Strategie terapeutiche nell'infarto miocardico acuto.
Rivascolarizzazione miocardica e terapia trombolitica:
scelte antitetiche o integrate?
M
Marco
Tubaro
T b
UTIC – Dipartimento Cardiovascolare
Ospedale San Filippo Neri - Roma
mt
Paramedic--diagnosed STEMI
Paramedic
Culumulative
e survival
mortaality (%)
1.00
P=0.017
n=2
n=20
n=20
Paramedic‐referred primary PCI group
(n=108)
0.95
0.90
Control group
C
t l
(n=225)
0. 85
0.80
0
10
20
30
Days
Le May MR. Am J Cardiol 2006;98:1329–1333
MT
BLITZ: hospital presentation
1959 pts, 65% STEMI
n° pts %
26 %
26 %
time from onset of symptoms ‐ median 120 min (IQR 60‐300)
to hospital arrival
‐ 48 % pts < 2 h
‐ 76 % pts < 6 h
Di Chiara A. Eur Heart J 2003
MT
field vs. interhospital transfer
Le May, N Engl J Med 2008
MT
primary PCI vs fibrinolysis: equipoise
Tarantini G. EHJ 2010
MT
primary PCI vs thrombolytic therapy
-short term outcomes 25
PTCA
Lysis
p<0.0001
21
Frequenccy (%)
20
p<0.0001
14
15
p=0.0002
10
9
7
p=0.032
p<0.0001
7
6.8
5
5
0
p=0.0003
6
2.5
Death
Death Non fatal Recurrent excluding
MI
ischaemia
shock
Keeley EC, et al. Lancet 2003;361:13–20
6.8
p=0.0004
1
2
8
5.3
p<0.0001
0 05
0.05
1.1
Total Haem‐
CVA rrhagic CVA
Major bleeds
Death/ CVA/AMI
MT
Danchin N. Circulation 2008
Danchin N. Circulation 2008
Local System of Care: The Vienna model
all cath labs active between 7.00 and 16:00 h
permanent availability of cath labs and teams during non-official catheter times
General Hospital
University of Vienna
Mon - Fri (on call), Sa-Sun
Hospital Rudolfstiftung
Mon
Viennese Viennese
Ambulance System
call 144
call 144
Hanusch Hospital
Fri
Wilhelminen Hospital
Donau Hospital
Thu
Tue
Hospital Hietzing
Wed
Courtesy K. Huber
equitable access to care
networking in Czech Republic
networking in Czech Republic
PCI centers
community H
(no cath lab)
(no cath lab)
1997-99
2005
STEMI in-hospital mortality
MT
primary PCI in Europe
Widimski P, EHJ 2010
MT
NORDISTEMI: thrombolysis and immediate PCI in STEMI
Bohmer, JACC 2009
MT
Bologna network
• reperfusion therapy: 58.4% f i th
58 4%
• in‐hospital mortality: 17.0% Saia Heart 2009
76.3 %
76
3%
12.3 %
MT
reti per lo STEMI - conclusioni
chiara definizione delle aree di interesse
protocolli scalari a seconda della stratificazione del rischio
trasporti sicuri con ambulanze appropriatamente equipaggiate in termini
di macchinari e personale
stretta organizzazione di riduzione dei ritardi: < 10 min trasmissione ECG,
< 5 min teleconsulto, < 30 min D2N, < 30 min D2B (in ospedale)
protocolli
lli di trasporto pre-ospedaliero
d li
che
h bypassino
b
i gli
li ospedali
d li senza
emodinamica h 24
b
bypass
ss d
dell DEA e dell
d ll'UTIC
UTIC in
i caso
s di PCI primaria
i
i
stretta cooperazione tra 118, cardiologi e centri ospedalieri
utilizzare la trombolisi pre-ospedaliera
pre ospedaliera ogniqualvolta sia indicata
utilizzare tutte le strategie terapeutiche per migliorare l'esito della
PCI primaria
Rokos IC. Am Heart J 2006;152:55.
MT
components of total delay in STEMI reperfusion
Fox KAA, Nat Clin Pract CV Med 2008
MT
REACT trial: rescue PCI in STEMI
Gershlick AH. N Engl J Med 2005;353:2758.
