Acute Acute Coronary Coronary Syndromes Syndromes Kurt Glenn C. Jacoba*, MD, MHSA FPCP, FPCC, FPSCCII, FACC, FAHA *CHAIRMAN – QMMC INTERNAL MEDICINE CHAIRMAN – CLINICAL CARDIOLOGY DIVIISION, PHILIPPINE HEART CENTER
Oct 17, 2014
Acute Acute Coronary Coronary
SyndromesSyndromesKurt Glenn C. Jacoba*, MD, MHSAFPCP, FPCC, FPSCCII, FACC, FAHA
*CHAIRMAN – QMMC INTERNAL MEDICINE CHAIRMAN – CLINICAL CARDIOLOGY DIVIISION, PHILIPPINE HEART CENTER
Acute Coronary Acute Coronary SyndromesSyndromes
Coronary arterial
thrombosis
Unstable angina (UA)
Non-ST-elevation myocardial
infarction (MI)
ST-elevation MI
Chase SL, et.al.: Pharmacological Considerations In Acute Coronary Syndrome (ACS): An Expert Debate. Pharmacy and Therapeutics Vol 32(3):Suppl 1; March 2007
15-20%
Endothelium Platelet Fn
Inflammatory State
Atherosclerotic Plaque
Gene
Profile
Adipocyte Products
Circulating Endothelial
Cells
vWF
EPCs CD40/CD40L P-Selectin
CRP/CD40MPOIL-18
MMPs/?PAPP-AFLAP/LTA4
AdinopectinTNF-αVEGFPAI-1IL-6
Endothelial Dysfunction
+ InflammationPlaque
Morphology/ Stability
Endothelial Dysfunction
+ + + +Endothelial Dysfunction
Proinflammatory/ Prothrombotic
State
=
ACS
Anwaruddin, S et al, Redefining Risk in Acute Coronary Syndromes Using Molecular Medicine. J Am Coll Cardiol 2007; 49:279-89
A Model of Risk Stratification Based on a A Model of Risk Stratification Based on a Representative Panel of Molecular and Representative Panel of Molecular and
Genetic FactorsGenetic Factors
vWF = Von Wille-brand factorEPC = endothelial progenitor cell
fn = platelet functionCRP = C-reactive protein
FLAP = 5-lipoxygenase activating protein pathwayLTA4 = leukotriene A4 pathway
MPO = myeloperoxidaseIL = interleukinMMP = matrix metalloproteinasesPAPP-A = pregnancy-associated plasma protein A
TNF-α = tumor necrosis factor alphaVEGF = vascular endothelial growth factorPAI-1 = plasminogen activator inhibitor
Acute Coronary Acute Coronary SyndromesSyndromes
Antman EM, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
75%25%
WBC Blood clotFoam cell
NATURAL HISTORY OF ACUTE CORONARY SYNDROME
PREPATHOGENESIS PERIOD PERIOD OF PATHOGENESIS
Factors that lead to ACS
ENVIRONMENTAL FACTORSOccupation, income, lifestyleMedical care availability
HOST FACTORSAge men: >45y
women: >55 yFamilial dispositionHistory of Coronary Artery DiseaseGenetic predispositionConcomittant medical illness
Above mentioned factors occurring singly or in combination can cause ACS
ASYMPTOMATIC PHASE
50 years
Early Pathogenesis Progression of the disease Convalescence or death
Natural Course of ACS
Death
STEMI Non-STEMI Unstable angina
Elevated/ Not elevated markers of myocardial necrosis
Acute cardiac ischaemia with or w/o ST segment elevation
Thrombus formation with or w/o embolisation
Plaque disruption
PREPATHOGENESIS PERIOD PERIOD OF PATHOGENESIS
Health Promotion
•Awareness
•Right nutrition
•Lifestyle modification
SPECIFIC PROTECTION
•Genetic counseling
•Drug use prevention
•Health care promotion
EARLY DIAGNOSIS & TREATMENT
•Medical Therapy
•Mechanopharmacolgical approaches
•Thrombolytics
•Percutaneous Coronary Intervention
•Coronary Artery Bypass Graft
DISABILITY LIMITATION
•Continuous medical therapy
•Lifestyle modification
REHABILITATION
•Cardiac rehabilitation
•Manageable exercise regimen
Primary Prevention Secondary Prevention Tertiary
Typical Chest PainTypical Chest Pain
UAUA NSTEMINSTEMI STEMISTEMI
ThrombusThrombus Non-occlusive Non-occlusive Partial occlusion, Partial occlusion, sufficient to cause sufficient to cause tissue damage & tissue damage & mild myocardial mild myocardial necrosisnecrosis
Complete occlusionComplete occlusion
ECGECG Non-specificNon-specific ST depression ST depression
+/- T wave inversion +/- T wave inversion
No Q waveNo Q wave
ST-elevationST-elevation
New LBBBNew LBBB
Q waveQ wave
Cardiac markersCardiac markers NormalNormal ElevatedElevated ElevatedElevated
UNSTABLE UNSTABLE ANGINA ANGINA
and and NSTEMINSTEMI
Timing of Release of Various Biomarkers After Acute Myocardial Infarction
Anderson JL, et al.. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:e1–157.
