GUSTO I 90-93 GUSTO I 90-93 2.8 Median Time (hrs) Between Symptom Onset and Treatment GUSTO III...
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Transcript of GUSTO I 90-93 GUSTO I 90-93 2.8 Median Time (hrs) Between Symptom Onset and Treatment GUSTO III...
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GUSTO I90-93
GUSTO I90-93
2.82.8
Med
ian
Tim
e (h
rs)
Bet
wee
n S
ymp
tom
On
set
and
Tre
atm
ent
Med
ian
Tim
e (h
rs)
Bet
wee
n S
ymp
tom
On
set
and
Tre
atm
ent
GUSTO III95-97
GUSTO III95-97
InTIME II97-99
InTIME II97-99
ASSENT 300-01
ASSENT 300-01
ASSENT II97-98
ASSENT II97-98
GUSTO V99-01
GUSTO V99-01
2.82.82.72.7 2.72.72.72.7
2.92.9
Gibson CM, Circulation 2001;104:2632-2634Gibson CM, Circulation 2001;104:2632-2634
1.0
1.5
2.0
2.5
3.0
Tim
e (
ho
urs
)
All patients
Men
Women
All patients 2.2 2.2 2.2 2.1 2.0 2.0 2.0 2.0 2.0 1.8 1.8 1.8 1.8 1.7 1.7 1.7 1.6
Men 2.0 2.0 2.0 2.0 1.9 1.8 1.8 1.8 1.8 1.7 1.7 1.7 1.7 1.6 1.6 1.6 1.5
Women 2.6 2.6 2.6 2.5 2.3 2.2 2.2 2.2 2.1 2.1 2.0 2.0 2.0 2.0 2.0 1.9 1.8
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
National Registry of Myocardial Infarction,1990-2006National Registry of Myocardial Infarction,1990-2006
Trends in symptom onset-to-door time among STEMI patients, stratified by sex
Gibson CM, ACC 2008
The AngelMed Guardian SystemThe AngelMed Guardian System
• AnAn Implantable DeviceImplantable Device ( (IMDIMD) ) - - Implantable cardiac Implantable cardiac event recorder with ST-segment measurement and event recorder with ST-segment measurement and alarm. Records electrogram and will issue an alarm alarm. Records electrogram and will issue an alarm for acute ST shift changesfor acute ST shift changes
• A A ProgrammerProgrammer to program the IMD and retrieve to program the IMD and retrieve and process the data captured by the IMD.and process the data captured by the IMD.
• An An External DeviceExternal Device ( (EXDEXD)) that provides an additional that provides an additional (audio) alarm and telemetry up to 6 feet between the (audio) alarm and telemetry up to 6 feet between the implant and the EXD. The EXD has an alert silence implant and the EXD. The EXD has an alert silence button, labeled LEDs to indicate the type of alarm and button, labeled LEDs to indicate the type of alarm and printed patient instructions.printed patient instructions.
Patient B9 Acute ST Elevation Event September 2007Patient B9 Acute ST Elevation Event September 2007
2nd Em. Alarm
Emergency Alarm at 12:20 pm 9/17/07
Arrival at hospital ~1 hour later
Start of Arterial Occlusion
Patient B9 – ST Elevation 1st Emergency AlarmPatient B9 – ST Elevation 1st Emergency Alarm
Patient arrives at the hospital
Patient B9 – ST Elevation Emergency Patient B9 – ST Elevation Emergency AlarmsAlarms
1st Em. Alarm 2nd Em. Alarm (in hospital)
Patient put on Heparin and ClopidogrelPatient put on Heparin and Clopidogrel
Ruptured Plaque Site in Pt. B9 CircumflexRuptured Plaque Site in Pt. B9 Circumflex
March 1, 2007 Sept 18, 2007
Gersh, B. J. et al. JAMA 2005;293:979-986.
