Warong Lapanun MD. Bhumibol Adulyadej Hospital 6/2/2011
Jun 03, 2015
Warong Lapanun MD.Bhumibol Adulyadej Hospital
6/2/2011
Mr PM: 54-y-o presenting at a non-PCI hospital
• 12.00 Myalgia and fatigue Epigastric fullness for 2 hrs
• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferior wall+ RVMI BP 90/40 mmHg
•Nearest cath lab 40 min away
Transfer for primary PCI Lysis on Site Lysis with immediate transfer to cath lab
Which type of Lytic Rx will be selected?
McNamara et al. JACC. 2006;47:2180-6.
Door-to-Balloon Time (minutes)
3.04.2
5.7
7.4
0
5
10
15
20
90 91-120 121-150 150
p < 0.01
><
Mo
rtal
ity
%
n = 29,222
Pinto et al. Circulation. 2006;114:2019-2025
192, 509 pts at 645 NRMI hospitals
• 43801 pts STEMI PPCI• ACC registry 2005-2006• In hospital Mortality• Median D2B 83 min.• Overall MR 4.6%
Rathor SS,et al. BMJ2009:338;1807
•D2B Mortality( P<0.001)
• 30 min = 3.0%• 60 min = 3.5%• 90 min = 4.3%• 120 min = 5.6%• 180 min = 8.4%
Rathor SS,et al. BMJ2009:338;1807
Mortality Reduction(%)
8
4
6
2
0
1 3 6 12 24
10
A
D
E
C
B
Hr
Time to Rx is Critical Opening the artery is 1o Goal ( PCI>lysis)
Gersh BJ et al. JAMA 2005;293:979-986
Potential outcomes
A-B : No benefit
A-C : Benefit
B-C : Benefit
E-D : Harm
Francone M, et al.JACC2009;23:2145
Infarct size Myocardial Edema
Myocardial Salvage Microvascularobstruction
SK r-tPA TNK
TIMI flow gr 3 ~30% ~50% ~60%
Fribrinolytic Characteristic
Boden et al. JACC 2007,50;10. 923
Risk Factors Age > 75 yr Black race Female Hx of stroke SBP > 160 mmHg Wt <65(w),<80(m) INR>4 Use of rt-PA
Risk Score ICH(%)0-1 0.69
2 1.023 1.634 2.49>5 4.11
Bonnefoy, E. et al. Eur Heart J 2009 30:1598-1606
<2 hrs
>2 hrs
CAPTIM: 5 Year Survival
Prehospital Thrombolysis vs Primary PCI
Su
rviv
al o
f P
roab
ility
PPCI
Prehosp lysis
Prehosp lysis
PPCI
35.9
26.8
23.4
16.1
12.4
7.3
4.42.21.60.8
0
5
10
15
20
25
30
35
40
0 1 2 3 4 5 6 7 8 >8
Antman et al Circulation 2000;102:2031-7
Historical Points
Age > 75 3
65-74 2
DM or HT or 1
Angina
Exam.
SBP<100 3
HR >100 2
Killip II-IV 2
Wt < 67kg 1
Presentation
Ant. STE or LBBB 1
Time to Rx > 4 hr 1
Points
%
Benjamin M. Scirica JACC 2010;55;1403-1415
ST Resolution
Primary PCI Rescue PCI Facilitated PCI Pharmaco-invasive
without PCI capability who cannot be
transferred and PCI within 90 min of FMC
should be Rx with Lytic Rx within 30 min,
unless Lytic Rx is contraindicated.
with PCI capability should be Rx with p-
PCI within 90 min of FMC .
IIbI IIa III
A
B
Modified
Modified
FMC: First Medical Contact
STEMI within 12 h after onset of symptoms At centre without PCI facilities with
>1 high risk features:1. Cumulative ST-segment elevation of > 15 mm 2. New onset LBBB3. Previous MI4. Killip class of 2 or more or 5. LV ejection fraction of 35% or less.
Carlo Di Mario, Lancet 371 February 16, 2008
Carlo Di Mario, Lancet 371 February 16, 2008
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
Pts with STEMI within 12 hrs after onset of symptoms At centers : No PCI capability Rx with Tenecteplase (TNK) ST-segment elevation of ≥ 2 mm in two anterior leads or ST-segment elevation of ≥ 1 mm in two inferior leads and
One high-risk characteristics:1. Systolic BP < 100 mm Hg,2. HR > 100 bpm,3. Killip class II or III, 4. ST- depression of ≥ 2 mm in the anterior leads, or 5. ST- elevation of ≥ 1 mm in V4R indicative of RV
involvement.
