STEMI ACS and Thrombosis in the Emergency Setting.
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Transcript of STEMI ACS and Thrombosis in the Emergency Setting.
STEMI
ACS and Thrombosis in the Emergency Setting
Q1: Which reperfusion strategy would you select as optimal for this patient if the nearest cardiac center were 3 hours drive away?
a) Immediate transfer to cardiac cath lab for primary PCIb) Immediate fibrinolysis and then transfer to cardiac centrec) Immediate fibrinolysis with transfer only if no reperfusion
Choosing the Optimal Reperfusion Strategy
Goal is rapid reperfusion Time targets from first medical contact to treatment
Fibrinolysis 30 minutes Primary angioplasty (PPCI) 90-120 minutes
Delayed reperfusion associated with increased mortality When time to PPCI will exceed 90-120 minutes fibrinolysis
should be given immediately Time delay for PPCI to achieve greater benefit than
fibrinolysis may be less than 90 minutes when Anterior MI Patient age <65 yrs Time from symptom onset <120 minutes
Impact of Delay to Primary PCI
90 DAY MORTALITY RELATED TO DOOR-TO-BALLOON TIME
Hudson MP et al. Hudson MP et al. Circ Cardiovasc Qual Outcomes 2011;4:183-92
SURVIVAL(%)
0 10 20 30 40 50 60 70 80 90
(n=1071)(n=1354)(n=1186)(n=1762)
<60 min60-90 min90-120 min≥120 min
99%
98%
97%
96%
95%
94%
93%
92%
100%
3.2%
90-day mortality
4.0%4.6%
5.3%
DAYS
P<0.0001
Which Patients Cannot Afford a PPCI Delay?
Pinto DS et al. Circulation 2006; 114: 2019-2025Pinto DS et al. Circulation 2006; 114: 2019-2025
PCI RELATED DELAY (DB-DN) WHERE PCI AND FIBRINOLYTIC
MORTALITY ARE EQUAL (MIN)
NonAnt MI65+ YRS
180
120
60
0Ant MI65+ YRS
NonAnt MI < 65 YRS
Ant MI < 65 YRS
0-120 Prehospital Delay (min)121+
40 43
58
103107
148
168179
20,424
10,614
9,812
3,739
41,774
16,119
19,517 5,296
Prehospital and In-Hospital Management and Reperfusion Strategies
ESC STEMI Guidelines 2012ESC STEMI Guidelines 2012
aThe time point the diagnosis is confirmed with patient history and ECG ideally within 10 min from the first medical contact (FMC). All delays are related to FMC (first medical contact).
Cath = catheterization laboratory; EMS = emergency medical system; FMC = first medical contact; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction
STEMI diagnosisaSTEMI diagnosisaPrimary-PCI capable center
Primary-PCI capable center
EMS or non primary-PCI capable center
EMS or non primary-PCI capable center
Preferably ˂60 min
Primary-PCIPrimary-PCI
Rescue PCIRescue PCI
Coronary angiographyCoronary angiography
NONO
YESYES
Immediately
Preferably 3-24 h
YESYES NONO
PCI possible ˂120 min? PCI possible ˂120 min?
Immediate fibrinolysis
Immediate fibrinolysisSuccessful fibrinolysis?Successful fibrinolysis?
Immediate transfer to PCI center
Preferably ≤90 min(≤60 min in early presenters)
Immediate transferto PCI center
Preferably≤30 min
Q2: In the event that the patient receives fibrinolysis, which anticoagulant is preferred?
a) UHFb) Enoxaparinc) Fondaparinux
Q3: Which would be the optimal antiplatelet agent to add to the anticoagulant?
a) clopidogrelb) ticagrelorc) prasugrel
Anticoagulation and Antiplatelet Therapy with Fibrinolysis
Anticoagulation Initiate UFH, enoxaparin or fondaparinux immediately after
administration of fibrinolytic agent• UFH 70u/kg iv• Enoxaparin
– <75yrs old 30mg iv bolus followed by s/c 1mg/kg– >75yrs old no iv bolus, s/c 1mg/kg
Fondaparinux 2.5mg s/c
Antiplatelet Therapy ASA 81-160mg po Clopidogrel
• <75 yrs old 300mg load followed by 75mg daily• > 75 yrs old no load, 75mg po daily
NB Ticagrelor and Prasugrel should not be used with fibrinolysis as they have not been tested in this situation
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Need for PCI after Fibrinolysis
Rescue PCI Failed fibrinolysis
• Persistence of chest pain• Failure of ST elevation to decrease more than 50% at 1 hr
after fibrinolysis
Pharmaco-Invasive strategy Consider routine transfer patients to cardiac centre for PCI
within 2-24 hrs of fibrinolysis
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction
Impact of Routine Early Transfer for PCI after Fibrinolysis
Cantor et al N Eng J Med 2009;360:2705Cantor et al N Eng J Med 2009;360:2705
DEATH, REINFARCTION, WORSENING HEART FAILURE, OR CARDIOGENIC SHOCK
0.20
0.15
0.10
0.00
0.05
0 5 30 DAYS10 15 20 25
Standard treatment
Routine early PCI
Death, reinfarction, or recurrent ischemia HR 0.65 (95% CI 0.44–0.96)
HR 0.64; 95% CI, 0.47 - 0.87
Early PCI 2.8 hrsStandard treatment PCI 32.5 hrs
Primary PCI for STEMI
Improved outcomes if PPCI performed in timely manner
Delayed PPCI worse than timely fibrinolysis
Goal Patient contact to PCI < 90 minutes for most patients
Adjuvant anticoagulation / antiplatelet agents By agreement with local interventional cardiology team
