Optimal Timing of PCI in ACS Patrick Hildbrand. Trends and Prognosis in ACS Furman MI, JACC 2001,...

Optimal Timing of PCI in ACS

Patrick Hildbrand

http://www.rsv-gnw.ch/index.php?lang=de

Trends and Prognosis in ACS

Furman MI, JACC 2001, 37:1571-1580Hospital 1 year

ACC/AHA2007 STEMI GUIDELINES Focused Update 2004 12/2007

ACC/AHAPCI GUIDELINES Focused Update 2005 12/2007

ESCGUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF NON-ST-SEGMENT ELEVATIONAUTE CORONARY SYNDROMS 06/2007


4

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Recommendations and Level of Evidence

5

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Applying Classification of Recommendations and Level of Evidence

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect

Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies Limited (2-3) population risk strata evaluated

Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2) population risk strata evaluated

Therapeutic Options

Anti-ischemic agents

Anti-coagulants UFH or LMWH Factor-Xa inhibitors (Fondaparinux) Direct Thrombin inhibitors (Bivalirudin)

Anti-platelet agents ASA Clopidrogel GP IIb/IIIa Inhibitors

Revascularization

ACS


Diagnosis and Risk assessment of ACS

Therapeutic Options > Timing Revascularization

Summary Management Strategy


Chest Pain

ECG

Kaul P, JACC 2001, 38:64-71

Biochemistry

Risk Stratification

Summary Diagnosis and Risk assessment

Diagnosis and short-term risk stratification should be based on a combination of

Clinical history Symptoms ECG and (10 minutes, 6h, 24h and before hospital discharge) Biomarkers (admission and after 6-12 h) Risk score results

Echocardiography is recommended to rule out differential diagnosis

Patient without recurrence of pain, normal ECG findings and negative troponins tests > non invasive stress testing


Diagnosis and Risk assessment of ACS

Therapeutic Options



Coronary revascularization

Revascularization for ACS is performed to

RELIEVE ANGINA

RELIEVE ONGOING MYOCARDIAL ISCHEMIA

PREVENT PROGRESSION TO MI OR DEATH

15

Acute Coronary Syndromes

UA/NSTEMI

STEMI


Primary PCIRescue PCI

Facilitated PCIDelayed PCI

16

Primary PCI

STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal.

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

Primary PCI versus Fibrinolysis

7 7

2

14

5

3

1

8

0

5

10

15

Death Re MI Total Stroke Total

Pe

rce

nta

ge

fibrinolysis prim PCI

Primary PCI versus fibrinolysis for MIMeta analysis of 23 trials

Keeley EC. Lancet 2003;361:13-20

P<0.0001

Defeated

CAPTIM: Mortality at different time points

Mortality Pre-hospital*

fibrinolysis

Primary PCI

p-value

Patients 419 421

At 30 days 3.8% 4.8% 0.29

At 1 year 5.4% 7.3% 0.08

*26% of patients had rescue PCI Steg PG. Circulation 2003;108:2828-2830

Time to randomisation and one-year mortality in CAPTIM

2.2%

5.7%

0%

5% 5.9%

3.7%

0%

10% < 2h 2h

p = 0.05 p = 0.34

Lysis pPCI Lysis pPCI

Steg PG. Circulation 2003;108:2828-2830

22

Fibrinolytic Therapie

STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.


Facilitated PCI

Meta-analysis: Facilitated PCI vs Primary PCI

1.03(0.15-7.13)

3.07(0.18-52.0)

1.43(1.01-2.02)

1.03

(0.49-2.17)

Mortality Reinfarction Major Bleeding

Fac. PCIBetter

PPCIBetter

Fac. PCIBetter

PPCIBetter

Fac. PCIBetter

PPCIBetter

Keeley E, et al. Lancet 2006;367:579.

0.1 1 10 0.1 1 10 0.1 1 10

1.38 (1.01-1.87)

1.71 (1.16 - 2.51)

1.51 (1.10 - 2.08 )

Lytic alone N=2953

IIb/IIIa alone N=1148

Lytic +IIb/IIIaN=399

All (N=4500)

1.40 (0.49-3.98)

1.81

(1.19-2.77)

A planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI is not recommended and may be harmful.

Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present:

a. Patients are at high risk,b. PCI is not immediately available within 90 minutes, andc. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight).

Facilitated PCI



Facilitated PCI

Further Studies Ongoing

• Prehospital fibrinolytic therapy• Better anticoagulant and antiplatelet

therapy• Use in circumstances of longer delays to

PCI

However, based on available data, facilitated PCI offered no clinical benefit, and was associated with harm when full dose fibrinolytics were used.D

efeated

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

EMSDispatch

EMS on-scene• Encourage 12-lead ECGs.

GOALS

Sion

SZO

Inter-HospitalTransfer

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

Patient EMS EMS transportEMS-to-balloon within 90 min.

Patient self-transport Hospital door-to-balloon

within 90 min.Dispatch

1 min.

5 min.

ECGTriage

Late PCI

Occluded Artery Trial (OAT)

Eligibility:• Total IRA occlusion• 3-28 days (>24 hours)

Death, MI, CHF Class IV

Fatal and Non fatal MI

4 year event rate: n.s.

Hochman JS, et al. Am Heart J 2005;150:627-42; Hochman JS, et al. N Engl J Med 2006;355:2395-407.

Exclusion criteria:• Significant left main or 3 vessel

CAD • Hemodynamic or electrical

instability• Rest or low-threshold angina • NYHA Class III-IV HF or shockRESULTS

2166 randomized1082 PCI + optimal medical therapy1084 Optimal medical therapy

(MED)

PCI of a hemodynamically significant stenosis in a patent infarct artery > 24 hours after STEMI may be considered as part of a invasive strategy.

PCI of a totally occluded infarct artery > 24 hours after STEMI is not recommended in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia.

Late PCI after Fibrinolysis or for Patients Not Undergoing Primary Reperfusion



Acute Coronary Syndromes

UA/NSTEMI

STEMI

Routine Invasive (Timing)

Selective Invasive


Coronary revascularization

Randomized trials comparing early invasive (dark bars)

vs. conservative strategy (open bars)

Invasive vs. Conservative Strategies

New data coming from long-term follow up of RITA-3 and FRISC-2 and Mehta meta-analysis show significant risk reduction for death

and „death & MI“ at long-term follow up

Early hazard shown in ICTUS Trial

Early hazard shown in Mehta meta-analysis

ICTUS, Lancet 2007FRISC 2, Lancet 2000

RITA 3 Lancet 2005Metha JAMA 2005

Timing of Intervention NSTEMI Few studies have shown superiority of very early intervention vs. deferred intervention

ISAR-COOL (small sample size) JAMA 2003

VINO

Many trials have shown early hazard with early intervention vs. deferred intervention

ICTUS trial NEJM 2005

Mehta meta-analysis JAMA 2005

Grace and Crusade registries Heart 2007, Arch Intern Med 2006

> Timing of intervention recommended on the basis of risk stratification

Clinical Outcomes for Patients Stratified by Age(Invasive Vs Conservative Strategies) from TACTICS–

TIMI-18 Trial

Outcomes According to Degree of Renal Function Impairment in NSTE-

ACS Patients in GRACE Registry

Special Conditions & Populations chronic Kidney Disease

Special Conditions& PopulationsDiabetes

Treatment Effect on 30-day Mortality Among Diabetic Patientswith NSTEMI from Six Randomized Clinical Trials

Special Conditions& PopulationsDiabetes

Risk Stratification

Options for Transport of Patients With NSTEMI and Initial Reperfusion Treatment

EMS Transport

Onset of symptoms of

STEMI

EMSDispatch

EMS on-scene• Encourage 12-lead ECGs.

GOALS

SionSZO

Inter-HospitalTransfer

Patient EMS Diagnosis before treatment

Risk stratificationDispatch

1 min.

5 min.

ECGTriage

Urgent

Early

No Transfer

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Optimal Timing of PCI in ACS Patrick Hildbrand. Trends and Prognosis in ACS Furman MI, JACC 2001,...

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Transcript of Optimal Timing of PCI in ACS Patrick Hildbrand. Trends and Prognosis in ACS Furman MI, JACC 2001,...