibitions since bleeding tendency is increasing with age without additive prognostic value to the therapy. Triton study did not show an advantage for presogrel over clopidogrel above the age of 75. Similarly OASIS indicated fundaparinoux to be superior to enoxoparine in the old age. Nevertheless, the Crusade registry showed that adherence to guidelines recommended therapy improves survival even for nonagenarians. Even less evidence is known about coronary intervention and revascularization in the elderly. Therefore we have to rely more and more on our clinical judgment. Formal geriatric assessment prior to decision about invasive policy is needed. This should include major and minor characteristics including frailty, cognitive functions, dependence on others and depression as well as assessment of the supportive function of the family to enable recovery from the insult of intervention. In summary, treatment options for the old are similar to the young. However, assessment and policy decision should take into account special factors obtained usually by geriatric professionals.
Professor Vrints discussed the management of ACS in patients with peripheral artery disease. His discussion included evidence that PAD is an independent risk factor in ACS (Special attention on the combination of coronary and carotid disease and several notes on the importance of vascular access). The Crusade registry showed that PAD is very common in ACS patients i.e. 60% have 2 or 3 arterial territories involved. The involvement of other territories is associated with more CHF, RI, hypertension and diabetes. Polyvasuclar disease is associated with increased rate of death, MI, stroke and CHF. So the rate of the in-hospital composite is 20% when 3 territories are involved. Similarly bleeding rate is increased in these patients. Polyvascular disease is an independent predictor of in hospital ischemic events with an odds ratio greater than that associated with diabetes mellitus. He concluded the report from the Crusade registry by indicating that despite the increased risk of patients with polyvascular disease there is a sub optimal use of guideline recommended evidence based therapies including both recommendation for lifestyle alterations pharmacological therapy and coronary intervention. When faced with the combined coronary and carotid disease the recommendation is to treat first the most unstable artery taking into consideration both clinical and angiographic factors. When approaching a patient with PAD, the access site becomes of paramount importance and whenever possible, the radial access should be applied. Expertise should be developed so that even complex intervention like unprotected left main can be performed safely via this approach. Special access techniques should be applied when necessary such as subclavian for IABP insertion. In conclusion PAD is a major risk factor in ACS. Routine assessment of PAD (including ankle brachial index) should be incorporated into the routine patient assessment. Special considerations should be applied including access site and combined treatment of the affected. Guideline recommended evidence based therapies should be applied avoiding therapeutic nihilism.
Management of acute coronary syndromes in high-risk patients
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