STEMI – My Approach 2010
-
Upload
ishakansari -
Category
Education
-
view
4.763 -
download
7
description
Transcript of STEMI – My Approach 2010
STEMI – My Approach
2010
Dr S A MerchantInterventional Cardiologist
DM MD DNB FSCAI Lilavati, CritiCare, BSES, Breach Candy Hospitals
Clinical manifestations of arterial thrombosis
UA/NQMI:Partially-occlusive thrombus
(primarily platelets)
Intra-plaque thrombus (platelet
dominated)
Plaque core
ST MI:occlusive thrombus
(platelets, red blood cells, and fibrin)
Intra-plaque thrombus (platelet
dominated)
Plaque core
SUDDEN DEATH
Adapted from Davies MJ. Circulation. 1990; 82 (supl II): 30-46.
Dr S A Merchant
Initial Diagnosis of STEMI
Dr S A Merchant
Small, vulnerable plaques are responsible for causing MI
68%
18% 14%0
20
40
60
<50% 50%–70% >70%
% Stenosis
MI Patients
(%)
Falk et al: Circulation 1995;92:657–671 Dr S A Merchant
Pre CCU era CCU era Reperfusion era0
5
10
15
20
25
30
35
4030
15
6.5
% Mortality
Defibrillation,Hemodynamic
monitoringBeta Blockade Thrombolysis/
adjuct therapyPTCA, Stent
THE IMPACT OF MEDICAL THERAPY
MANAGEMENT OF Acute Myocardial Infarction
Dr S A Merchant
Transport of Patients With STEMI and Initial Reperfusion Treatment
J Am Coll Cardiol. 2004;44:671; Circulation. 2004;110:588.
EMS transport
Onset of symptoms of STEMI
9-1-1EMS
dispatch
EMS on scene• Encourage 12-lead ECGs• Consider prehospital
fibrinolytic if capable and EMS–to–needle within 30 minGOALS
PCIcapable
Not PCIcapable
Hospital fibrinolysis: Door–to–needle
≤ 30 min
EMS triage
plan
Inter-hospitaltransfer
“Golden Hour” = 1st 60 minTotal ischemic time: within 120 min
Patient EMS Prehospital fibrinolysisEMS–to–needle≤ 30 min
EMS transportEMS–to–balloon ≤ 90 min
Patient self-transport Hospital door–to–balloon
≤ 90 min
Dispatch
1 min
5 min
8 min
Boersma et al, Lancet 1996 348:771
Thrombolysis Versus Primary PCI - Time DependancyAbsolute 35 day mortality reduction v treatment delay
0 3 6 9 12 15 18 21 240
20
40
60
80
Treatment delay (h)
Ab
so
lute
be
ne
fit:
liv
es
s
av
ed
/1
00
0 p
ts t
rea
ted N=50246
Primary PCI
Dr S A Merchant
Primary PCI
angioplasty vs
thrombolysis
angioplasty vs
thrombolysis
Dr S A Merchant
PerCutaneous Interventions following AMI : A variety !!
Thrombolytic Therapy Prior to PCI
Successful reperfusion after Thrombolysis
Timing of PCI after Thrombolysis
Direct (Primary ,Emergency)
No Not Applicable Not Applicable
Rescue (Salvage)
Yes No 1.5 to 2 h
Facilitated (Immediate)
Yes +/- Immeterial Immediate
Early Yes Yes 12-48 h
Deferred (Elective)
Yes Yes >48 h
Dr S A Merchant
Primary PCI
POBA vs StentPOBA vs Stent
Dr S A Merchant
primary PTCA vs stentprimary PTCA vs stent
6-month outcomes6-month outcomes
00 0.50.5 1.51.511 22
OR (95% CI)OR (95% CI)stentstent
death
reMI
death/ reMI
TVR
death/reMI/TVR
death
reMI
death/ reMI
TVR
death/reMI/TVR
3.3%
1.7%
4.9%
8.3%
13.7%
3.3%
1.7%
4.9%
8.3%
13.7%
3.8%
3.0%
6.8%
18%
25.9%
3.8%
3.0%
6.8%
18%
25.9%
PTCAPTCA
stent betterstent better
PTCA betterPTCA better
0.85 (0.57-1.27)0.85 (0.57-1.27)
0.58 (0.35-0.96)0.58 (0.35-0.96)
0.72 (0.52-0.98)0.72 (0.52-0.98)
0.41 (0.32-0.52)0.41 (0.32-0.52)
0.45 (0.37-0.55)0.45 (0.37-0.55)
Dr S A Merchant
Real world situation: Door to balloon times in USA
N=365N Engl J Med 2006;355
Dr S A Merchant
Conclusion : Every minute delay in P’PCI affects 1 year mortality. Therefore, all efforts should be made to shorten Ischemia time not only for thrombolysis but also for P’PCI.