* ST segment resolution < 50% & persistent chest pain, or hemodynamic instability
Failed Reperfusion* Successful Reperfusion
Cath / PCI within 6 hrs regardless of reperfusion
status
Cath and Rescue
PCI GP IIb/IIIa
Inhibitor
Elective Cath
PCI
> 24 hrs later
Community
Hospital
Emergency
Department
TNK + ASA + Clopidogrel +
Heparin or Enoxaparin
Pharmacoinvasive :
Urgent PCI Centre
Standard Strategy:
Assess chest pain, ST resolution
at 60-90 min after randomization
Randomization
PCI Centre
High Risk STEMI 12 hrs, 1059 Pts
TRANSFER AMI
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
Kaplan-Meier Curves
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
*Primary endpoint was death, reinfarction, recurrent ischemia,
new or worsening heart failure, or cardiogenic shock at 30 days
Primary Endpoint* at 30 Days Re-infarction at 6 MonthsStd Rx
Early PCIEarly PCI
Std Rx
Verheugt, NEJM 2009; 360, 26: 2779-2781
Pharmacoinvasive
Facilitated PCI
No Class III
ER physician activate the Cath Lab One call activate the cath lab Cath lab team ready in 20-30 min Prompt data feed back Senior management commitment Team-based approach
รอบัตร รอแพทย์ตรวจ
ท ำ EKGใน 10 นำที
แพทย์เวร ER
ปรึกษำ staff cardio ผ่ำน single
call operator, [email protected]
ส่งท ำ PCI
ผู้ป่วยเจ็บหน้ำอก
แพทย์เวร Med
Fellow cardio
ตำมเจำ้หน้ำที่ Cath Lab
Time to Lab
PCI-Center
Fast Track MI
EKG ด่วนแพทย์ดูใน 10 นำที
ST elevation ตำม staff cardio ทันที
No ST elevation ………………. MD.
European Heart Journal (2008) 29, 2909–2945
ESC GUIDELINES
ESC PCI Guidelines 2O10
Mr PM: 54-y-o presenting at a non-PCI hospital
• 12.00 Myalgia and fatigue Epigastric fullness for 2 hrs
• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferior wall+ RVMI BP 90/40 mmHg
•Nearest cath lab 30 min away
Transfer for PPCI 14.30 Lab 100% Prox. RCA Clot aspiration 14.50 Balloon Stent 4.0x20 mm Final TIMI III flow
Oxygen,NTG, Morphine ASA / Clopidrogrel /Prasugrel/Ticangrelor Heparin/ LMWH/ Fonda GP IIb IIIa antagonist Lab Echo IABP CAG / PCI : Early or Late
Benjamin M. Scirica JACC 2010;55;1403-1415
Thygesen et al,Circulation November 27, 2007
Universal Definition of MI
Spontaneous AMI
Secondary AMI
Sudden cardiac death
Post PCI : 3x 99%URL
Post CABG : 5x 99%URL URL: upper reference limit
Thygesen et al,Circulation November 27, 2007
Benjamin M. Scirica JACC 2010;55;1403-1415
Goncalves PA, et al. Eu Heart J 2005;26:865
Equally Effective
Prevalence increased RFs:▪ Older age,
▪ Predominance of females
▪ high rate of DM
▪ Smoking and obesity
Use of preventive medications Increasing sensitive Troponin Assay
Robert P, et al. Circulation 2009; 54: 1544
NSTE-ACS
63%
CASPAR: Coronary Artery Spasm in Patients With ACSOng P, et al. JACC 2008; 52:523
Plaque rupture: 80% Plaque erosion/spasm CASPAR study : 448 ACS
pts
~ 25% of ACS: no culprit lesion
~ 50% of no culprit
IC Ach spasm
CCBs / nitrates : may benefit
Endothelial function
OCT Thin-Capped fibroatheromatous ( TCFA)Positive remodeling
Plaque rupture : Rest-onset, Exertion-trigger
Tanaka A. et al. Circulation 2008;118;2368
Thin-capped Thick-capped
Plaque shoulder
Lipid coreLipid core
OCT: Optical Coherence Tomography
Everyone should be on anti-plt and anti-coag Choose Rx Consevative vs Invasive Choose antithrombotic regimen
The strategy selected
Bleeding risk of patients
Strategy selected Pt risk stratification Bleeding vs Ischemic risk Equally
important
Antman. Circulation 2001;103:2310-4
Inf. epigastric
artery
89-y-o lady with severe Lt. RAS and TVD
Assess/document bleeding risk in every pt. Avoid crossover : UFH and LMWH Proper doseWt. and renal function Use radial access in pts at high risk of
bleeding Stop anticoag after PCI/ indication? Selective “downstream” use of GPI