ACS Risk Stratification - The Exercise Test.pdfVIP

ACS Risk Stratification The Exercise Test Bernard R Chaitman MD Professor of Medicine Director of Cardiovascular Research St Louis University School of Medicine Non-Invasive Risk Stratification PostACS Exercise Testing ED/Admission Hospital discharge STEMI Biomarker positiveNSTEMI Hospital course Early follow-up Biomarker negativeUA Risk assessment is continuous; evaluate initial presentations, early hospital course and response to anti-ischemic, anti-thrombotic, or PCI/CABG therapy Relative Risk of All-Cause Mortality with Early Invasive vs Conservative Strategy for UA/NSTEMI After 2-Years ICTUS: 1200 troponin positive ACS pts treated with OMT and randomized to early vs selective invasive therapy (Hirsch A et al. Lancet. 2007;369:827-35). After 3-yrs, rate of death/MI/ischemic rehospitalization similar in both groups . 47% of pts in the selective invasive strategy ultimately required revascularization Initial conservative (selective invasive) strategy is an acceptable treatment option particularly for low intermediate risk ACS patients (ACC/AHA , - Guidelines JACC 2007; 50: e75) Non-Invasive Risk Stratification after ACS ? Estimate pretest risk from clinical history (prior MI, HF, LVF, residual angina, cardiac arrhythmias cath/PCI results etc) , , ? Use non-invasive tests to guide therapeutic approach – Exercise testing – Echocardiography, MRI or other imaging modality – Myocardial perfusion imaging ? Estimate the post-test risk of major adverse cardiac outcomes Non-Invasive Testing after ACS Class I Recommendation Evaluation of low-intermediate risk patients with unstable angina (biomarker negative) or myocardial infarction (biomarker positive) patients free of active signs/symptoms of myocardial ischemia or heart failure at rest or with low-level activity for a minimum of 12-24 hours ACC/AHA Guidelines JACC 2007; 50: e75 TIMI Risk Score for STEMI Clinical Risk Indicator Points Age 75/65-74 yrs 3/2 Hx