Mreža urgentne PCI u tretmanu bolesnika sa akutnim infarktom miokarda u Bosni i

Hercegovini

BH Centar za srce Tuzla

Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.

Akutni MI

Ucinak savremene terapije na mortalitetUcinak savremene terapije na mortalitet

Adapted from Antman, Braunwald In:Braunwald ed. Heart Disease p 1184.

Pre-CCUEra

Pre-CCUEra

CCUEra

CCUEra

ReperfusionEra

ReperfusionEra

00

1010

2020

3030

4040Short-Term Mortality (%)Short-Term Mortality (%)

3030

1515

6.56.5

DefibrillationHemodynamic

Monitoringb-Blockers Aspirin

ThrombolysisPTCA

ECS smjernice

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

1-2-4EMS

Dispatch

EMS on-scene• Encourage 12-lead ECGs.• Consider prehospital fibrinolytic if

capable and EMS-to-needle within 30 min.

GOALS

PCIcapable

Not PCIcapable

Hospital fibrinolysis:

Door-to-Needle

within 30 min.

EMS Triage Plan

Inter-HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital fibrinolysisEMS-to-needlewithin 30 min.

EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

8 min.

Correct S

TEMI diagnosis in >90%

only by phone conversation and sometim

es faxing

No need for a

dvanced ECG transmission

“Telelink”

Lifenet

1. PATIENT WITH CHEST DISCOMFORT- Recognition

- ASA, nitroglycerin- Immediate “124” phone call

2. PREHOSPITAlL EMERGENCY UNIT - 12-lead ECG within 10 minutes- Phone “cath lab alert”

3. EMERGENCY TRANSPORT WITH “BYPASSING” -Non-PCI hospital -ER, CCU of PCI hospital

4. PRIMARY PCI CENTER -Primary PCI -CICU support

“STEMI-F

AST TRACK” SYSTEM

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

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.

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.

Primary PCI for STEMI:General Considerations

Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB

PCI of infarct artery within 12 hours of symptom onset

Balloon inflation within 90 minutes of presentation

Skilled personnel available (individual performs > 75 procedures per year)

Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI)

Cardiac surgical backup available

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Keeley, Boura & Grines. Lancet. 2003;361:13-20.

Short-term death

(4-6 weeks)

Non-fatal

reinfarction

Odds ratios (95% CI)

Comb endpt of death,

non-fatal reinfarction,

and stroke

Tromboliticka terapija

• Do 12 sati od pocetka simptoma – svi koji odbijaju invazivne procedure

• Pacijenti bez arterijskog pristupa

• Logisticki problemi(tehnicki problemi u katlabu,vremenski problemi I sl)

Prednosti primarne PCI

• Smanjuje mortalitet• Duzinu hospitalizacije• Brzi oporavak • Manje ponovnih hospitalizacija

Ciljevi primarne PCI

1. Primarna PCI >70% STEMI pacijenata

2. Primarna PCI > 600/milion stanovnika

3. Postojeci PCI centri – 24/7 princip –tretirati sve STEMI primarnom PCI

Primarna PCI NSTEMI

• Rekurentna – refraktorna progresivna angina

• Sa progresivnim ST EKG promjenama • Sercana insuficijencija • Aritmija – vitalno ugrozavajuca• Hemodinamska nestabilnost

Minimalno iskustvo operatera i centra za primarnu PCI

• Individualni 75 elektivnih PCI godisnje

15 primarnih PCI

PCI centar 200 PCI god.

50 primarnih PCI

High volume Low volume p(>400 PCI/year) (<400 PCI/year)

6.75% 8.54%0.028

PRIMARY PCI FOR STEMI HAS LOWER MORTALITY IN HIGH VOLUME CENTERS !

Spaulding C, et al. Eur Heart J 2006;27:1054-65.

