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Management dell’Infarto Miocardico Acuto a presentazione “sopralivellamento del tratto ST” STEMI Linee Guida ESC 2012. 100. Mortality reduction (%). Potential outcomes. D. 80. A-B – no benefit. 60. C. %. 40. B. A. 20. Extent of salvage (% of area at risk). 0. 1. 3. 6. 12. - PowerPoint PPT Presentation
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Management dell’Infarto Miocardico Acuto a presentazione
“sopralivellamento del tratto ST”
STEMI
Linee Guida ESC 2012
Time to Reperfusion and OutcomeTime to Reperfusion and Outcome
0
20
40
60
80
100
1 3 6 12 12-24
%%
Extent of salvage (% of area at risk)
Mortality reduction (%)
D
A-B – no benefit
Potential outcomes
A-C – benefitD-C – harm
C
B A
B-C – benefit ?
Gersh JAMA 2005
Time to treatment is critical
Opening the IRA PPCI>lysis
13Tcheng J Am Coll Cardiol 48:1336, 2006
Systemdelay
Protocollo condiviso
Monitoraggio continuo
Direttamente in sala emodinamica
Bypass DEA
FMCDiagnosi
Ecg teletrasmesso
Cardiologo UTIC
Emodinamista reperibile& staff : infermiere/TRS
1 accesso diretto sala Accesso diretto sala per 1PTCA
Percorso+ attivazione sala
Trasporto monitoraggio
Ritardo di sistema
Percoso STEMI pistoia
STEMI ENTRO 12 ORE ANNO 2012STEMI ENTRO 12 ORE ANNO 2012N.TOTALEPAZIENTI 0
0173
POST-TL
RESCUE
PCI PRIMARIA
6437%
2615%
8348%
DIRETTAAL CL
TRASFERITADA SPOKE
AMMESSAAD HUB
173
0
50
100
150
200
250
300
350
0 20 40 60 80 100 120 140 160 180 200
N. PAZIENTI 173 – MEDIANA D2B: 90 MINUTIN. PAZIENTI 173 – MEDIANA D2B: 90 MINUTI
D2B TOTALE PAZIENTI N. 173D2B TOTALE PAZIENTI N. 173M
INU
TI
PAZIENTI
N. PAZIENTI 64 – MEDIANA D2B: 84 MINUTIN. PAZIENTI 64 – MEDIANA D2B: 84 MINUTI
D2B AMMISSIONE DIRETTA 118D2B AMMISSIONE DIRETTA 118
N. PAZIENTI 47 – MEDIANA D2B: 90 MINUTIN. PAZIENTI 47 – MEDIANA D2B: 90 MINUTID2B AMMISSIONE PS PO PISTOIAD2B AMMISSIONE PS PO PISTOIA
N. PAZIENTI 45 – MEDIANA D2B: 100 MINUTIN. PAZIENTI 45 – MEDIANA D2B: 100 MINUTID2B AMMISSIONE PS PO PESCIAD2B AMMISSIONE PS PO PESCIA
MIN
UTI
0
50
100
150
200
250
300
350
0 5 10 15 20 25 30
N. PAZIENTI 26 – MEDIANA D2B: 125 MINUTIN. PAZIENTI 26 – MEDIANA D2B: 125 MINUTIPCI di trasferimento tra POPCI di trasferimento tra PO
MIN
UTI
PAZIENTI
36
Motality benefit of primary PCI declines with Motality benefit of primary PCI declines with “PCI-related time delay”“PCI-related time delay”
Favors PCI
Favors fibrinolysis with a fibrin-specific agent
13 RCTsN = 5494 P = 0.04
Abs
olut
e R
isk
Diff
eren
ce in
Dea
th (%
)
30 40 50 60 70 80
PCI-Related Time Delay (minutes)
10 −
5 −
0 −
-5 − ┬ ┬ ┬ ┬ ┬ ┬
Nallamothu and Bates. Am J Cardiol 2003;92:824.