Anderson JL, et al.. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:e1–157.
Troponin I Levels to Predict the Risk of Mortality in Acute Coronary Syndromes
Selection of Initial Treatment Strategy: Selection of Initial Treatment Strategy: Invasive Versus Conservative StrategyInvasive Versus Conservative Strategy
Preferred strategyPreferred strategy Patient CharacteristicsPatient Characteristics
InvasiveInvasive Recurrent angina or ischemia at rest or with low-level activities despite Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapyintensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depressionNew or presumably new ST-segment depression
Signs and symptoms of HF or new or worsening mitral regurgitationSigns and symptoms of HF or new or worsening mitral regurgitation
High-risk findings from noninvasive testingHigh-risk findings from noninvasive testing
Hemodynamic instabilityHemodynamic instability
Sustained ventricular tachycardiaSustained ventricular tachycardia
PCI within 6 monthsPCI within 6 months
Prior CABGPrior CABG
High risk score (e.g., TIMI, GRACE)High risk score (e.g., TIMI, GRACE)
Reduced left ventricular function (LVEF less than 40 %)Reduced left ventricular function (LVEF less than 40 %)
ConservativeConservative Low risk score (e.g., TIMI, GRACE)Low risk score (e.g., TIMI, GRACE)
Patient or physician preference in the absence of high-risk featuresPatient or physician preference in the absence of high-risk features
CABG = coronary artery bypass graft surgery; GRACE = Global Registry of Acute Coronary Events; HF = heart failure; LVEF = CABG = coronary artery bypass graft surgery; GRACE = Global Registry of Acute Coronary Events; HF = heart failure; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis In Myocardial Infarction; TnI = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis In Myocardial Infarction; TnI = troponin I; TnT = troponin Ttroponin I; TnT = troponin T
Anderson JL, et al.. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007;50:e1–157.
UA/NSTEMI
ASA, enoxaparin or heparin,
Β-block., nitrates, clopidogrel
Risk stratify
High or intermediate risk Low risk
Algorithm for the management of patients Algorithm for the management of patients with unstable angina or non-ST elevation with unstable angina or non-ST elevation
myocardial infarction.myocardial infarction.
Older Trials of Antiplatelet and Anticoagulant Therapy in UA/NSTEMI
ATACS = Antithrombotic Therapy in Acute Coronary SyndromesCAPTURE = c73e Fab AntiPlatelet Therapy in Unstable REfractory anginaFRISC = FRagmin and fast Revascularization during InStability in Coronary artery diseasePARAGON = Platelet IIb-IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization NetworkPRISM = Platelet Receptor inhibition in Ischemic Syndrome ManagementPRISM-PLUS = Platelet Receptor inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and symptomsPURSUIT = Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin TherapyRISC = Research on InStability in Coronary artery disease
0.012
0.005
0.0005
0.018
0.001 0.0005
0.003
0.034
0.042
0.0022
SYNERGY Primary Outcomes at 30 d
Superior Yield of the New strategy of Enoxaparin, Revasculariation and Glycoprotein IIb/IIIa inhibitors
ACUITY Clinical Outcomes at 30 d
Acute Catheterization and Urgent Intervention Triage strategy
OASIS 5 Cumulative Risks of Death, MI, or Refractory Ischemia
Fifth Organization to Assess Strategies for Ischemic Syndromes
Kaplan-Meier Curves Showing Cumulative Incidence of Death or MI
Kaplan-Meier Curves Showing Cumulative Incidence of Death or MI
Cumulative Risk of Death or Myocardial Infarction (top) orDeath (bottom) in RITA-3
Relative Risk of Outcomes With Early Invasive Versus Conservative Therapy in UA/NSTEMI
FRISC-II = FRagmin and fast Revascularization during InStability in Coronary artery diseaseICTUS = Invasive versus Conservative Treatment in Unstable coronary SyndromesISAR-COOL = Intracoronary Stenting with Antithrombotic Regimen COOLing-off studyRITA-3 = Third Randomized Intervention Treatment of Angina trialTIMI-18 = Thrombolysis In Myocardial Infarction-18TRUCS = Treatment of Refractory Unstable angina in geographically isolated areas without Cardiac SurgeryVINO = Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction
Relative Risk of All-Cause Mortality for Early Invasive Therapy Compared With Conservative Therapy at a mean
follow-up of 2 years
Relative Risk of Recurrent Nonfatal Myocardial Infarction for Early Invasive Therapy Compared With Conservative Therapy at a mean follow-up of 2 years
Relative Risk of Recurrent Unstable Angina Resulting in Hospitalization for Early Invasive Therapy Compared With Conservative Therapy at a mean follow-up of 13
months
Weaver WD and Block P: Is There a Conservative Strategy for NSTEMI? American College of Cardiology. February 2006.