Door to Balloon minus
Door to Needle time
Anticipated delay between door to balloon minus door to needle time if more than one hour , then thrombolysis is a better strategy.
Assessment of time is the key point in the choice of reperfusion strategy
Dr S A Merchant
USIC 2000, French Registry Data Hospital administered ‘lysis as good as PCI
EURO-PCR Paris 2003
Pre hospital lysis
Dr S A Merchant
French USIC 2000 survey: real world
No reperfusio
n
Pre-hosp TT
Hosp TT
Primary PCI
Patients 386 (30%)
155 (12%)
322 (25%)
425 (33%)
Age (year)
71 60 61 61
Time to admission (h)
2.8 2.4 2.2 2.1
1 year death
14.7% 3.2% 9.0% 7.9%
USIC. Circulation 2004;110:1909-1915
Dr S A Merchant
Fibrinolysis vs Transfer for PCI
Pre Hosp Primary In Hosp Lysis PCI
Lysis
CAPTIM CAPTIM DANAMI 2 DANAMI 2
Death (%) 3.8 4.8 6.6 7.6
1yr 5.4 7.3
Reinfarction (%) 3.7 1.7 1.6 6.3
Disabling CVA (%) 1.0 0.0 1.12.0
Any of Above (%) 8.2 6.2 8.0 13.7*(* P < 0.003)
Vahanian ESC, 2002
Dr S A Merchant
Pre Hospital thrombolysisCAPTIM 1 Year Results (TNK)
Series10%
5%
2.2%
5.7%
Pre HospitalLysis
Pre HospitalLysis
PrimaryPCI
PrimaryPCI
P=0.057P=0.057DeathDeath
GW Symposium, AHA 2002GW Symposium, AHA 2002
Sx < 2 hours
Dr S A Merchant
Blush Score : 30 D, M in AMI receiving fibrinolysis regardless of TIMI Grade flow in Epicardial Artery,
Myocardial perfusion by blush score predicts mortality
Gibson : Circulation 2000;101-125
Improved flows
Failed flows
Se-ries1
0
5
10
15
20
25
30
35
74.5
2.2
6
1 0
7 897 7
21
2 1
5
13
PTCA vs Fibrinolysis:Short Term Clinical Outcomes (23
RCTs)
PTCA
Fre
qu
en
cy
(%)
Keeley E. et al., Lancet 2003; 361:13-20.
P=0.0002
P=0.0003 P<0.0001
P<0.0001
P<0.0001P=0.0004
P=0.032
P<0.0001
Death Death, no
SHOCKdata
ReMI Rec. Isch
Total Stroke
Hem. Stroke
Major Bleed
DeathMICVA
Fibrinolysis
N = 7739
Is timing an issue even for Primary PCI?
Dr S A Merchant
Survival Benefit by Time to Treatment with Lytics
Dr S A Merchant
Dr S A Merchant
door-to-balloon times in primary PCIdoor-to-balloon times in primary PCI
8%8%
21% 21%24%24%
17%17%
10%10%
20%20%
<60<60 60-9060-90 120-150120-15090-12090-120 150-180150-180 >180>18000
55
1010
1515
2020
% of patients% of patients
minminC.P. CANNON. JAMA 2000;283:2941-7C.P. CANNON. JAMA 2000;283:2941-7
NRMI-2 : 27080 consecutive patientsNRMI-2 : 27080 consecutive patients
Dr S A Merchant
Mortality by time to reperfusion with Primary PCINRMI-2 Registry (27,080)
C.P. CANNON. JAMA 2000;283:2941-7 Dr S A Merchant
Why is Primary PCI less time dependent than Lysis?