Oral Antiplatelets in STEMI
All primary PCI
Mortality HR, 0.82; P=0.05 MI HR 0.80 p=0.03Stent thrombosis HR 0.60 p=0.03Stroke increased 1.7% vs 1.0% HR 1.63 p=0.02 No increase in major bleeding
60% Primary PCI 30% Secondary delayed PCI
No reduction of mortality, MI HR 0.70 p=0.01Stent thrombosis HR 0.58 p=0.23
No increase in TIMI major or life threatening bleeding
Montelescot et al Montelescot et al LancetLancet 2009; 373: 723 2009; 373: 723 Steg et al Circulation. 2010;122:2131Steg et al Circulation. 2010;122:2131
TRITON TIMI 38 Prasugrel vs ClopidogrelCV death / MI / Stroke
CUMULATIVE INCIDENCE (%)
DAYS FROM RANDOMISATION
HR 0.79 95% CI 0.65-0.97 p=0.0221
15
10
5
00 50 300100 150 200 250 350 400 450
Clopidogrel
Prasugrel
P=0.0017 P=0.0221
At risk
PLATO Ticagrelor vs ClopidogrelCV death / MI / Stroke
Clopidogrel
Ticagrelor
CUMULATIVE INCIDENCE (%)
012
3456789
101112
MONTHS0 1 2 3 4 5 6 7 8 9 10 11 12
HR 0.87; 95% CI 0.75 - 1.01; P= 0.07
Pre-Hospital Fibrinolysis + PCI vs Primary PCI for Patients Unable to Undergo Primary PCI within 1
Hour
STREAM Study Armstrong et al N Eng J Med 2013;368:1379 STREAM Study Armstrong et al N Eng J Med 2013;368:1379
RR 0.86; 95% CI, 0.68 -1.09; P = 0.21
DEATH, SHOCK, CHF, OR REINFARCTION
% 20
15
10
0
5
0 5 30 DAYS10 15 20 25
Primary PCI
Fibrinolysis
Q4: How would you have handled this patient if in addition to medical history described, he also had a recent (past 6 months) CVA?
a) Administer fibrinolysisb) Transfer to regional cardiac centre for PCIc) Manage medically with UFH and ASA
2013 STEMI Management
Early identification of STEMI- pre hospital preferred Performing 12-lead ECG by EMS personnel or at site of first
medical contact Early decision for reperfusion strategy and administration
within 12 hours of symptom onset for all eligible STEMI patients Primary PCI preferred if can be performed in timely manner
(First medical contact to PCI < 90 -120 min) Consider fibrinolysis in young anterior STEMI presenting
< 120 minutes from symptom onset if PCI not available within 60 minutes
O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive SummaryO’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary
2013 STEMI Management (cond’t)
Following fibrinolysis consider referral for early PCI
Choice of anticoagulant / antiplatelet agent depends upon reperfusion strategy and policy of PCI centre (P2Y12 receptor inhibitor therapy prior to PCI and maintenance for a year; ASA 160-325mg loading and 81mg maintenance; UHF, bivalirudin with or without prior UHF)
O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive SummaryO’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary
2013 STEMI Management
O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive SummaryO’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary
Figure 1. Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. Performance of PCI is dictated by an anatomically appropriate culprit stenosis. *Patients with cardiogenic shock or severe heart failure initially seen at a non-PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Ϯangiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. CABG indicates coronary artery bypass graft; DiDO, door-in-door-out; FMC, first medical contact; LOE, Level of Evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.
STEMI patient who is a candidate for reperfusionSTEMI patient who is a
candidate for reperfusionInitially seen ata PCI-capable
hospital
Initially seen ata PCI-capable
hospital
Initially seen at anon-PCI-capable
Hospital*
Initially seen at anon-PCI-capable
Hospital*
Send to cath lab for primary PCI FMC-device
time ≤90 min(Class 1, LOE: A)
Send to cath lab for primary PCI FMC-device
time ≤90 min(Class 1, LOE: A)
Diagnostic angiogramDiagnostic angiogram
PCIPCI CABGCABGMedical
therapy onlyMedical
therapy only
DIDOtime≤30 min
Transfer for primary PCIFMC-device time as soon
as Possible and ≤120 min
(Class 1, LOE: B)
Transfer for primary PCIFMC-device time as soon
as Possible and ≤120 min
(Class 1, LOE: B)
Administer fibrinolyticagent within 30 min of
arrival when anticipated FMC- device >120 min
(Class 1, LOE: B)
Administer fibrinolyticagent within 30 min of
arrival when anticipated FMC- device >120 min
(Class 1, LOE: B)
Transfer for angiography and revascularization
within 3-24 h for other patients as part of an
invasive strategyϮ(Class IIa, LOE: B)
Transfer for angiography and revascularization
within 3-24 h for other patients as part of an
invasive strategyϮ(Class IIa, LOE: B)
Urgent transfer forPCI for patients
with evidence offailed reperfusion
or reocclusion (Class IIa, LOE: B)
Urgent transfer forPCI for patients
with evidence offailed reperfusion
or reocclusion (Class IIa, LOE: B)