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PEER  TO  PEER: A New Model for Improving Guideline- and Evidence-Based ACS Care - Schedule Your ACS CME Teleconference

WHAT IS PEER TO PEER?
Med-IQ's new complimentary, certified continuing medical education (CME) activity,
Peer to Peer: A New Model for Improving Guideline- and Evidence-Based ACS Care, is connecting healthcare professionals from across the country. This exciting, first-of-its-kind CME series provides participants with access to acute coronary syndrome (ACS) faculty experts during personalized sessions focusing on improving ACS patient care in their practices. This real-time exchange of ideas has helped address some of the major challenges that clinical practices face in managing ACS cases.

WHAT ARE E-BRIEFS?
Each month, Med-IQ will be publishing a short e-brief to highlight real-world questions, opportunities for improvement, and front-line perspectives gained from these ACS Peer to Peer teleconferences. Below, you'll find the first of these e-briefs; this installment recounts questions regarding invasive strategies in non-ST-segment myocardial infarction (NSTEMI) posed by a physician practicing in the Boston, Massachusetts area.

Questions From a Practicing Clinician About
Invasive Strategies in NSTEMI

—In this E-Brief——

Optimal Timing for Invasive Intervention

Upstream Use of Glycoprotein (GP) IIb/IIIa Inhibitors in NSTEMI

Switching From Low-Molecular-Weight Heparin (LMWH) to Unfractionated Heparin (UFH)

Steps and Strategies for Further Improvement

Christopher P. Cannon, MD

Faculty Advisor:
Christopher P. Cannon, MD
Senior Investigator
TIMI Study Group
Associate Physician
Cardiovascular Division
Brigham and Women's Hospital
Boston, MA

Writer:
Katherine Kahn
Southampton, MA


Optimal Timing for Invasive Intervention
Question: I work in a community hospital with no percutaneous coronary intervention (PCI) capabilities. Patients with NSTEMI who are to undergo invasive therapy are transferred to a cath lab at a nearby hospital. Sometimes there is a 24-hour to 48-hour delay—such as over a weekend—in transfer. Would outcomes be better if these patients were transferred sooner?

Answer: Generally, for unstable angina (UA)/NSTEMI patients, cardiac catheterization can occur within the first 48 hours (and does not need to be immediate, as in the case of STEMI). However, some recent data do suggest that for the highest-risk patients, early catheterization (ie, within 12 hours of presentation) is optimal.

Researchers from the TIMACS (Timing of Intervention in Acute Coronary Syndromes) study group published data earlier this year that address this issue. Patients with UA/NSTEMI were randomized to undergo either early invasive intervention within 24 hours (median 14 hours) or delayed intervention at 36 hours or more (median 50 hours). Results indicated no difference in the primary outcome of a composite of death, myocardial infarction, or stroke at 6 months between the two groups. In patients identified as high risk according to GRACE (Global Registry of Acute Coronary Events) scores (score of > 140), however, earlier intervention provided a significant benefit.1

Thus, for most patients who are hemodynamically stable with no recurrent ischemia, an acceptable time-to-angiography is within 48 hours.

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Upstream Use of GP IIb/IIIa Inhibitors in NSTEMI
Question: Given the recently reported results of the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndrome) trial, should I be routinely using GP IIb/IIIa blockers upstream in NSTEMI patients who are to undergo invasive treatment strategies?

Answer: The role of GP IIb/IIIa inhibitors in invasively-managed NSTEMI patients and the timing of administration are subjects of controversy. Guidelines on their upstream use have evolved over time as studies have revealed conflicting results. The 2007 joint ACC/AHA guidelines state that the use of either a GP IIb/IIIa inhibitor or clopidogrel is indicated in patients being managed with an early invasive strategy and that using both is a reasonable choice in higher-risk patients2. This guideline was reexamined in the ACC/AHA Joint STEMI/PCI Focused Updates released in November 2009, but the available clinical data did not warrant a change to the current recommendation.3

Optimal timing of the use of GP IIb/IIIa inhibitors in invasive strategies remains undetermined. The EARLY ACS trial found no significant difference between patients who received eptifibatide 12 or more hours prior to angiography (an “upstream” strategy), compared with provisional use of eptifibatide after angiography for PCI. Moreover, early use of eptifibatide was associated with an increased risk of non–life-threatening bleeding.4 These results challenge current guideline recommendations on the use of GP IIb/IIIa inhibitors in patients undergoing invasive treatment. They also suggest that even if there is a slight benefit to the upstream use of GP IIb/IIIa inhibitors, the risk of bleeding may outweigh the benefits in some patients, such as those with normal troponin levels and older patients.

The widespread implementation of more aggressive upstream cotherapies, such as dual antiplatelet therapies and anticoagulant therapy, may also partially mitigate the expected benefit of the early use of GP IIb/IIIa inhibitors.4 Nevertheless, even if GP IIb/IIIa inhibitors are not used upstream, strong evidence supports their procedural use in PCI to prevent complications.2

Foregoing the use of GP IIb/IIIa inhibitors until the patient is in the cath lab has the added benefit of allowing the interventionalist the flexibility to provisionally choose either bivalirudin or GP IIb/IIIa inhibitors.

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Switching from LMWH to UFH
Question: The cath lab where my patients are transferred prefers to use UFH. Can I give enoxaparin upstream instead of intravenous heparin, or am I setting them up for an increased risk of bleeding in the cath lab?

Answer: In the NSTEMI patient who is slated for an invasive strategy, the guidelines are clear that all patients should receive anticoagulant therapy upstream. Enoxaparin, UFH, fondaparinux, or bivalirudin are all acceptable options. Although trials such as A to Z (Aggrastat to Zocor) and SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors) suggest enoxaparin is associated with increased bleeding, the differences between outcomes of enoxaparin and UFH are small. It's probably best to use UFH if the interventional cardiologist prefers it. The decision to use UFH, however, should hinge on how effectively the anticoagulant activity of UFH can be monitored and how quickly the doses can be adjusted. LMWH may be more appropriate if there are difficulties with appropriate monitoring and dosing adjustments of UFH.

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Steps and Strategies for Further Improvement:
Consider Participating in a National ACS Registry

ACS registries, such as the ACTION Registry®-GWTG, can be very helpful to facilities in identifying areas of excellence and opportunities for improvement. They allow you to compare your facility's treatment strategies with national benchmark data and peer facilities. In addition, they offer tools for implementing and adhering to guidelines. Find out more at the National Cardiovascular Data Registry Web site at http://www.ncdr.com/webncdr/ACTION/.

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REFERENCES

1. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009;360(21):2165-2175.

2. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2007;116(7):e148-e304.

3. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2009;120:2271-2306.

4. Giugliano RP, White JA, Bode C,et al. Early versus delayed, provisional eptifibatide in acute coronary syndromes. N Engl J Med. 2009;360(21):2176-2190.

This activity is supported by an educational grant from sanofi-aventis U.S.

sanofi-aventis

Published by Med-IQ, 5523 Research Park Drive. Suite 210. Baltimore, MD 21228.

Statements of fact or opinion are the responsibility of the authors alone and do not imply an opinion of the publishers or the officers of any sponsoring organization. Materials may not be reprinted without written consent from the publisher.

For reprint or other information, call 866 858 7434. © 2009 Med-IQ. All rights reserved.




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