Sergio BertiFondazione CNR-Reg. Toscana G. Monasterio

Ospedale del Cuore, Massa

Versilia7-8 ottobre 2011

“Dal territorio alla preservazione della funzione ventricolare”

Importance of Prompt Treatment

Prompt treatment increases the likelihood of survival for patients with myocardial infarction with ST-segment elevation (Berger et al., 1999; Cannon et al., 2000, McNamara et al., 2006).

McNamara et al., McNamara et al., JACC,JACC, 2006 2006

Mortality and Doorn to Balloon Time

Ting HH, et al. Circulation 2007;116:729-736

Beyond a D2B of 90 minutes….Every 15-min delay adds mortality

(Nallamothu 2007 NEJM 357:1631)

2008 ESC STEMI GUIDELINESKey Messages remain unchanged:

• Early diagnosis

• Reperfusion therapy as soon as

possible

• Optimal secondary prevention

(tempo decisionale)

Ritardo extraospedalie

ro sanitario

Ritardo extraospedalie

ro NON sanitario

Ritardo intraospedalier

o

Ritardo Evitabile

Campagne educazionali

Percorsi extraospedalie

ri

Percorsi intraospedalier

i

Fonti di possibili ritardi tra comparsa sintomi e inizio terapia riperfusiva

Problema Soluzione

Ritardo del paziente:Tempo tra la comparsa sintomi e chiamata 118

Educazione del paziente

Ritardo nel trasportoStrategia organizzativa

118

Ritardo inizio del trattamentoStrategia organizzativaInter-intraospedaliera

Strategia concordata:

Modello di Rete per l’emergenza coronarica

Favorire una diagnosi precoce, un trasporto rapido ed un ottimale trattamento riperfusivo a tutti i pazienti

Obiettivi

Documento di consenso

La rete interospedaliera per l’emergenza coronarica

IHJ Nov. 2005 Vol.6/Suppl.6

• FIC

• SICI

• SIMEU

• SIS 118

La “realtà” italiana: la “Rete”

Door to Balloon Times: Door to Balloon Times:

Achieving 90 Minutes and LessAchieving 90 Minutes and Less

W. Douglas Weaver, MDW. Douglas Weaver, MD

President-Elect ACCPresident-Elect ACC

November 2007November 2007

Strategies that Reduce Treatment Delays

1. ED physician activates the cath lab

2. Single call activates the cath lab

3. Cath lab team ready in 20-30 minutes

4. Prompt data feedback for case review

5. Pre-hospital ECG to activate the cath lab while patient is en route

6. Having attending cardiologist always on site

D2B Alliance Goal

Goal: To achieve a door-to-balloon time

of ≤ 90 minutes for at least 75% of non-transfer primary PCI patients with STEMI

D2B Alliance Participants

• Over 900 hospitals currently participating• Representing 45 states and 8 countries

15.6West

12.7Southwest

27.5Midwest

26.8Southeast

16.2Northeast

%Region

Salvare il miocardioSalvare il miocardiodei Pazienti con SCAdei Pazienti con SCA ottimizzando tempi e ottimizzando tempi e modalità di soccorso modalità di soccorso

e di interventoe di intervento medicomedico

RITARDOEVITABILE

2008-2010• Ridurre i tempi pre-ospedalieri

• Aumentare accesso tramite 118

• Ridurre i tempi inter-ospedalieri

• Ridurre i tempi intra-ospedalieri

• Ridurre i tempi pre-ospedalieri

• Aumentare accesso tramite 118

• Ridurre i tempi inter-ospedalieri

• Ridurre i tempi intra-ospedalieri

In tutte le Regioni la Campagna ha coinvolto Cardiologi, 118, Medicina Urgenza, Assessorati e Agenzie

CAMPAGNA RITARDO EVITABILE

COORDINAMENTO F. Chiarella L. Oltrona Visconti A. Di Chiara

La Campagna presentata in tutte le Regioniha proposto una semplice scheda di automisurazione dei dati

Disponibili i dati dei Centriche hanno accettato di centralizzare i dati

Obiettivo:

Ottenere nel 75% dei pazienti: D2B entro 90 minutiD2N entro 30 minuti

Un intervento mirato ai singoli Ospedali ed alla rete.