Mortality equipose:60 min
F. Van de Werf, ACC 2013
F. Van de Werf, ACC 2013
• Large contemporary international registries continue to demonstrate persisting delays to primary PCI in STEMI patients first presenting to EMS or non-cath capable hospitals
• Subsequent transfer for primary PCI commonly results in reperfusion times exceeding current guideline recommendations
• These delays are associated with commensurate increases in morbidity and mortality
BACKGROUND
F. Van de Werf, ACC 2013
A strategy of early fibrinolysis followed by coronary angiography within 6-24 hours or rescue PCI if needed was compared with standard primary PCI
in STEMI patients with at least 2 mm ST-elevation in 2 contiguous leads
presenting within 3 hours of symptom onset and unable to undergo primary PCI within 1 hour.
STUDY AIM
F. Van de Werf, ACC 2013
no lytic
STUDY PROTOCOL
RANDOMIZATION 1:1 by IVRS, OPEN LABEL
Primary endpoint: composite of all cause death or shock or CHF or reinfarction up to day 30
ECG at 90 min: ST resolution ≥ 50%
Standard primary PCI
Aspirin Clopidogrel:
LD 300 mg + 75 mg QDEnoxaparin:
30 mg IV + 1 mg/kg SC Q12h
Antiplatelet andantithrombin treatment
according to local standards
angio >6 to 24 hrsPCI/CABG if indicated
immediate angio + rescue PCI if
indicated
YES
NO
Strategy A: pharmaco-invasive Strategy B: primary PCI
AspirinClopidogrel:
75 mg QDEnoxaparin:
0.75 mg/kg SC Q12h
STEMI <3 hrs from onset symptoms, PPCI <60 min not possible, 2 mm ST-elevation in 2 leads
≥75y: ½ dose TNK<75y:full dose After 20% of the planned recruitment, the TNK dose was reduced by
50% among patients ≥75 years of age.
F. Van de Werf, ACC 2013
62
Sx onset1st Medical
contact
611 Hour 2 Hoursn=1892
29
Randomize IVRS
9
Rx TNK
31 86
Sx onsetRx PPCI
100 min
178 min
MEDIAN TIMES TO TREATMENT (min)
1st Medical contact
78 min differenceRandomize IVRS
F. Van de Werf, ACC 2013
62
Sx onset
611 Hour 2 Hours
29 9
Rx TNK
31 86
Sx onsetRx PPCI
100 min
178 min
MEDIAN TIMES TO TREATMENT (min)
36% Rescue PCI at 2.2h
n=1892
64% non-urgent cath at 17h
1st Medical contact
Randomize IVRS
1st Medical contact Randomize IVRS
F. Van de Werf, ACC 2013
PRIMARY ENDPOINT
TNK 12.4%PPCI 14.3%
TNK vs PPCIRelative Risk 0.86, 95%CI (0.68-1.09)
p=0.24
Dth/
Shoc
k/CH
F/Re
MI (
%)
The 95% CI of the observed incidence in the pharmaco-invasive arm would exclude a 9% relative excess compared with PPCI
F. Van de Werf, ACC 2013
STROKE RATES
www.escardio.org/guidelines
Bleeding Risk SubgroupsBleeding Risk SubgroupsTherapeutic ConsiderationsTherapeutic Considerations
Significant Net Clinical Benefit
with Prasugrel80%
MD MD 10 mg10 mg
Reduced MD
Guided by PK
Age > 75 or
Wt < 60 kg16%
Avoid
Prasugrel
Prior
CVA/TIA4%4%
0
2
4
6
8
0 1 2 3
1
0 3060 90 180 270 360 450
HR 0.82P=0.01
HR 0.80P=0.003
5.6
4.7
6.9
5.6
Days
Prim
ary
Endp
oint
(%)
Prasugrel
Clopidogrel
Prasugrel
Clopidogrel
Loading Dose Maintenance Dose
Timing of BenefitTiming of Benefit(Landmark Analysis)(Landmark Analysis)
www.escardio.org/guidelines
Time-related Kaplan–Meier estimates of the time to first occurrence of the primary end point (incidence of MI, stroke, or vascular death; HR, 0.87; 95% CI, 0.75 to 1.01; P=0.07)
PLATO - STEMI substudy - Outcomes
Steg P.G., et al. Circulation 2010;122:2131-2141