Transfer pacijenata sa AMI

• 12 kanalni EKG• Defibrilator• Kisik,pribor za intubaciju I ev

asist.ventilaciju• Medikamenti:aspirin,klopidogrel,heparin,nit

roliglicerin,beta bloker,morfij

Symptom Recognition

Call to Medical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied

Katlab organizacija

• Medicinski tehnicar 24/7 – priprema materijal I pacijenta

• Invazivni kardiolog – on call -30 minuta • Medicinski – Rtg tehnicar – on call

Financijski aspekti

• Fiksna naknada po PCI proceduri za PCI centre(od vlasti ili fonda zdravstvenog osiguranja)

• Extra naknada za tim (za rad u nocnim satima i vikendom)

• Druga opcija – povecati broj osoblja za kontinuirani rad 24/7 po rotirajucem principu

Politicki aspekti

• Nacionalni Program primarne PCI

• Koordinacija nacionalnog udruzenja kardiologa, ministrastva zdravlja,zdravstvenog osiguranja –hitna pomoc,non PCI I PCI centri

• Nacionalni registar – sa evidencijom mortaliteta,kompliikacija ,kontrolom kvaliteta

NO CALL TO THE PRIMARY PCI CENTER- STEMI PATIENT STAYS IN NON-PCI HOSPITAL !

Hospital mortality in Ljubljana

Thrombolysis 1996-97 16.3%

Primary PCI 2000-5 6.2%

Inicijativa za formiranje regionalne mreze primarne PCI

u BiH

• Inicijalna faza • PCI centri u BH koji mogu obezbjediti

24/7servis• Pokrivati regione udaljenosti do 100 km ili

90 min transporta za primarnu PCI• Pacijenti iz ostalih regiona koji se jave u

<3h od pocetka simptoma- tromboliticka th

Regionalna mreza PCI

• EMS – hitna pomoc• Non PCI bolnice • PCI centri

Mreza primarne PCI u BiH - nastavak

• >3h -12h od pocetka simptoma – transfer u PCI centar – primarni transport

• Nakon neuspjele trombolize – hitni transfer u PCI centar – rescue PCI

• Nakon uspjele trombolize transport u PCI centar unutar 24 h – sekundarni transport

• Nakon 24-48 h transport u lokalne non PCI bonice- tercijarni transport

Mreza primarne PCI u BiH

• Preostali interventni PCI centri koji nisu u stanju obezbjediti 24/7 servis – u incijalnoj fazi ne ulaze u mrezu

• Kao low volume centri rade elektivne procedure

• Nakon edukacije kadrova i obezbjedjenja kontinuiranog servisa ravnopravno ulaze u mrezu

Mreza primarne PCI u BiH

• Nacionalni program za primarnu PCI – koordiniran od strane Ministarstve zdravlja

• Nacionalni registar primarne PCI • Koordinirajuce tijelo regionalnih mreza kao

I centralno koordinirajuce tijelo na drzavnom nivou .

• Rok 2 godine za formiranje mreze na cijeloj teritoriji BiH – preko 70%STEMI primarnom PCI I 2000 infarkta godisnje

STRUKTURA DATABASIS

• DEMOGRAFSKI PODACI• ISTORIJA BOLESTI

– relevantnu za koronarnu bolest: uključuje podatke kao što su raniji infarkt, AP, ranije intervencije i postupke kao što su PCI i CABG

• FAKTORI RIZIKA: – relevantni za koronarnu bolest (hipertenzija,

hiperlipidemija, pušenje, šećernu bolest...)

STRUKTURA DATABASIS

• UČINJENE PRETRAGE• PCI SEKCIJA

– fokusira se na revaskularizaciju• MEDIKACIJA

– prije – u toku PCI• ISHOD

– podaci o neposrednom ishodu nakon PCI• LIJEKOVI NA OTPUSTU I FOLLOW-UP

”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

D.M. 46 y m.STEMI inf.

G.M.42y.m.STEMI,ant.

G.M.63y f.STEMI inf S-P CABG