1) Lysis is less effective at restoring infarct artery patency as the clot ages
2) Myocardial salvage and infarct size after lytics are very sensitive to time to reperfusion
3) Cardiac rupture is more likely to occur as the time to lysis increases
Dr S A Merchant
Recommendations
When performed by experienced* operators/centers, PCI is the reperfusion strategy of choice for patients with AMI
PCI for AMI: door-to-balloon time < 2hrs (time window up to 12 hours accepted)
* operator: 75 PCI (any type) / year; center: 36 Primary PCI / year
Dr S A Merchant
After 12 hours???
BRAVE-2
Rationale: While thrombolysis has been shown to produce no benefit after 12 hours, no similar studies have looked at primary PCI in this group.
Study: 365 patients randomized to in an invasive arm or a conservative arm. The invasive group underwent angiography and then PCI if necessary, while the conservative group was treated with conventional medical therapy. The primary end point was infarct size determined by SPECT at five to 10 days.
Results: Infarct size (%LV) was significantly reduced in the invasive arm (8.0 vs 13%; p=0.002). No clinical differences.
Kastrati ACC 2005 Dr S A Merchant
• primary PCI • primary PCI
Role of PCI in the management of STEMIRole of PCI in the management of STEMI agendaagenda
• the challenges• the challengeshow to achieve optimal reperfusionhow to achieve optimal reperfusion
what to do with the occluded IRAwhat to do with the occluded IRA
replacing the function of death cellsreplacing the function of death cells
- angioplasty vs thrombolysis- angioplasty vs thrombolysis
- added benefit of stent placement- added benefit of stent placement- timing
- culprit vessel vs all vessel intervention- role of 2b/3a inhibitors
- timing
- culprit vessel vs all vessel intervention- role of 2b/3a inhibitors
• transfer, rescue and facilitated PCI• transfer, rescue and facilitated PCI
• primary PCI • primary PCI
Dr S A Merchant
Dr S A Merchant
culprit vessel vs all vessel intervention
The ACC/AHA guidelines on PCI give elective PCI of a non-infarct related artery at the time of AMI a class III recommendation with a C level of evidence.
Exception: in case of cardiogenic shock, systematic intervention in multiple vessels may be required to optimize reperfusion of the heart.
Dr S A Merchant
Role of GP 2b/3a inhibitors
Dr S A Merchant
26.1%
11.2%9.7%
14.6%
4.5% 5.8%2.0%
6.0%
0%
10%
20%
30%
EPIC RAPPORT Neumann ADMIRAL
Placebo GP IIb/IIIa
p = 0.06
p = 0.03
p = 0.03
p = 0.01
N: 64 483 200 3002082
N: 64 483 200 3002082
GP IIb/IIIa Inhibitors For Primary PCI—30-Day Death, (re)MI or Urgent Revascularization
6.8%4.5%
CADILLAC
p = 0.02
Types of Thrombolytics
A. Clot Selective / Clot-Binding / fibrin Specific
B. Non clot Selective/ Non–Clot-Binding / Non Fibrin Specific
Dr S A Merchant
Action of Non–Clot-Binding AgentsAction of Clot-Binding Agents
(Alteplase, Tenecteplase) (Urokinase, Streptokinase)
Clot-BindingPlasminogen
Activators
Clinical Relevance of Fibrin Affinity
Clot Blood Vessel Non–Clot-BindingPlasminogen
Activators
Clot Blood Vessel
Dr S A Merchant
Thrombolytic Agents
Fibrin-Specific Recombinant tissue
plasminogen activator (rt-PA) Mutants and Variants of
Tissue-type Plasminogen Activator TNK-rt-PA Reteplase Lanetoplase
Single-chain Urokinase-type Plasminogen Activator Recombinant pro-urokinase
(saruplase) Staphylokinase
Non-Fibrin-Specific Streptokinase Anisoylated
Plasminogen Streptokinase Activator Complex
Dr S A Merchant
Overview of Thrombolytics
SK TNK t-PA r-PA
Molecular Wt 45,000 65,000 65,000 39,000
Fibrin specificity - ++++ ++ +
Plasma Half life (min)
~20 20 4-6 11-14
Speed of admistration
++ ++++ ++ +++
Systemic effect ++++ - + ++
Dose 1.5M unit iv infusion 30-60 min.
