SHOULD THE 2012 STEMI GUIDELINES BE UPDATED? Frans Van de Werf, MD, PhD, FESC University of Leuven Belgium
SHOULD THE 2012 STEMI GUIDELINES BE UPDATED?
Frans Van de Werf, MD, PhD, FESCUniversity of Leuven
Belgium
Disclosures
• Research grants and speaking feesfrom Boehringer Ingelheim
History of ESC STEMI guidelines
11/14/2014
1996 2003
2008 2012
ESC STEMI guidelines almost 20 years ago……
Task Force Chair Julian D. Eur Heart J 1996. STEMI, ST-elevation myocardial infarction
CathPCI and Medicare data (USA):Door-to-balloon times and 30-day unadjusted mortality
Menees DS, et al. N Engl J Med 2013;369:901-909.
No. of patients
Median door-to-balloon time
4013 4700 5078 6167 6244
Deaths 311 360 398 369 388
Morta
lity (%
)
Media
n do
or-to
-ball
oon
time
(min)
Median door-to-balloon time (p<0.001)30-day mortality (p=0.64)
Year of procedure
Menees et al. N Engl J Med 2013;369:901-909. PCI, percutaneous coronary intervention
FAST-MI: Five-year cumulative survival in patients with STEMI according to reperfusion therapy
Danchin et al. Circulation 2014;129:1629-1636.
Numbers at risk
No reperfusion 462 314 277 248
Pre-hospital lysis 294 276 265 249
In-hospital lysis 153 137 130 114
PPCI 583 524 476 439
100
80
60
40
20
00 12 24 36 48 60
Months
% S
urviv
al
Adjusted HR [95% CI] (reference PPCI)PH fibrinolysis 0.57 [0.36-0.88]IH fibrinolysis 1.19 [0.72-1.96]
PHTIHTPPCI
No reperfusion
Numbers at risk
No reperfusion 462 314 277 248
Lysis 447 413 395 362
PPCI 583 524 476 439
PHT, pre-hospital thrombolysis; IHT, in-hospital thrombolysis; PPCI, primary percutaneous coronary intervention; HR, hazard ratio; IV, intravenous
Adjusted HR [95% CI] (reference no reperfusion)Primary PCI 0.57 [0.43-0.74]IV fibrinolysis 0.48 [0.35-0.68]
Adjusted HR [95% CI] fibrinolysis vs PPCI0.73 [0.50-1.06]
100
80
60
40
20
00 12 24 36 48 60
Months
% S
urviv
al
PPCI
No reperfusion
Fibrinolysis
Conclusions
• The lack of further reductions in mortality with current primary PCI strategies AND….
• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIb LOE A )
• Whether the dose of tenecteplase should be halved in all elderly patients needs more study
PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence
Conclusions
• The lack of further reductions in mortality with current primary PCI strategies AND….
• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIa LOE A )
• Whether the dose of tenecteplase should be halved in all elderly patients needs more study
PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence
Medical School of the University of Leuven