MT
STEMI: routine early PCI after thrombolysis
Halvorsen S, Thromb & Haemost 2011
MT
pre--hospital ECG & SRC networks
pre
Rokos IC. JACC Intv 2009
MT
PH--ECG and ED bypass in STEMI
PH
Baran, Circ CQO 2010
MT
bypass emergency room
USIC 2000 Registry
direct admission
to ICCU/cath lab
admission
via ER
symptom
t
onsett to
t admission
d i i ((min)
i )
244 ***
292
symptom onset to thrombolysis (min)
204 **
258
symptom onset to PCI (min)
292 **
402
4.9 *
8.6
mortality at 5 days (%)
admission via ER independently predicts mortality: OR 1.67 (1.01-2.75)
Steg PG, Heart 2006
MT
high risk pts (DANAMI‐2)
3 yrs mortality (%)
fibrinolysis
low risk
#
high risk
§
primary PCI
5.6
8.0
36.2
25.3 *
3 yrs event rate¶ (%)
fibrinolysis
low risk
#
high risk
§
primary PCI
15.7
13.7
45 9
45.9
32 3 *
32.3
# TIMI risk score 0-4; § TIMI risk score > 5
¶ death,
d th reinfarction,
i f ti
di
disabling
bli stroke
t k
Thune JJ, Circulation 2005;112:2017
MT
primary PCI in Europe
Widimski P, EHJ 2010
MT
time to treatment and mortality
- Vienna STEMI Registry -
Kalla K, Circulation 2006;113:2398
MT
long--term mortality in a regionalized STEMI system of care
long
Bologna
mortality
cardiac
card
ac
mortality
MT
strategies to reduce D2B time
6 strategies significantly associated with a reduced D2B time
1.
2.
3
3.
4.
5.
6
6.
Bradley EH, NEJM 2006
cath lab activation by the EMS physician
single call to a central page operator
ED activates
i
cath
h llab
b while
hil patient
i
is
i en route
cath lab staff arrival within 20 min from page
attending cardiologists always on site
real-time
l ti
data
d t f
feedback
db k tto ED and
d cath
th llab
b staff
t ff
MT
FINESSE: facilitated PPCI in STEMI
Ellis SG. N Engl J Med 2008
MT
back-up slides
SMALL COUNTRY, HIGHWAYS, ACCEPTABLE TRAFIC, HELICOPTER FOR REMOTE AREAS....
Hungary
Austria
91 km
50 km
61 km
73 km
106km
78 km
115 km
Italy
Croatia
32 km
•Area 20.273 km
•Population 2.053.470
2 053 470
•PCI centers (5)
•-“24
“24--7” (2)
•No “24“24
24-77” (3)
24•3500
3500--4000 PCI/year
•1100 PPCI for STEMI
STEMI reperfusion treatment in Europe
Widimski P, EHJ 2010
MT
EMS use for STEMI in Europe
Widimski P, EHJ 2010
MT
emergency number
Mantova
1st period
2nd period
118 EMS
78
46
37
Territory 1st period
138
2nd period
118 EMS
Zanini R, Ital Heart J Suppl 2003
91
66
MT
time (min)
Milan STEMI network
advanced
ambulance
b l
Marzegalli M. G Ital Cardiol 2008
advanced
ambulance
b l
+ ECG
basic
self-presenters
ambulance
b l
MT
pre--hospital management
pre
MT
pre--hospital emergency cardiac care
pre
MT
pre‐hospital triage
12 leads pre-hospital ECG
- meta-analysis
meta analysis -
Brainard AH, Am J Emerg Med 2005
cardiogenic shock
- Bologna,
Bologna Italy -
Ortolani P, Eur Heart J 2006
MT
EGYPT: early GPI in PP-PCI
- abciximab data -
pre-procedural
d
l
TIMI 3 flow
post-procedural
post
procedural
TIMI 3 flow
ST segment
resolution
late abcx better
De Luca, Heart 2008
early abcx better
MT
EUROTRANSFER: early abciximab in PP-PCI
- European multicentre registry -
Dudek D, Am Heart J 2008
MT
ON--TIME 2: preON
pre-hospital tirofiban in PPCI in STEMI
ST resolution
van't Hof AWJ, Lancet 2008
death – reMI – uTVR ‐ bailout tirofiban
MT
On--TIME
On
TIME--2: prepre-hospital highhigh-dose tirofiban and early stent thrombosis
Heestermans AACM, J Thromb Haemost 2009
MT
organizzazione per la PCI primaria in Europa
condizione strutturale ottimale:
200-800 pPCI/centro/anno
p
50-100 pPCI/operatore/anno
0.3-1.1 milioni abitanti/centro pPCI
criticità
personale scarso
attitudine conservatrice dei cardiologi clinici
motivazione insufficiente dei cardiologi interventisti
mancanza di programmi di training
mancanza di sostegno economico per i progetti di rete
("pay for performance")
Widimski P, EHJ 2010
MT
ischaemic time and mortality in PP-PCI
De Luca G. Circulation 2004
MT
guidelines applied in practice (GAP) projects
baseline
post‐GAP
p
40
**
35
mortaality (%)
30
25
20
***
15
10
**
5
0
in hospital 30 days 1 year
Eagle KA. JACC 2005;46:1242)
MT
TRANSFER--AMI
TRANSFER
End-point
Primary end point
Death
R i f
Reinfarction
ti
Recurrent ischemia
Death/MI/ischemia
New/worsening CHF
Cardiogenic shock
Standard
(%)
16.6
Pharmacoinvasive
(%)
10.6
0.0013
3.6
60
6.0
2.2
11 7
11.7
5.2
2.6
3.7
33
3.3
0.2
65
6.5
2.9
4.5
0.94
0 044
0.044
0.019
0 004
0.004
0.069
0.11
p
Cantor WJ. ACC 2008 Scientic Sessions/i2 Summit-SCAI Annual Meeting; March 30, 2008; Chicago, IL.