30-50 mg iv bolus
5-10 sec.
15mg bolus 50 mg 30m 35mg 60m
10mg +10mg iv double
bolus 30 min apart
Overview of Thrombolytics
SK TNK t-PA r-PA
PAI-1 resistance no Yes no no
Hypotensive effect
Yes no no no
Allergic effect Yes no no ?
Mortality Advantage
Inferior to t-PA
Equivalent to t-PA
Gold standard
Equivalent to SK
Trade Name Streptase Kabikinase
Metalyse Actilyse Rapilysin
Generic names streptokinase tenecteplase alteplase reteplase
Comparison with Streptokinase
Dr S A Merchant
Dr S A Merchant
Dr S A Merchant
Dr S A Merchant
rescue PCI
short term outcome: deathrescue PCI
short term outcome: death
Belenkie
RESCUE
PRAGUE
Vermeer
Belenkie
RESCUE
PRAGUE
Vermeer
n PCI cons.n PCI cons.
28
151
200
149
28
151
200
149
6.3%
5.1%
7%
8.7%
6.3%
5.1%
7%
8.7%
33.3%
9.6%
14.0%
6.7%
33.3%
9.6%
14.0%
6.7%
00 0.50.5 1.51.511 2.02.0
odds ratio (95% CI)odds ratio (95% CI)
0.13 (0.01-1.40)0.13 (0.01-1.40)
0.51 (0.12-2.06)0.51 (0.12-2.06)
0.46 (0.16-1.30)0.46 (0.16-1.30)
1.24 (0.31-4.49)1.24 (0.31-4.49)
0.55 (0.30-1.01)0.55 (0.30-1.01)p=0.052p=0.052totaltotal 528528 6.7%6.7% 11.5%11.5%
Dr S A Merchant
Series10%
5%
10%
15%
20%
2.5%
4.9%
Pre HospitalLysisPre HospitalLysis
PrimaryPCIPrimaryPCI
P=0.09P=0.09Incidence of ShockIncidence of Shock
CAPTIM – Prehospital tPA vs 1°PCI1 Year Results
Bonnefoy Lancet 2002Bonnefoy Lancet 2002
Series10%
10%
5.4%
7.3%
P=0.27P=0.27Death at 1 YearDeath at 1 Year
Pre HospitalLysisPre HospitalLysis
PrimaryPCIPrimaryPCI
Dr S A Merchant
Tenecteplase is the lytic of choice
Cantor also emphasized that previous trials have used different lytics and no clopidogrel preloading.
"Streptokinase is not very cath-lab friendly, so
patients were more prone to getting bleeding complications when they went to the cath lab.
Those previous trials were also done before we knew the benefits of preloading patients with clopidogrel and using antithrombotic therapies like GP IIb/IIIa inhibitors during the angioplasty."
Dr S A Merchant
Dr S A Merchant
Death / Nonfatal MI / Nonfatal ICH
Death / Nonfatal MI / Nonfatal Major Bleed
Death / Nonfatal MI / Nonfatal Disabling Stroke
Enox Better UFH BetterRR
UFH (%) Enox (%) RRR (%)
12.3 10.1 18
12.8 11.0 14
12.2 10.1 17
ExTRACT TIMI 25Net Clinical Benefit at 30 Days
ExTRACT TIMI 25Net Clinical Benefit at 30 Days
Dr S A Merchant
CLARITY–TIMI 281° Endpoint: Occluded Artery (or D/MI Thru Angio/HD)
| | | | | |0.4 0.6 0.81.01.2 1.6
Odds ratio 0.64(95% CI, 0.53 – 0.76)
P < 0.001
Clopidogrel Placebobetter better
Series10
5
10
15
20
25
15.0
21.7
Clopidogrel PlaceboLD 300 mgMD 75 mg
Occlu
ded
art
ery
or
death
/MI
(%)
36% odds
reduction
n = 1,752 n = 1,739
Sabatine MS, N Engl J Med. 2005;352:1179-1189. Dr S A Merchant
Pro
port
ion
dead
befo
re fi
rst
dis
ch
arg
e (
%)
Time since randomization (days)
Placebo + ASA: 1,845 deaths (8.1%)
Clopidogrel + ASA:1,726 deaths (7.5%)
0.6% ARD7% RRR P = 0.03
COMMIT: Effect of Clopidogrel on Death Inhospital
N = 45,852 No age limit; 26% age ≥ 70
years
Lytic Rx 50%
No LD given
Chen ZM, et al. Lancet. 2005;366:1607-1621.
