STEMI patient and Hypothermia

Grigoris Karamasis

Consultant Interventional Cardiologist

Essex Cardiothoracic Centre, UK

• I do not have any disclosures

Cardio-protection against myocardial reperfusion injury

Infarct Size and Prognosis

Partial List of pharmacologic studies toreduce Reperfusion Injury that failed!

Hypothermia for cardio-protection in experimental MI

> 150 publications

Abendschein DR, Tacker WA Jr, Babbs CF. Protection of ischemic myocardium by whole-body hypothermia after

coronary artery occlusion in dogs. Am Heart J 1978;96:772–780.

Hypothermia prior to reperfusion!

Delay of reperfusion, but benefit in IS

Hypothermia in STEMI patientsEarly studies

• Primary endpoints not achieved

• Only 1/3 of the patients reached ≤35°C at the time of reperfusion

• In anterior STEMI patients cooled to ≤35ºC before reperfusion, a trend for

reduction in ISO’Neil et al. TCT 2003

Grines et al. TCT 2004

CHILL – MI trial

• Randomised control trial

• 120 anterior + inferior STEMIs < 6h

• Rapid intravascular cooling + infusion cold saline

• Primary endpoint: Infarct Size/Myocardium at Risk at 4±2 days

Erlinge et al. JACC 2014 13;63:1857-65

CHILL-MI: Infarct size by location when symptom onset < 4 hrs

Erlinge, ECS 2015

The ideal STEMI patient for with hypothermia treatment

• Early presenter (4-6h)

• Large area at risk (anterior STEMI)

• Fast cooling

• Low T prior to reperfusion

Erlinge et al. Ther Hypothermia Temp Manag. 2015 ;5:77-84.

COOL AMI EU Pilot study

Conclusions:

• Rapid cooling of anterior STEMIs is

feasible and safe

• Reperfusion T was 33.6oC ( ≥1.1oC

than previous studies)

• No AE, except self terminating AF

COOL-AMI EU Pivotal Trial

• Multicenter, Prospective, Randomized-Controlled Trial

• Primary PCI + Hypothermia vs. primary PCI alone

• Intravascular Hypothermia with ZOLL Proteus IVTM System

• 18 minutes of cooling prior to reperfusion

• Sample size : 468 anterior STEMIs < 6h

• Primary endpoint: IS in CMR 4-6 days

• ClinicalTrials.gov: NCT03173313

COOL AMI EU program in Greece

Alexandra Hospital, Athens

PI: Ass. Prof. Kimon Stamatelopoulos

University Hospital, Ioannina

PI: Prof. Lampros Michalis

University Hospital,

Patra

PI: Prof. George Hahalis

Ippokrateio Hospital, Athens

PI: Prof. Petros Nihoyannopoulos

ZOLL Proteus Intravascular Temperature Management system (1)

ZOLL Proteus Intravascular Temperature Management system (2)

Anti-shivering treatment

• Initiated before start of cooling

• Buspirone 60 mg p.o.

• Pethidine bolus + infusion

• Bair Hugger® for skin counter-warming

Case 1

• 51 year old male

• BG: NIDDM, Smoker

• Sudden onset of typical cardiac chest pain at 06:30 am

• ECG : Inferior STEMI

• Recruited in COOL AMI EU pilot

Case 1 Diagnostic coronary angiography

Case 1 PCI results, d/c, f/up

• Self-terminated asymptomatic AF (100-115 b/min) during cooling

• Patient discharged on day 3

• Asymptomatic in 12 months f/up

Case 1

Baked Alaska

Case 2

• 39 year old male

• No past medical history

• Ex-smoker

• Sudden onset of typical cardiac chest pain at 12:50 pm

• ECG: anterior STEMI

• Recruited in COOL AMI EU pilot

Case 2 Diagnostic coronary angiography

Case 2 However...

• VF arrest

• Multiple DCCV

• DCCV and patient agitation hadcaused loss of guide catheterposition

• LAD occluded at fist angio shot

• Attempts to wire LAD challengingdue to anatomy and on-going e-CPR

Case 2

Case 2

• 30 minutes CPR

• Back to ROSC after stent deployment

• Transferred intubated to ITU

• Ex-tubated day 1

• Angio for stent optimisation IVUS guided – day 4

• D/c home day 6

• Asymptomatic at 12 months f/up

• Cause of VF arrest (advisory & safety board) : vessel re-occlusion

Intra-coronary coolingAn alternative ?

Conclusions

• Hypothermia consistently reduces infarct size in animal models

• Hypothermia in STEMI is feasible and safe

• Previous clinical trials: benefit of hypothermia in specific sub groups (early presenters with anterior STEMI , lower temperature at reperfusion)

• COOL-AMI EU Pivotal on going multicenter RCT

Questions ?

grigoris.karamasis@btuh.nhs.uk

Hypothermia and Stent Thrombosis

• CA patients with AMI undergoing PCI 2006 – 2011

• 49,109 CA patients

• 1,193 (2.4%) underwent TH

• ST : 3.9% vs. 4.7%, p = 0.61