Relationship Between Duration of Symptoms of Acute MI Before Relationship Between Duration of Symptoms of Acute MI Before Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial
SalvageSalvage
Relationship Between Duration of Symptoms of Acute MI Before Relationship Between Duration of Symptoms of Acute MI Before Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial
SalvageSalvage
Time is Muscle: Delays in Symptom to Door Time are Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent Associated with Poorer Flow in the Muscle Independent
of Flow in Arteryof Flow in Artery
Time is Muscle: Delays in Symptom to Door Time are Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent Associated with Poorer Flow in the Muscle Independent
of Flow in Arteryof Flow in Artery
16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) Gibson, JACC 200416% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) Gibson, JACC 2004
Normal LargeCapillary Lumen
Clinical Picture: Clinical Picture: Open ArteryOpen Artery
Closed MuscleClosed MuscleBlistering of CapillariesBlistering of Capillaries
& Endothelium& Endothelium
“Blistered” / Swollen Endothelium /wall of the capillary
Normal non-infarcted
wall without edema
Infarcted wall with edema (white
areas)
Interstitial Edema Interstitial Edema
EHJ (2004) 25, 794–803EHJ (2004) 25, 794–803
Gibson CM 2008
Symptom – balloon inflation (min)Symptom – balloon inflation (min)
On
e-ye
ar m
ort
alit
y, %
On
e-ye
ar m
ort
alit
y, %
6 RCTs of Primary PCI by Zwolle Group 1994 – 20016 RCTs of Primary PCI by Zwolle Group 1994 – 2001N = 1791N = 1791
RR = 1.08 for each 30 min delayRR = 1.08 for each 30 min delay((PP = 0.04) = 0.04)
PP < 0.0001 < 0.000112
10
8
6
4
2
00 60 120 180 240 300 360
Symptom Onset-Balloon Time and Symptom Onset-Balloon Time and Mortality in Primary PCI for STEMIMortality in Primary PCI for STEMI
DeLuca, Suryapranata, Circ 109:1223, 2004DeLuca, Suryapranata, Circ 109:1223, 2004
The relative risk of 1-year mortality increases by7.5% for each 30-minute delay
20
30
40
50
60
70
Tim
e (
min
ute
s)
Door-to-needle time 59 55 55 48 43 40 38 35 35 34 34 33 32 32 30 30 29
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Trend in door-to-needle time among reperfusion-eligibleSTEMI patients receiving fibrinolytic therapy
Gibson CM, ACC 2008
National Registry of Myocardial Infarction, 1990-2006National Registry of Myocardial Infarction, 1990-2006
5.0
5.5
6.0
6.5
7.0
7.5
8.0
Mo
rta
lity
(%
)
In-hospital mortality 7.0 7.5 7.0 7.1 7.0 7.0 6.6 6.2 5.8 5.8 5.4 5.3 6.0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
National Registry of Myocardial Infarction, 1994-2006National Registry of Myocardial Infarction, 1994-2006
Trend in in-hospital mortality among reperfusion-eligible STEMI patientstreated with fibrinolytic therapy
Gibson CM, ACC 2008
50
100
150
200
250
Tim
e (
min
ute
s)
All patients
Transfers
Non-transfers
All patients 120 117 116 111 113 110 107 106 108 105 101 94 87
Transfers 226 208 196 190 192 185 186 186 176 168 152 146 139
Non-transfers 111 109 110 105 108 105 102 101 103 99 94 86 79
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
National Registry of Myocardial Infarction, 1994-2006National Registry of Myocardial Infarction, 1994-2006
Trends in door-to-balloon time among reperfusion-eligible STEMI patientstreated with primary PCI, stratified by transfer status
Gibson CM, ACC 2008
0
1
2
3
4
5
6
7
8
9
10
Mo
rta
lity
(%
)
All patients
Transfers
Non-transfers
All patients 8.6 7.4 6.7 5.4 5.2 5.3 4.9 4.5 4.1 3.9 3.4 3.2 3.3
Transfers 8.7 9.1 9.4 6.3 7.2 7.5 6.3 6.3 4.4 5.1 4.0 3.0 3.9
Non-transfers 8.6 7.0 6.2 5.3 4.9 4.9 4.7 4.3 4.1 3.7 3.3 3.2 3.1
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
National Registry of Myocardial Infarction, 1994-2006National Registry of Myocardial Infarction, 1994-2006
Trends in in-hospital mortality among reperfusion-eligible STEMI patients treatedwith primary PCI, stratified by transfer status
Gibson CM, ACC 2008