0 7 14 21 28
10
9
8
7
6
5
4
3
2
1
0
Dr S A Merchant
Summary
Acute therapy in STEMI focuses on reperfusion & antithrombotic therapy
Reasonable options for hospitals without onsite PCI capability
Fibrinolytic Therapy (goal : door to needle time ≤ 30 minutes)
Transfer for Primary PCI (goal: door to balloon time ≤ 90 minutes)
Transfer for Rescue PCI if reperfusion with lytic fails Facilitated PCI : no clinical benefit seen to date
Clopidogrel in combination with aspirin results in significant further improvements in outcomes of patients with STEMI (CLARITY-TIMI 28/COMMIT)
Dr S A Merchant
Current ACC/AHA STEMI guidelines recommend IV UFH as ancillary therapy to reperfusion therapy
Enoxaparin is superior to current standard of UFH as the antithrombin to support fibrinolysis (ExTARCT TIMI 25)
Enoxaparin has a beneficial effect in patients undergoing elective PCI,with no increase in bleeding (PCI - ExTARCT TIMI 25)
Fondaparinux is beneficial in STEMI without increasing the risk of bleeding or stroke (OASIS 6), but some subsets do not benefit (eg primary PCI)
Fondaparinux was not superior to UFH is Stratum 2 of OASIS 6 for STEMI
Long term treatment involves aggressive multifactorial lifestyle modification & both antithrombotic & anti ischemic therapies
Summary (cont.)
Dr S A Merchant
Complete obstruction
Partial flow
Full flow
Partial success with
pharmacologicreperfusion
Rethrombosis:Prevented by antiplatelet
and anticoagulant Rx
PCI p lyticIdeal goal of
pharmacologicreperfusion
Pharmacoinvasive approach
Dr S A Merchant
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
ACC/AHA Guidelines for Management of Patients With STEMI, 2004 Reperfusion Options for STEMI Patients
If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either
strategy.
ACC/AHA Guidelines for Management of Patients With STEMI,Journal of the American College of Cardiology 2004 Dr S A Merchant
Emerging ModalitiesPharmacoinvasive Management
(PCI following TNK) is a better , safer option than PAMI as proved recently .
JACC Sept 2007
It widens the time window for PCI
This seems to combine the benefits of Mechanical and pharmacological strategies in reperfusion
Dr S A Merchant
When patients present to a primary unit without interventional capabilities:Therapeutic options
a) lyticsb) “transfer” to a facility with a cardiac cath lab
(with or without adjunctive therapy – “facilitated PCI”).
Any such “transfer” needs to be effected rapidly to take advantage of the early benefits of revascularization.
Dr S A Merchant
‘Best of both worlds’ :
Local rapid Thrombolysis to
majority
&
PCI Routinely
Dr S A Merchant
TRANSFER-AMI:
high-risk STEMI
Standard treatment after fibrinolysis (rescue PCI for failed reperfusion, with elective PCI encouraged for successfully reperfused patients after 24 hours)
Pharmacoinvasive strategy (transfer for PCI within six hours of fibrinolysis).
Both groups received Tenecteplase
Dr S A Merchant
TRANSFER-AMI: 30-Day Primary End Point and Components
Dr S A Merchant
TRANSFER-AMI:
STEMI to centers without timely access to a catheterization lab pharmacoinvasive approach consisting of full-dose thrombolytics, followed by emergent transfer for cardiac catheterization within 6 hours, is safe and efficacious compared to treatment with thrombolytics and transfer for rescue PCI only.
This suggests that transfer to PCI centers should be initiated immediately after fibrinolysis without waiting to see whether reperfusion is successful or not.