TIMI III B1 year
(p = 0.42)
VANQWISH1 year
(p = 0.025)
MATE2 years (p = 0.6)
FRISC II1 year
(p = 0.005)
TACTICS-TIMI 18
6 months (p = 0.0498)
VINO6 months (p < 0.001)
RITA-31 year
(p < 0.007)
ICTUS1 year
nonfatal MI (p = 0.005)
death (p = 0.97)
STEMISTEMI
Cardiac biomarkers in ST-elevation myocardial infarction (STEMI)
Major components of time delay between onset of symptoms from ST-elevation MI and restoration of flow in the infarct artery.
Antman EM, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
Onset of symptoms of STEMI
911EMS
Dispatch
EMS on-scene•Encourage12-lead ECGs•Consider prehospital fibrinolytic if capableand EMS-to-needle within 30 min
Call 9-1-1
Call fast
EMSTriage Plan
Not PCI capable
Hospital fibrinolysis: Door-to-Needle within 30 min
PCI capable
Inte
r-hosp
ital
Tra
nsfe
r
Goals
Antman EM, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
Patient
5 min after symptom onset
Dispatch
1 min Within 8 min
EMS on scene
Prehospital fibrinolysis: EMS-to-Neddle within 30 min
EMS transport
Patient self-transport: Hospital Door-to-Balloon within 30 min
EMS transport: EMS-to-Balloon within 90 min
Total ischemic time: Within120 min*
*Golden hour = First 60 minutes
Options for transportation of patients with STEMI and initial reperfusion treatment
Antman EM, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
Options for transportation of patients with STEMI and initial reperfusion treatment
Fibrinolysis
Primary PCI
Noninv Risk Stratification
PCI or CABG
Late Hosp Care & Secondary PrevNot PCI
capable
PCI capable
Receiving Hospital
Isch
em
ia d
riven
Rescu
e
Noninvasive Risk Noninvasive Risk StratificationStratification
High risk (>3% annual mortality rate)High risk (>3% annual mortality rate)
1.1. Severe Severe resting LV dysfunctionresting LV dysfunction (LVEF <0.35) (LVEF <0.35)2.2. High-risk High-risk treadmill scoretreadmill score (score ≤ -11) (score ≤ -11)3.3. Severe Severe LV dysfunctionLV dysfunction (exercise LVEF <0.35) (exercise LVEF <0.35)4.4. Stress-induced Stress-induced large perfusion defectlarge perfusion defect (particularly if (particularly if
anterioranterior))5.5. Stress-induced Stress-induced multiple perfusion defects of moderate sizemultiple perfusion defects of moderate size6.6. Large, fixed perfusion defect with LV dilation or increased Large, fixed perfusion defect with LV dilation or increased
lung uptake (thallium-201)lung uptake (thallium-201)7.7. Stress-induced moderate perfusion defect with LV dilation Stress-induced moderate perfusion defect with LV dilation
or increased lung uptake (thallium-201)or increased lung uptake (thallium-201)8.8. Echocardiographic wall motion abnormality (involving > 2 Echocardiographic wall motion abnormality (involving > 2
segements) developing at a low dose of dobutamine (≤ 10 segements) developing at a low dose of dobutamine (≤ 10 mg·kgmg·kg-1-1·min·min-1-1) or at a low heart rate (<120 bpm)) or at a low heart rate (<120 bpm)
9.9. Stress echocardiographic evidence of extensive ischemiaStress echocardiographic evidence of extensive ischemia
Braunwald E, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). 2002.
