Pharmaco-Invasive Approach for STEMI Michael C. Kontos, MD Medical Director, Coronary Intensive Care Unit Director, Chest Pain Evaluation Center Associate Professor Departments of Internal Medicine (Cardiology), Radiology and Emergency Medicine Virginia Commonwealth University Medical Center Richmond, Virginia
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Pharmaco-Invasive Approach for STEMI
Michael C. Kontos, MD
Medical Director, Coronary Intensive Care Unit
Director, Chest Pain Evaluation Center
Associate Professor
Departments of Internal Medicine (Cardiology), Radiology and
Emergency Medicine
Virginia Commonwealth University Medical Center
Richmond, Virginia
Disclosures
• Consultant:
• Roche
Primary PCI vs Thrombolysis in STEMI: Quantitative Analysis (23 RCTs, N=7739)
Keeley EC, et al. Lancet. 2003;361:13-20
Treatment Strategies for Patients with Who Require Transfer for Primary PCI
• Primary PCI (no matter how long it takes)
• Full dose fibrinolytics with elective transfer or for rescue PCI
• Full dose fibrinolytics with routine transfer and rescue PCI as needed
• Half dose fibrinolytics with transfer and rescue PCI as needed
30 Day Mortality for Transfer for Primary PCI vs
Immediate Thrombolysis
Giuseppe De Luca et al Ann of Emer Med 2008;52;665–676
23% decrease (p=0.02)
58% decrease in re-MI
Advantage of PCI Compared With Fibrinolysis
Decreases as PCI-Related Delay Increases
Pinto DS, et al. Circulation. 2006;114:2019-2025.
Od
ds o
f D
eath
Wit
h F
ibri
no
lysis
PCI-Related Delay (door-to-balloon–door-to-needle time), min
PC
I B
ett
er
Fib
rin
oly
sis
Bett
er
2.0
1.5
1.25
1.0
0.8
0.5
60 75 90 105 114 135 150 165 180
STEMI Door-to-Balloon Times For Transfer Patients Remain Prolonged
Transfer in DTB Times Non-Transfer in DTB Times
Tim
e (
min
)
ACTION Registry-GWTG DATA: January 01, 2014 - December 31, 2014
25th %tile median
Facilitated PCI
• A strategy to enhance primary PCI by improved early infarct vessel patency
• Options: • full dose thrombolytics
• half dose thrombolytics with GP IIb/IIIa inhibitors
• GP IIb/IIIa inhibitors alone
• No benefit and/or worse outcomes • ASSENT-IV trial--TNK
• FINESSE trial—TNK +/- abciximab
• Limitations: minimal delay to PCI, no routine ADP antagonist used
Pharmaco-Invasive PCI
• A strategy to improve fibrinolysis outcomes for patients where transfer for primary PCI cannot be achieved in recommended times
• Fibrinolytics administered per current guidelines
• Immediate transfer to PCI centers
• PCI of the infarct related artery subsequently performed
45% decrease re-MI
35% decrease D/MI
April 11, 2013
no lytic
Study Protocol 1892 patients randomized
RANDOMIZATION 1:1 by IVRS, OPEN LABEL
Am
bu
lan
ce
/ER
Primary endpoint: composite of all cause death or shock or CHF or reinfarction up to