Dr S A Merchant
TRANSFER-AMI: 30-Day Bleeding End Points
Dr S A Merchant
direct stentingn 102
direct stentingn 102
angio end pointslow flow (TIMI 3 2)no-flow (TIMI 0-1)distal embolization
clinical outcomes (6-m F/U)deathre-MITVR
angio end pointslow flow (TIMI 3 2)no-flow (TIMI 0-1)distal embolization
clinical outcomes (6-m F/U)deathre-MITVR
direct stenting in acute MI direct stenting in acute MI
C. LOUBEYRE et al. JACC 2002;39:15-21C. LOUBEYRE et al. JACC 2002;39:15-21
11.7%
2.9%4.9%3.9%
0.9%2.9%8.8%
11.7%
2.9%4.9%3.9%
0.9%2.9%8.8%
pre-dilatationn 104
pre-dilatationn 10426.9
%
12.5%
7.6%6.7%
3.8%3.8%6.7%
26.9%
12.5%
7.6%6.7%
3.8%3.8%6.7%
p=0.01
p=0.02
p=0.01
p=0.02
angio end pointangio end point 11.7%
11.7%
26.9%
26.9%slow flow (TIMI 3 2)slow flow (TIMI 3 2) 2.9%2.9% 12.5%
12.5%
endovascular coolingendovascular cooling
SR DIXON. JACC 2002;40:1928-34SR DIXON. JACC 2002;40:1928-34 COOL-MI n 400 ptsCOOL-MI n 400 pts
% pts% pts
00MACEMACE
1010
0%0%
10%10%
median infarct sizemedian infarct size
2%2%
8%8%% LV% LV
55
00
1010
55
cooling n 21 cooling n 21 control n 21 control n 21
new cathether-based techniquesnew cathether-based techniques
thrombectomy
distal protection
thrombectomy
distal protection
mechanismmechanismCRTs in
AMICRTs in
AMIX-AMINE
AIMI
EMERALD
X-AMINE
AIMI
EMERALD
N 200N 200
N 500
PROMISE
N 200
N 500
PROMISE
N 200
devicedeviceX-SIZER•
ANGIOJET
EXPORT
CATHETER
PERCU-SURGE
FILTER-WIRE
X-SIZER•
ANGIOJET
EXPORT
CATHETER
PERCU-SURGE
FILTER-WIREDr S A Merchant
RECOMMENDATION
Task Force ESC 2005 guideline
Routine Coronary Angio & PCI, if applicable,
in successful Thrombolysis: 1 A
LYSE NOW, STENT LATER !!
Dr S A Merchant
Despite the clinical superiority of PAMI, thrombolytic therapy is the default treatment in many countries due to the practical
limitations of PAMI
Dr S A Merchant
Conclusion
In Indian context – Thrombolysis is the commonly accepted method of treatment in STEMI
PCI is superior as per data but not practical and feasible, not only in India but also all over world
Dr S A Merchant
New TNK is an ideal , novel thrombolytic agent, IV bolus reduces door to needle time and higher TIMI III and II flow( 86%)
New emerging post fibrinolysis PCI has emerged as an alternative method of treatment that appears to be safer &better as compared to PAMI
Dr S A Merchant
API Guidelines
Indications for thrombolytic therapy
Early presentation (3 h or less from symptom onset and delay to invasive strategy)
Invasive strategy is not an option- Catheterization laboratory not available / occupied.
- Financial reasons
- Lack of access to a skilled PCI laboratory
- Vascular access difficulties Delay to invasive strategy
Prolonged transport (Door-to-Balloon)- (Door-to-Needle) time > 1 hour.