Noninvasive Risk Noninvasive Risk StratificationStratification
Intermediate risk (1-3% annual mortality Intermediate risk (1-3% annual mortality rate)rate)
1.1. Mild/moderate Mild/moderate resting LV dysfunctionresting LV dysfunction (LVEF 0.35- (LVEF 0.35-0.49)0.49)
2.2. Intermediate-risk Intermediate-risk treadmill scoretreadmill score (-11 < score <5) (-11 < score <5)
3.3. Stress-induced Stress-induced moderate perfusion defect without moderate perfusion defect without LV dilation or increased lung intakeLV dilation or increased lung intake (thallium- (thallium-201)201)
4.4. Limited stress echocardiographic ischemia with a Limited stress echocardiographic ischemia with a wall motion abnomality only at higher doses of wall motion abnomality only at higher doses of dobutamine involving ≤2 segmentsdobutamine involving ≤2 segments
Braunwald E, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). 2002.
Noninvasive Risk Noninvasive Risk StratificationStratification
Low risk (<1% annual mortality Low risk (<1% annual mortality rate)rate)
1.1. Low-risk Low-risk treadmill scoretreadmill score (score ≥5) (score ≥5)
2.2. Normal or small myocardial Normal or small myocardial perfusion perfusion defect at rest or with stressdefect at rest or with stress
3.3. Normal stress echocardiographic wall Normal stress echocardiographic wall motionmotion or no change of limited resting or no change of limited resting wall motion abnormalities during wall motion abnormalities during stressstress
Braunwald E, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). 2002.
Assessment of Reperfusion Assessment of Reperfusion Options for STEMI PatientsOptions for STEMI Patients
STEP 1: Assess time and riskSTEP 1: Assess time and risk
STEP 2: Determine if fibrinolysis or STEP 2: Determine if fibrinolysis or invasive strategy is preferred invasive strategy is preferred
Fibrinolysis generally Fibrinolysis generally preferred if:preferred if:
Early Presentation Early Presentation Invasive Strategy is not an optionInvasive Strategy is not an option Delay to Invasive StrategyDelay to Invasive Strategy
Prolonged transportProlonged transport (Door-to-Balloon)-(Door-to-Needle) >1hr(Door-to-Balloon)-(Door-to-Needle) >1hr Medical contact-to-balloon or door-to-Medical contact-to-balloon or door-to-
balloon >90minballoon >90min
Contraindications and Contraindications and Cautions for Fibrinolytic Cautions for Fibrinolytic
Use in STEMIUse in STEMIAbsolute contraindicationsAbsolute contraindications Prior intracranial hemorrhagePrior intracranial hemorrhage Structural cerebral vascular lesionStructural cerebral vascular lesion Malignant intracranial neoplasmMalignant intracranial neoplasm Ischemic stroke w/in 3 mo. EXCEPT acute Ischemic stroke w/in 3 mo. EXCEPT acute
ischemic stroke w/in 3 hischemic stroke w/in 3 h Suspected aortic dissectionSuspected aortic dissection Active bleeding or bleeding diathesisActive bleeding or bleeding diathesis Significant closed head or facial trauma w/in Significant closed head or facial trauma w/in
3 mo.3 mo.