Liguria

Valle d'Aosta

Piemonte

Veneto

Bolzano Trento

Toscana

Lombardia

Abruzzo

FVG

Emilia Romagna

Lazio

Basilicata

Campania Puglia

Umbria

Sicilia

Calabria

Sardegna

Marche

Ascoli Piceno - Pesaro

Avezzano - Pescara Teramo - Vasto

Catanzaro - Cosenza

Crotone - Vibo Valentia

Andria – Bari - Gallipoli – Scorrano - Terlizzi

Cagliari – Olbia Carbonia

Siracusa – Ragusa

Roma Centri N.6

AlbanoTerme

Rieti SalernoVallo della LucaniaNocera InferiorePozzuoli

Lagonegro - MateraPolicoro - Potenza

Ivrea - Novara Torino Centri N.2Moncalieri

Genova Centri N. 2

Pietra Ligure - SanremoEmpoli - Grosseto – Lucca –

Massa - Piombino - Pisa

Rimini - Sassuolo

Bolzano – MeranoRovereto - Trento

Pordenone - Trieste – Udine – Gorizia -Tolmezzo - San Daniele - Palmanova

Latisana - San Vito al Tagliamento

Città di Castello - Foligno Gubbio - Perugia - Terni

Milano Centri N. 4 - Treviglio – Lecco – Tradate - Pavia – Saronno - Varese - Lodi - Gravendona – Sondrio - Desenzano - Gallarate

Treviso -Castelfranco Veneto - Mestre

Cardiologie aderenti alla raccolta dati n = 78

Zona Apuane-Versilia

Zona LunigianaZona Lunigiana

Triage direttoPaziente con IMA

Unità 118 - PS I° LIV

TELECONSULTOFTGM

Ospedale del CuoreECG normale

o ST

PS - UTIC

IMA ST

Protocollo Terapeutico Concordato

SALA DIEMODINAMICA

MobiMed System

HWSSERVER

Hospital 1

La Trasmissione ECG

Hospital 2

Matrix Network STEMI1227 Pazienti

0

40

80

120

160

DtB

(m

inu

ti)

2006 2007 2008 2009 2010

p<0.0001107.5n=166

107.7n=220

109.7n=219 99.7

n=238 82.3n=247

D2B (1227 Pz)

Network STEMI “Zona Apuane-Versilia”

0

20

40

60

80

DtB

<90

min

uti

(%

)

2006 2007 2008 2009 2010

58(34.9%)

80(36.4%)

81(40.0%)

89(46.3%)

104(72.3%)

p<0.0001

% pazienti con DtB ≤ 90 min (1227 Pz)

Network STEMI “Zona Apuane-Versilia”

Network STEMI “Zona Apuane-Versilia”1227 pts

DtB (minutes)

EF%

72.3%

1227 pts

Network STEMI “Zona Apuane-Versilia”

How Effective is the Hub?

Reperfusion Therapy: Primary PCI

• Preferred reperfusion treatment if performed by an experienced team as soon as possible after FMC

I A

Recommendations Class

LoE

Physician Volume and Hospital Volume and Mortality during Primary PCI

Srinivas VS J Am Coll Cardiol 2009: 53:574-9

Physicians

High Volume Low Volume

(N=92) (N= 174)

Odds Ratio

(95% CI)

Mortality

3.25% 4.9% 0.66

(0.48-0.92)

Physician Volume and Hospital Volume and Mortality during Primary PCI

Physician Volume and Hospital Volume and Mortality during Primary PCI

Hospitals

High Volume Low Volume

(N=23) (N= 18)

Odds Ratio

(95% CI)

Mortaliy

3.4% 5.4% 0.58

(0.38-0.88)

PCI for STEMI Less Safe, Effective When

Performed Off-Hours

Glaser R J Am Coll Cardiol Intv 2008;1:681-8

Off Hours Routine Hours p

Device use

Stent 76% 82.4% 0.04

IVUS 0.8% 4.6% 0.005

Thrombectomy 1.9% 6.3% 0.007

Periprocedural Clopidogrel

48.2% 58.2% 0.01

Major Dissections 10.3% 5.2% 0.2

Mechanical strategies to prevent distal embolization

P < 0.001

Pat

ient

s (%

)

Thrombus aspiration Conventional PCI

TAPAS TrialPrimary endpoint: Myocardial Blush Grade

Svilaas T, et al N Engl J Med 2008;358:557

TAPAS: 1,071 pts with STEMI undergoing PCI randomized to thrombus aspiration vs control

Vlaar P et al. Lancet 2008; 371:1915

Cardiac Magnetic Resonance Imaging Results

Thrombus aspiration during Primary Percutaneous Coronary Intervention: myocardial reperfusion and infarct size

The EXPIRA (Thrombectomy With Export Catheter in Infarct-Related Artery During Primary Percutaneous Coronary Intervention) Prospective, Randomized Trial