Medical contact-to-balloon or door-to-balloon time > 90 minutes
Dr S A Merchant
ELAXIM INDIAN REGISTRY
Series160
65
70
75
80
85
9086.71
89.1485.06
73.88
% Clinically Successful Thrombolysis
overall <3hrs 3-6hrs >6hrs
Dr S A Merchant
ELAXIM INDIAN REGISTRY
Adverse events reportedIndian Registry ASSENT-2
Any bleeding (excluding ICH*) 4.62% 21.76%
ICH (without GpIIb/IIIa inhibitors) 0.48% 0.93%
Stroke (Non-ICH) 0.24% 1.78%
Myocardial re-infarction 3.33% 4.10%
Ventricular arrhythmias 5.71% 20.5%
Mortality (All cause) 3.48% 6.18%
* ICH = Intracranial hemorrhage Dr S A Merchant
2.5%
4.9%
0%
5%
10%
15%
20%
Pre HospitalLysisPre HospitalLysis
PrimaryPCIPrimaryPCI
P=0.09P=0.09Incidence of ShockIncidence of Shock
CAPTIM – Prehospital tPA vs 1°PCI
1 Year Results
Bonnefoy Lancet 2002Bonnefoy Lancet 2002
5.4%
7.3%
0%
10%P=0.27P=0.27
Death at 1 YearDeath at 1 Year
Pre HospitalLysisPre HospitalLysis
PrimaryPCIPrimaryPCI
Dr S A Merchant
TIMI 0 Complete occlusion
TIMI 1 Penetration of obstruction by contrast but no distal perfusion
TIMI 2 Perfusion of entire artery
but delayed flow
TIMI 3 Full perfusion, normal flow
10.6
7
4.7
0
2
4
6
8
10
12
14
TIMI 0/1 TIMI 2 TIMI 3
Mortality at 42 Days
P < 0.005
TIMI 1
OPEN ARTERY THEORY:Better flow in the infarct artery improves survival
Chesebro JH et al. Circulation 1987;76:142-54
Full-Dose TNK 3-12h Before PCI: GRACIA-2
Characteristic TNK+PCI PCINo. patients 103 102TIMI flow grade 3 59%* 43%Complete STRes (6h) 61%* 43%Death, MI, RI-UR 9% 12%Major bleeding 2% 3%
No differences in infarct size, LV function*p < 0.05
Aviles ESC 2003Aviles ESC 2003 Dr S A Merchant
Occluded Artery Trial (OAT)Occluded Artery Trial (OAT)
1º endpoint: death/reMI/rehosp. CHF (NYA class IV) over 3 years1º endpoint: death/reMI/rehosp. CHF (NYA class IV) over 3 years
multicenter, randomized, controledmulticenter, randomized, controled
randomizationrandomization
n 3200 patientsoccluded IRA (TIMI 0,1) n 3200 patientsoccluded IRA (TIMI 0,1)
PCI (3-28 days after MI) + risk factor modificationPCI (3-28 days after MI) + risk factor modification
no PCIno PCI
ASA-blockersACE inhibitors
ASA-blockersACE inhibitors
Apoptotic Rate in Occlued vs Open IRA
Abbate A et al. Circulation 2002
• hazards of stem cell manipulation
• arrhythmogenic potential of implanted cells
• hazards of stem cell manipulation
• arrhythmogenic potential of implanted cells
open questions on infarct/necrotic tissue
open questions on infarct/necrotic tissue
• economic issues• economic issues
• the capacity of the stem cells to find their
optimal myocardial ‘niche’
• the capacity of the stem cells to find their
optimal myocardial ‘niche’
• long-term fate of transplanted cells in the
recipient heart
• long-term fate of transplanted cells in the
recipient heart
• optimal timing for transplantation• optimal timing for transplantationDr S A Merchant
Take Home Message:
Optimum management of STEMI – A PharmacoInvasive Approach
Initial Fibrinolysis with t-PA within 30-60 mins of chest pain in ambulance, nursing home, non-PCI hospital
Endovascular cooling: Aspirin, loading dose clopidogril/prasugrel, Inj Enoxyparin, GpIIb/IIIa Inhibitor, nitrates, Ace-Inhibitors, beta blocker, diltiazem, high dose statins, trimatazione, sedation
Dr S A Merchant
Transfer patient within 6 hours to PCI centre for
Cor angiography
Thrombectomy: Suction by Export Cath, AngioJet
Direct stenting
Intracoro NTG/Nicorandil
This makes sense to everyone – patient, relations, family doctor, consultant physician, interventional cardiologist. Also, both short term & long term clinical trials show excellent result with pharmacoinvasive approach in terms of reduce mortality, re-infarction & overall preservation of LV function
Dr S A Merchant
Rescue PCI, Cardiogenic shock PCI, Facilitated
PCI, Elective PCI are special
subsets where clinician
discretion is required
Dr S A Merchant
LONG DIFFUSE STENOSIS
HOW FAST SHOULD WE GO ?
QUICKER IS BETTER
THANK YOU