I International Symposium on Prevention of Cardiovascular Diseases Kraków 9-11.06.2005 Prevention of Heart Failure after AMI MAŁOPOLSKA STUDY A 2256-Patients

I International Symposium on Prevention of

Cardiovascular Diseases Kraków 9-11.06.2005

Prevention of Heart Failure after AMI

„MAŁOPOLSKA STUDY” A 2256-Patients Registry in Krakow

Prewencja niewydolności krążenia po

zawale – „Program Małopolski”

Prof. dr hab. Jacek S Dubiel

Dr med. Dariusz Dudek

Dr hab. med. Krzysztof Żmudka

Dr med. Mieczysław Pasowicz

Prof. dr hab.. Wiesława Tracz

Dr med. Łukasz Rzeszutko



The Krakow ExperiencePrimary PCI

II

1999 year invasive reperfusion for 2 mlns

Primary PCI + GpIIb/IIIa transfer delay <90min

2004 year 700 primary PCI / 1 mln



Primary PCI - ESC PCI, march’2005

REMARKS

1) Prolonged symptom to treatment times are associated with impaired

myocardial perfusion independent of epicardial flow

2) PRIMARY PCI - Data based on:

a. high volume centers

b. experienced operators

c. short response time (delay)

RESULTS DO NOT NECESSARILY APPLY IN OTHER SETTINGS

3) DELAY in initiating Primary PCI > 2-3h

=> recommendation for fibrynolitic agents (2nd or 3rd

generation)



p. tatrzański65,3 tys.

p. nowotarski179,9 tys.

p. limanowski120,2 tys.

Nowy Sącz + p. nowosądecki

279,4 tys.

p. gorlicki106,4 tys.

p. suski81,5 tys.

p. wadowicki153,4 tys.

p. oświęcimski153,1 tys.

p. chrzanowski128,7 tys.

p. olkuski114,7 tys.

p. miechowski51,5 tys.

p. proszowicki43,6 tys.

p. dąbrowski58,6 tys.

p. wielicki102,5 tys.

p. bocheński99,7 tys.

p. brzeski89,7 tys.

Kraków + p. krakowski

998,8 tys.

p. myślenicki114,9 tys.

86 km

60 – 120minTarnów + p. tarnowski

310,5 tys.

85 km

60-120min

98 km

100 – 150min

125 km

120 – 180min



Facilitated PCI - ESC PCI, march’2005

Facilitated PCI is defined as planned intervention within

12hrs after onset of chest pain or symptoms, soon after

clot dissolving medication to bridge the delay between

first medical contact and primary PCI

term not uniformly used

1. Thrombolysis facilitated primary PCI

2. Gp IIb/IIIa inhibitor facilitated primary PCI



Cathlab

Acute MI < 12 hrsin the region of 3.4 mln inhabitants

transfer delay

< 30min (Ia)

Thrombectomy

and

PCI

PCI

and

abciximab

Tele ECG

transfer delay

< 90min (Ib)

abciximab

PCI

transfer delay

> 90min (II)

abciximab + ½ lyitcs & transfer for PCI

IIII

Ib

150 km150 km

IaIa



p. nowotarski179,9 tys.

p. limanowski120,2 tys.

Nowy Sącz + p. nowosądecki

279,4 tys.

p. gorlicki106,4 tys.

p. suski81,5 tys.

p. wadowicki153,4 tys.

p. oświęcimski153,1 tys.

p. chrzanowski128,7 tys.

p. olkuski114,7 tys.

p. miechowski51,5 tys.

p. proszowicki43,6 tys.

p. dąbrowski58,6 tys.

p. brzeski89,7 tys.

p. tatrzański65,3 tys.

p. myślenicki114,9 tys.

Tarnów + p. tarnowski

310,5 tys.

Kraków + p. krakowski

998,8 tys.

p. wielicki102,5 tys.

p. bocheński99,7 tys.



AMI : ST

pain onset < 12h

transfer time to the cath lab > 90 minutes

½ tPA +

full dose

Gp IIb/IIIa

Facilitated

PCI

Interhospital transfer for long distance

Age < 75 years, no shock, eligible for lytics

Transfer

to the cath lab

Facilitated PCI in Patients with Acute Myocardial Infarction

D, Dudek et al., Am J Cardiol, 2003



Jagiellonian UniversityInstitute of Cardiology, Krakow, Poland

- 2 buildings; 6 cathlabs

- 24 interventional cardiologists

In 2004, have been performed:

4000 PCIs



June’2001 – June’2003AMI ST n=2256

IIII

II

3.4 millions population

70%

30%

Primary PCI n=1 584

Facilitated PCI n=672



Time delays

189 0 17

190 35 106 26

0 50 100 150 200 250 300 350 400

PRIMARY

FACILITATED

pain to admission admission to lysis transport cathlab to needle

357 min.357 min.

