I International Symposium on Prevention of Cardiovascul Diseases Kraków 9-11.06.2005 Prevention of Heart Failure after AMI „MAŁOPOLSKA STUDY” A 2256-Patients Registry in Krakow Prewencja niewydolności krążenia po zawale – „Program Małopolski” Prof. dr hab. Jacek S Dubiel Dr med. Dariusz Dudek Dr hab. med. Krzysztof Żmudka Dr med. Mieczysław Pasowicz Prof. dr hab.. Wiesława Tracz Dr med. Łukasz Rzeszutko
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I International Symposium on Prevention of Cardiovascular Diseases Kraków 9-11.06.2005 Prevention of Heart Failure after AMI MAŁOPOLSKA STUDY A 2256-Patients.
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I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Prevention of Heart Failure after AMI
„MAŁOPOLSKA STUDY” A 2256-Patients Registry in Krakow
Prewencja niewydolności krążenia po
zawale – „Program Małopolski”
Prof. dr hab. Jacek S Dubiel
Dr med. Dariusz Dudek
Dr hab. med. Krzysztof Żmudka
Dr med. Mieczysław Pasowicz
Prof. dr hab.. Wiesława Tracz
Dr med. Łukasz Rzeszutko
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
The Krakow ExperiencePrimary PCI
II
1999 year invasive reperfusion for 2 mlns
Primary PCI + GpIIb/IIIa transfer delay <90min
2004 year 700 primary PCI / 1 mln
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Primary PCI - ESC PCI, march’2005
REMARKS
1) Prolonged symptom to treatment times are associated with impaired
myocardial perfusion independent of epicardial flow
2) PRIMARY PCI - Data based on:
a. high volume centers
b. experienced operators
c. short response time (delay)
RESULTS DO NOT NECESSARILY APPLY IN OTHER SETTINGS
3) DELAY in initiating Primary PCI > 2-3h
=> recommendation for fibrynolitic agents (2nd or 3rd
generation)
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
p. tatrzański65,3 tys.
p. nowotarski179,9 tys.
p. limanowski120,2 tys.
Nowy Sącz + p. nowosądecki
279,4 tys.
p. gorlicki106,4 tys.
p. suski81,5 tys.
p. wadowicki153,4 tys.
p. oświęcimski153,1 tys.
p. chrzanowski128,7 tys.
p. olkuski114,7 tys.
p. miechowski51,5 tys.
p. proszowicki43,6 tys.
p. dąbrowski58,6 tys.
p. wielicki102,5 tys.
p. bocheński99,7 tys.
p. brzeski89,7 tys.
Kraków + p. krakowski
998,8 tys.
p. myślenicki114,9 tys.
86 km
60 – 120minTarnów + p. tarnowski
310,5 tys.
85 km
60-120min
98 km
100 – 150min
125 km
120 – 180min
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Facilitated PCI - ESC PCI, march’2005
Facilitated PCI is defined as planned intervention within
12hrs after onset of chest pain or symptoms, soon after
clot dissolving medication to bridge the delay between
first medical contact and primary PCI
term not uniformly used
1. Thrombolysis facilitated primary PCI
2. Gp IIb/IIIa inhibitor facilitated primary PCI
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Cathlab
Acute MI < 12 hrsin the region of 3.4 mln inhabitants
transfer delay
< 30min (Ia)
Thrombectomy
and
PCI
PCI
and
abciximab
Tele ECG
transfer delay
< 90min (Ib)
abciximab
PCI
transfer delay
> 90min (II)
abciximab + ½ lyitcs & transfer for PCI
IIII
Ib
150 km150 km
IaIa
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
p. nowotarski179,9 tys.
p. limanowski120,2 tys.
Nowy Sącz + p. nowosądecki
279,4 tys.
p. gorlicki106,4 tys.
p. suski81,5 tys.
p. wadowicki153,4 tys.
p. oświęcimski153,1 tys.
p. chrzanowski128,7 tys.
p. olkuski114,7 tys.
p. miechowski51,5 tys.
p. proszowicki43,6 tys.
p. dąbrowski58,6 tys.
p. brzeski89,7 tys.
p. tatrzański65,3 tys.
p. myślenicki114,9 tys.
Tarnów + p. tarnowski
310,5 tys.
Kraków + p. krakowski
998,8 tys.
p. wielicki102,5 tys.
p. bocheński99,7 tys.
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
AMI : ST
pain onset < 12h
transfer time to the cath lab > 90 minutes
½ tPA +
full dose
Gp IIb/IIIa
Facilitated
PCI
Interhospital transfer for long distance
Age < 75 years, no shock, eligible for lytics
Transfer
to the cath lab
Facilitated PCI in Patients with Acute Myocardial Infarction
D, Dudek et al., Am J Cardiol, 2003
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Jagiellonian UniversityInstitute of Cardiology, Krakow, Poland
- 2 buildings; 6 cathlabs
- 24 interventional cardiologists
In 2004, have been performed:
4000 PCIs
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
June’2001 – June’2003AMI ST n=2256
IIII
II
3.4 millions population
70%
30%
Primary PCI n=1 584
Facilitated PCI n=672
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Time delays
189 0 17
190 35 106 26
0 50 100 150 200 250 300 350 400
PRIMARY
FACILITATED
pain to admission admission to lysis transport cathlab to needle
357 min.357 min.
206 min.206 min.
= 150 min.= 150 min.
Krakow, STEMI registry
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Transport complications for patients treated with facilitated PCI in AMI
Death 0 (0,0%)
stroke 0 (0,0%)
Rhythm disorders
• VF
• bradycardia (HR<60/min)
• ventricular disorders
•AF
116 (17,4%)
18 (2,7%)
21 (3,1%)
70 (10,5%)
7 (1,1%)
Conduction disorders (AV block 2 degree and higher)
15 (2,2%)
Hypotonia 31 (3,1%)
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Primary PCI vs Facilitated PCI
TIMI 2-3 ~85%TIMI 2-3 ~85%
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
0,8% 0,8%
4,2%
5,0%
0,9% 0,9%
3,9%3,4%
4,8%
3,0%
0%
2%
4%
6%
8%
De ath re MI re PC I de ath + re MI All MAC E
PRIMARY FACILITATED
30-day MACE
PRIMARY PCI vs FACILITATED PCI
NS
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Kaplan-Meier curves for survival1 year follow up
Zone II
Zone I
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
1,2%
7,4%
2,1%
12,7%
1,1%
3,4%
0%
2%
4%
6%
8%
10%
12%
14%
severe moderate mild
PRIMARY FACILITATED
Bleeding complications
PRIMARY PCI vs FACILITATED PCI
p= 0.0004 NS
p= 0.0001
0,0%
0,9%
0%
1%
2%
3%
4%
PRIMARY FACILITATED
ICH
p= 0.0006
Krakow, STEMI registry
I International Symposium on Prevention of
Cardiovascular Diseases Kraków 9-11.06.2005
Independent predictors of 6 months left ventricular EF recovery from multivariate analysis for patients treated with facilitated PCI