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Cross-sections of left ventricle after experimentalcoronary artery occlusion
Reimer KA, et al. Circulation. 1977;56:786-794.
Time Dependence of Reperfusion Therapy:Time Dependence of Reperfusion Therapy:“Wavefront” Phenomenon of Necrosis in Dogs“Wavefront” Phenomenon of Necrosis in Dogs
Time is Muscle: Delays in Symptom to Door Time are Associated Time is Muscle: Delays in Symptom to Door Time are Associated with Poorer Flow in the Muscle Independent of Flow in Arterywith Poorer Flow in the Muscle Independent of Flow in Artery
16% rise in risk of a closed muscle for every hour of delay in STEMI (p=0.0005) Gibson, JACC 2004
Normal LargeCapillary Lumen
Clinical Picture: Clinical Picture:
Open ArteryOpen Artery
Closed MuscleClosed Muscle
Blistering of CapillariesBlistering of Capillaries
& Endothelium& Endothelium
“Blistered” / Swollen Endothelium /wall of the capillary
Importance of Door-to-Balloon Time: Importance of Door-to-Balloon Time: 30-Day Mortality in the GUSTO-IIb Cohort30-Day Mortality in the GUSTO-IIb Cohort
Hypothetical Relationship Between Early Reperfusion, Hypothetical Relationship Between Early Reperfusion, Mortality Reduction, and Extent of Myocardial Salvage Mortality Reduction, and Extent of Myocardial Salvage
Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979-986.. 2005;293:979-986.
00
2020
4040
6060
8080
100100
1212 2424Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy
(hours)(hours)
Mor
talit
y Re
duct
ion,
(%
)M
orta
lity
Redu
ctio
n, (
%) Mortality Reduction (%)Mortality Reduction (%)
Extent of SalvageExtent of Salvage(% of area at risk)(% of area at risk)
Does a 90-Minute Door-to-Balloon Time Matter? Observations From Four Current Does a 90-Minute Door-to-Balloon Time Matter? Observations From Four Current Reperfusion TrialsReperfusion Trials
Time from Symptom Onset to TreatmentTime from Symptom Onset to TreatmentPredicts 1-year Mortality after Primary PCIPredicts 1-year Mortality after Primary PCI
De Luca et al, Circulation 2004
The relative risk of 1-year mortality increases by7.5% for each 30-minute delay
Time from Symptom Onset to Treatment Predicts One-year Mortality Time from Symptom Onset to Treatment Predicts One-year Mortality Among Patients with Occluded Epicardial ArteriesAmong Patients with Occluded Epicardial Arteries
The Advantage of PCI Compared with Fibrinolyisis Decreases as the PCI Related The Advantage of PCI Compared with Fibrinolyisis Decreases as the PCI Related Delay IncreasesDelay Increases
Pinto DS … Gibson CM, Circulation 2006Pinto DS … Gibson CM, Circulation 2006
0.8
1.25
1.5
Estimated Treatment Effect and 95% Confidence IntervalsConditional on PCI Related Delay (DB-DN)(min)
Pinto DS … Gibson CM. Circulation. 2006Pinto DS … Gibson CM. Circulation. 2006 *Betriu A. Am J Cardiol. 2005; 95:100-101.*Betriu A. Am J Cardiol. 2005; 95:100-101.
154 minMet goal without transfer: 99.8%Met goal with transfer: 100.0%(n=20,424 pts; n=271 hospitals)
121+ 50 minMet goal without transfer: 7.9%Met goal with transfer: 11.9% (n=5,296 pts; n=117 hospitals)
103 minMet goal without transfer: 89.1%
Met goal with transfer: 82.2%(n=16,119 pts; n=244 hospitals)
142 minMet goal without transfer: 98.1%
Met goal with transfer: 97.1%
(n=3,739 pts; n=91 hospitals)
183 minMet goal without transfer: 100.0%
Met goal with transfer: 100.0%(n=10,614 pts; n=191 hospitals)
Time At Which PCI Looses Superiority In Survival Over Time At Which PCI Looses Superiority In Survival Over Fibrinolysis Varies Depending Upon Patient Risk Fibrinolysis Varies Depending Upon Patient Risk
Pinto DS … Gibson CM, Circulation Pinto DS … Gibson CM, Circulation 20062006
NRMI 1: Includes patients where initial ECG was the method of MI diagnosis NRMI 2 and 3: Includes patients with ST on 1st 12-lead ECG results, where 1st 12-lead ECG date/time = 1st 12-lead ECG with ST and/or BBB date/time
National Trends in AMI Management:National Trends in AMI Management:Door to Balloon Time in PPTCADoor to Balloon Time in PPTCA
80
90
100
110
120
1994 1995 1996 1997 1998 1999
Med
ian
time,
min
utes NRMI 2 NRMI 3
116
108
Includes patients with ST on 1st 12-lead ECG results, where 1st 12-lead ECG date/time = 1st 12-lead ECG with ST and/or BBB date/time (non-transfer-in patients)