206 min.206 min.

= 150 min.= 150 min.

Krakow, STEMI registry



Transport complications for patients treated with facilitated PCI in AMI

Death 0 (0,0%)

stroke 0 (0,0%)

Rhythm disorders

• VF

• bradycardia (HR<60/min)

• ventricular disorders

•AF

116 (17,4%)

18 (2,7%)

21 (3,1%)

70 (10,5%)

7 (1,1%)

Conduction disorders (AV block 2 degree and higher)

15 (2,2%)

Hypotonia 31 (3,1%)



Primary PCI vs Facilitated PCI

TIMI 2-3 ~85%TIMI 2-3 ~85%



0,8% 0,8%

4,2%

5,0%

0,9% 0,9%

3,9%3,4%

4,8%

3,0%

0%

2%

4%

6%

8%

De ath re MI re PC I de ath + re MI All MAC E

PRIMARY FACILITATED

30-day MACE

PRIMARY PCI vs FACILITATED PCI

NS



Kaplan-Meier curves for survival1 year follow up

Zone II

Zone I



1,2%

7,4%

2,1%

12,7%

1,1%

3,4%

0%

2%

4%

6%

8%

10%

12%

14%

severe moderate mild

PRIMARY FACILITATED

Bleeding complications

PRIMARY PCI vs FACILITATED PCI

p= 0.0004 NS

p= 0.0001

0,0%

0,9%

0%

1%

2%

3%

4%

PRIMARY FACILITATED

ICH

p= 0.0006

Krakow, STEMI registry



Independent predictors of 6 months left ventricular EF recovery from multivariate analysis for patients treated with facilitated PCI

in AMI.

Variable Coef. p [95% Conf. Interval]

Age 0. 2282635 0.018 0.0401552 0.4163717

Occluded IRA -6.717246 0.01 -11.79538 -1.639111

Diabetes mellitus -6.56293 0.0023 -12.20437 -0.9214918

Time from chest pain onset to lysis

-0.7644607 0.044 -1.508914 -0.0200075

IRA TIMI flow after PCI

4.085302 0.197 -2.154946 10.32555

const -18.34014 0.102 -40.41806 3.737786



Facilitated PCI subanalysis - IRA patency and outcome

225 non shock pts with AMI

group A: 32 pts with TIMI 0+1 group B: 193pts with TIMI 2+3

Angiography post PCI

Echocardiography EF baseline and 6 month

Clinical 12 month follow up

14% 86%

Dudek et al EHJ, 2004 abstract



Facilitated PCI - subanalysis LV EF (BP - ellipse) baseline and 6 months follow up

52,9%55,6%

50,4%58,8%

40,00%

50,00%

60,00%

70,00%

Group A Group B

p=NSp<0.001

p=NS

p=0.012

Dudek et al EHJ, 2004 abstract



Facilitated PCI – 12-month Kaplan-Meier event-free survival curves for death and reinfarction.



Facilitated PCI – pain onset to admission at remote site impact on LV function recovery at 6 month

Krakow registry

4,0%2,9%

-4,2%

-15%

-10%

-5%

0%

5%

10%

15%

Delta EF at 6m.

0-3 h 3-6 h 6-12 h



Facilitated PCI is feasible for pts < 75 years with acute

MI transfered from remote hospitals (delay 150

minutes)

Transport is safe for pts on combined lytic and Gp

IIb/IIIa blockers therapy

Combined therapy opens infarct related artery (IRA)

(TIMI 3+2) in 86 % of pts before PCI ! ! !

The Krakow ExperienceInterventional Treatment of Acute MI



Patency of IRA before PCI influences: a. myocardial

perfusion, b. systolic function recovery, c. long term

clinical follow-up

The highest benefits related to facilitated PCI were

observed in pts with time from pain onset to

fibrynolysis < 6 hrs

Despite 150 minutes delay because of transporation

MACE rates at 12 months follow-up was similar for

facilitated and primary PCI

The Krakow ExperienceInterventional Treatment of Acute MI



STEMI - regional specific solutionswhen long transfer delays

Facilitated PCI with GpIIb/IIIa or combination lytic therapy may be an option for the future (FINESSE, CARESS in AMI)

30-40% of STEMI pts population

Community hospitals, interventional centers and ambulance service should set up networks for STEMI

60-70% of STEMI pts population

a. elderly

b. STEMI> 12 hrs

c. cardiogenic shock

d. ineligible for lysis

Documents

I International Symposium on Prevention of Cardiovascular Diseases Kraków 9-11.06.2005 Prevention of Heart Failure after AMI MAŁOPOLSKA STUDY A 2256-Patients