p. miechowski
51,5 tys.
p. olkuski
114,7 tys.
Kraków + p. a ó
p.
krakowski
998,8 tys.
p. proszowicki
43,6 tys.
p. dąbrowski
58,6 tys.
1 808 800
p. chrzanowski
128,7 tys.
558 500
p. bocheński
p. bocheński
99,7 tys.
99,7 tys.
p. wielicki
102,5 tys.
p. oświęcimski
153,1 tys.
p. wadowicki
153,4 tys.
p. brzeski
p. brzeski
89,7 tys.
89,7 tys.
Tarnów + p. tarnowski
310,5 tys.
p. myślenicki
114,9 tys.
p. suski
81,5 tys.
p. limanowski
120,2 tys.
, tys.
y
120,2
506 000
p. gorlicki
106,4 tys.
p. nowotarski
p.
nowotarski
179,9 tys.
261 400
p. tatrzański
65,3 tys.
Nowy Sącz + p. nowosądecki
ą
279,4 tys.
FOUR NETWORKS
NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT
OF ACUTE CORONARY SYNDROMES
PPCI IN LJUBLJANA‐SLOVENIA
Also STEMI’s from remote areas
“24‐7”
call for PPCI
1990
•6709 STEMI
•4813 PPCI
2000
Modified from Am J Cardiol 2008;101:162‐168
MT
Mayo Clinic STEMI protocol
Ting HH, Circulation 2007
MT
NRMI‐2: pre‐hospital ECG in AMI
NRMI‐2: pre‐hospital ECG in AMI
PH‐ECG (n=3,786)
No PH‐ECG (n=66,989)
P<0.001 for both comparisons
Lytic Rx (n=26,559)
Percentiles
(25th, 75th)
20, 53
%
% of patient
ts
26, 54
P<0.001 for both comparisons
Primary PCTA (n=4932)
65 33
65, 33
84, 64
Time (median, minutes)
Canto JG. J Am Coll Cardiol 1997;29:498–505
MT
barriers for networks
lack of p
public awareness
different technological levels of emergency vehicles
mandate to deliver to the nearest hospital
inter-hospital transfer with the "next available"
ambulance
ED diversion
need to restructure payments
Jacobs AR, Circulation 2007
MT
pre--hospital triage in STEMI pts. with cardiogenic shock
pre
Ortolani P. Am J Cardiol 2007
MT
ECG & triage
pre-hospital
p
p
symptoms onset to balloon
ED
p
154
249
< 0.001
peak
k CK in
i early
l presenters (U/L)
( / )
1435
2320
= 0.009
0 009
mortality in PCI-treated pts (%)
1.1
8.2
=0.025
overall mortality (%)
19
1.9
73
7.3
=0 046
=0.046
(median) (min)
Carstensen S. Eur Heart J 2007
MT
regional system of care: Mayo Clinic STEMI protocol
D2B time < 90 min:
- 75% pts group A
- 12% p
pts group
g
pB
Ting HH, Circulation 2007
D2N time < 30 min:
- 70% pts group C
MT
French nationwide surveys on STEMI
Danchin N. Eur Heart J 2010
MT
courtesy of P.Widimsky