G Sardella, MD, M Mancone, MD, C Bucciarelli-Ducci, MD et al; JACC Vol. 53, No. 4, 2009

*p 0.05 vs. control patients †p 0.05 compared to 24 h

In thrombus-aspiration patients, at each time point, ejection fraction was significantly better compared with control patients, and it further improved at 1 week and 6 months

Thrombus Aspiration Reduces Microvascular Obstruction After Primary Coronary Intervention

A Myocardial Contrast Echocardiography Substudy of the REMEDIA Trial

L Galiuto, MD, PHD, B Garramone, MD, F Burzotta, MD, PHD et al, JACC Vol. 48, No. 7, 2006

Illusion of reperfusion

In 1993, at the peak of the thrombolytic era, Lincoff and Topol wrote a provocative editorial wondering whether reperfusion was just an illusion.

At that time, they estimated that only “25% or less” of patients treated by thrombolysis had an optimal reperfusion.

Lincoff AM, Topol EJ. Illusion of reperfusion. Does anyone achieve optimal reperfusion during acute myocardial infarction? Circulation 1993;88:1361–74.

The no-reflow phenomenon is the inability to reperfuse a portion of the myocardium after re-establishment of

patency of previously occluded epicardial coronary artery

The No-Reflow Phenomenon:Defining the Problem

Agents studied to reduce reperfusion injury

AgentAgent Mechanism proposedMechanism proposed TrialTrial

Fluosol Neutr.inhib., O2 delivery TAMI 9

Magnesium Membrane stabilisation ISIS4,MAGIC

RheothRX O2 delivery CORE

Trimetazidine H+, free radicals, neutr. EMIP-FR

hSOD Prevent free radicals Flaherty

Cylexin Inhib.p-selectin, neutr. CALYPSO

Adenosine Neutr.inhib, vasodil, metab. AMISTAD I,II

ANTI CD-18 Neutr.inhib. HALT, LIMIT

Eniporide Na+/H+ exchange inhib. ESCAMI

Agents studied to reduce reperfusion injury

Trial N° Primary endpoint Result

TAMI 9 430 Infarct size, EF (22 v.17%)

ISIS4 58,050 35 d. mortality (7.6 v. 7.2%)

CORE pilot 114 Infarct size (16 v.26%)

CORE 2,607 Death, shock, reMI (14 v. 26%)

EMIP-FR 19,665 35 d.mortality (12.2 v.12.3%)

CALYPSO 153 Infarct size (larger)

AMISTAD I 236 Infarct size (ant. 20 v.13%)

AMISTAD II 2,118 30-d.death, CHF (18 v. 16%) ISz+

HALT MI 420 Infarct size (no effect)

LIMIT MI 413 Patency, infarct size (no effect)

ESCAMI 1389 Infarct size (no effect)

Ormoni tiroidei ed IMA: evidenze cliniche

Wiersinga WM et al. Thyroid hormones in acute myocardial infarction. Clin Endocrinol 1981; 14: 367-74.

Friberg L et al. Association between increased levels of reverse triiodothyronine and mortality after acute myocardial infarction. Am J Med. 2001; 111: 699-703.

Friberg L et al. Rapid down-regulation of thyroid hormones in acute myocardial infarction: is it cardioprotective in patients with angina? Arch Intern Med. 2002; 162: 1388-94.

Tiride e Cuore Nei pazienti con STEMI la riduzione dei livelli di fT3 durante la degenza correla con un peggiore recupero funzionale delle aree infartuali, come ben evidenziato dallo scarso recupero in termini di WMSI alla dimissione

12

34

MIN

_F

T3

1 1.5 2 2.5WMSI_DIM

R=-0.42

P<0.01

Recommended Logistics• Pre-hospital triage/care:

– EMS• unique telephone number• tele-consultation

– Ambulance• 12-ECG recorder/defibrillator• staff able to provide basic and advanced life

support

Recommended Logistics• Pre-hospital triage/care:

– EMS• unique telephone number• tele-consultation

– Ambulance• 12-ECG recorder/defibrillator• staff able to provide basic and advanced life

support

• Networks:– implementation of a network of hospitals with

different levels of technology connected by an efficient ambulance service using the same protocol

• Targets:– < 10 min ECG transmission– < 5 min tele-consultation– < 120 min to first balloon inflation– < 30 min start fibrinolytic therapy

Sergio BertiFondazione CNR-Reg. Toscana G. Monasterio

Ospedale del Cuore, Massa

Versilia7-8 ottobre 2011

“Dal territorio alla preservazione della funzione ventricolare”