KONGRES 2.pptx - STEMI in Norway changing paradigmas
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Transcript of KONGRES 2.pptx - STEMI in Norway changing paradigmas
Treatmant patients with acute myocardial infarcton in Bosnia and Herzegovina
BH Heart Centre Tuzla
Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.
Implementation of the STEMIESC Guidelines
ACC/AHA & ESC guidelines
ESC STEMI – guidelines
Primary PCI (Pre)hospital Thrombolyse
Rescue PCI
Onset of chestpain <12 h & transp.< 90 min to PCI
rTPA if <2-3 h from onset chestpain & transp. > 45 – 60 min to PCI-senter
No effect of thrombolyse after 45-60min:
Contraindication to thrombolysis
<50% ST-resolution, ongoing chestpain, arrythmias, hemodynamic unstable
Patients <75 with cardiac shock early after MI (12-36t)
<75 year & cardiac shock
On and off – symptoms for a longer period (EKG)
Myokardnekrose
• Starts 30-45min after occlusion• After 90min is 40-50% necrotised• After 6h the necrosis is often complete
• Collaterals modify• Occlusion is often sub-total or fluctuating
AHA Textbook of Advanced Cardiac Life Support, 1999
Trombolyse PCIPrehospitalt EKG
Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk.
Time Since Symptom
Onset
Time Required for Transport to
a Skilled PCI Lab
Risk of STEMI Risk of Fibrinolysis
Fibrinolysis generally preferred Early presentation ( ≤ 3 hours from symptom
onset and delay to invasive strategy)
Invasive strategy not an option Cath lab occupied or not available
Vascular access difficulties No access to skilled PCI lab
Delay to invasive strategy Prolonged transport
Door-to-balloon more than 90 minutes > 1 hour vs fibrinolysis (fibrin-specific agent) now
Reperfusion Options for STEMI Patients Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
Invasive strategy generally preferred Skilled PCI lab available with surgical backup
Door-to-balloon < 90 minutes
• High Risk from STEMI Cardiogenic shock, Killip class ≥ 3
Contraindications to fibrinolysis, including increased risk of bleeding and ICH
Late presentation > 3 hours from symptom onset
Diagnosis of STEMI is in doubt
Reperfusion Options for STEMI Patients Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
Evolution of PCI for STEMI
Antman. Circulation 2001;103:2310.
Balloon Antiplatelet Rx
Stent DES
GP IIb/IIIa inhibitor
ASAClopidogrel AngioJet
Thrombus Removal and
Distal Embolization
Protection Devices
Embolization Protection Device
Platelet
The essence in todays PCI -”Guidelines” (2005).
• STEMI should be evaluated with respect to reperfusion therapy immediately
• Establish good networks– Preshospital services– Local hospitals– PCI-centra
• Implement details in guidelines at all levels in the treatment chain
Reperfusion strategyRecommendation IA….
• Primary PCI– All when < 90 –120 (?) min. to balloon– All with contraindicasion to thrombolysis– Probably most patients with long chest
pain history (> 3 – 6 - 12 t??)• Thrombolyse to the others;
– preferably prehospital and within 3 h from onset of symptoms
Prognostic PCIRecommendation IA
• PCI within 24 hrs after sucessful thrombolysis– Randomised trials; effect on combined
endpoints – No effect on mortality– Discussed…..
Rescue PCIRecommendation IB-IIC
• Cardiac shock <75 y & <18 h after development of shock (IB)
• Unsuccessful thrombolysis after 45-60 min (ECG & clinical eval) (IIC)
Combined strategy, recomm IIB
• Pretreatment with thrombolysis or Gp-IIb-IIIa-inhibitor before PCI in high-risk?– Insufficient documentation (Garcia, SIAM..)– ASSENT IV; higher mortality with combined
treatment (6%)versus primary PCI(3,8%), but positiv for some groups and some weekness in the study
– STREAM??
”Facilitated PCI” (thrombolysis before PCI)
ASSENT-4 trial, Lancet 2006; 367:569-78.
PCI: 3,8%Tenecteplase + PCI: 6,0%
30d mort.
But, pts with prehospital thrombolysis; ~2%
Pretreatment before primary PCI
• MONA (morphine, Oxyg, Nitro, ASA 300)
• Heparin bolus;5-10.000 iv.(70IE/kg iv. )• Clopidogrel 600mg pr. os• Evt. Thrombolyse befor transportation
(facilitated PCI) when high risk??
TREATMENT MI IN EUROPE
• Anual incidence of hospital admissions 900-3120 on mil.• STEMI amdissions 440-1420 on mil.• P-PCI 20-920 on mil.• P-PCI 5-92%• TL – thrombolysis 0-55%• Single p-PCI centre 0.3-7.4 mil• In hospital mortality 4,2-13,5%• P-PCI mortality 2,7-8 %• TL mortality 3,5-14%
• 3.9 mill• 88/km2
• GNP 2300 US$/year (2005)
Bosnia and Herzegovina
Interventional cardiology in BiH
• PCI centres 5• PCI-mil. 770.000
• Independent interv.cardiologists 11• Anual MI admissions 7200• Anual STEMIs 3100
Invasive procedures in Bosnia and Herzegovina
Coronography PCI
2007. 3676 616
2008. 3167 784
2009. 3569 1018
Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
2009.
• 8 interventional cardiologists, • 4 PCI centres• PCI totaly 1018• PCI – per centre 254• PCI – per operator 127 • Primary PCI –NA les then 10%• Radial – brachial access (%) 1• Abciximab (%) 4• IABP (%) 1• Respirator (%) 1
Challenges:– Geography– Distances– Number of invasive centers– 24 hours on call – costs– Transportation– Revascularisation mode; PCI? Thrombolysis?– Prehospital ECG-systems– Responsibility for patients
Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
STEMI – Do we need more PCI-centers?
”Proposal” Centervolume > 600 PCI (1500-2000 angiograms) Cheaf > 500 PCI (historical experience) On-call operator >300 PCI (historical experience) Yearly operatorvolum >100 PCI 24 hours service On duty – how often? 4 – 5 – 6 ?? On call clinical cardiology service Defined geographical regions
New PCI – centers
M.R.38 y.m.STEMI inf.
B.M.44 mSTEMI ant.