49
37
8
-14-20
-10
0
10
20
30
40
50
60Liv
es S
aved p
er
Thousand
BBB ANT STElevation
INF STElevation
ST DEP
Effect of fibrinolytic therapy on mortality according to admission electrocardiogram
BBB=bundle-branch block; ANT ST Elevation=anterior ST-segment elevation; INF ST Elevation=Inferior ST-segment elevation; ST DEP= ST-segment depression
Antman EM, et al.: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
Invasive Strategy Invasive Strategy preferred if:preferred if:
Skilled PCI lab availableSkilled PCI lab available Medical contact-to-balloon or door-to-Medical contact-to-balloon or door-to-
balloon <90 minballoon <90 min (Door-to-Balloon)-(Door-to-Needle) <1 hr(Door-to-Balloon)-(Door-to-Needle) <1 hr
High risk from STEMIHigh risk from STEMI Contraindications to fibrinolysis Contraindications to fibrinolysis
including risk of bleeding and ICHincluding risk of bleeding and ICH Late presentationLate presentation Diagnosis of STEMI is in doubt Diagnosis of STEMI is in doubt
Primary Angioplasty Primary Angioplasty StrategyStrategy
Provides a greater chance for restoring Provides a greater chance for restoring blood flow and stabilization of the infarct blood flow and stabilization of the infarct artery compared to thrombolysisartery compared to thrombolysis
The expanded latitude of temporal benefit The expanded latitude of temporal benefit may mitigate the logical constraints may mitigate the logical constraints
Stents enhance the durability of the Stents enhance the durability of the procedureprocedure
The promise for evolution of the science The promise for evolution of the science of microcirculatory and myocardial of microcirculatory and myocardial protection during infarctionprotection during infarction
Comparison of Revascularization Comparison of Revascularization Strategies in Multivessel DiseaseStrategies in Multivessel Disease
AdvantagesAdvantages DisadvantagesDisadvantages
Percutaneous Coronary InterventionPercutaneous Coronary Intervention
Less invasiveLess invasive
Shorter hospital stayShorter hospital stay
Lower initial costLower initial cost
Easily repeatedEasily repeated
Effective in relieving symptomsEffective in relieving symptoms
RestenosisRestenosis
High incidence of incomplete High incidence of incomplete revascularizationrevascularization
Relative inefficacy in patients with Relative inefficacy in patients with severe left severe left
ventricular dysfunctionventricular dysfunction
Less favorable outcome in diabeticsLess favorable outcome in diabetics
Limited to specific anatomical Limited to specific anatomical subsetssubsets
Coronary Artery Bypass Graft Coronary Artery Bypass Graft SurgerySurgery
Effective in relieving symptomsEffective in relieving symptoms
Improved survival in certain Improved survival in certain subsetssubsets
Ability to achieve complete Ability to achieve complete revascularizationrevascularization
Wider applicability (anatomical Wider applicability (anatomical subsets)subsets)
CostCost
MorbidityMorbidity
TRIAL TRIAL NN EndpointsEndpoints PCIPCI(%)(%)
CABGCABG(%)(%)
pp
AArterial rterial RRevascularization evascularization TTherapy herapy SStudytudy
12051205 At 1 yearAt 1 yearRate of event-free survivalRate of event-free survivalRate of freedom from anginaRate of freedom from angina Use of antianginal Use of antianginal medicationsmedicationsAt 3 yearsAt 3 yearsRepeat revascularizationRepeat revascularization
73.873.890904242
26.726.7
87.887.879792121
6.66.6
<0.001 <0.001 <0.001<0.001<0.001<0.001
0.00010.0001
OCTOSTENTOCTOSTENT 280280 At 1 yearAt 1 yearEvent-free survivalEvent-free survivalTotal mortalityTotal mortalityCardiac deathCardiac death
85.585.50000
91.591.51.41.42.82.8
NSNSNSNS
SStent tent oor r SSurgeryurgery 988988 At median follow-up of 2 yearsAt median follow-up of 2 yearsRequired additional Required additional revascularizationrevascularizationDeath or QWMIDeath or QWMIDeathDeath
2121
9955
66
101022
<0.0001<0.0001
0.800.800.010.01
ERACI IIERACI II 450450 First 30 daysFirst 30 daysMajor adverse cardiac events: Major adverse cardiac events: Death, Q-wave MI, repeat Death, Q-wave MI, repeat revascularization or strokerevascularization or strokeMean follow-up 18.5 monthsMean follow-up 18.5 monthsSurvival rateSurvival rateFree from MIFree from MIRepeat revascularizationRepeat revascularization
3.63.6
96.996.997.797.716.816.8
12.312.3
92.592.593.493.44.84.8
0.002 0.002
<0.017<0.017<0.017<0.017<0.002<0.002
PCI VS CABG
Percutaneous coronary Percutaneous coronary intervention (PCI) versus intervention (PCI) versus
fibrinolysisfibrinolysis
Short-term clinical outcomes of patients in Short-term clinical outcomes of patients in 23 randomized trials of primary angioplasty 23 randomized trials of primary angioplasty
versus thrombolysisversus thrombolysis
0
5
10
15
20
Perc
enta
ge
Death Death (excludeSHOCK trial)
Reinfarction Stroke Hemorrhagic stroke Death, reinfarction,strokeAngioplasty Thrombolysis
P = 0.0003
P = 0.0003 P < 0.0001
P = 0.0004
P < 0.0001
P < 0.0001
For every 1,000 patients treated, PTCA compared with lytic therapy: 20 lives saved 43 re-MI prevented 13 ICH prevented