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Strategie terapeutiche nell'infarto miocardico acuto. acuto. Rivascolarizzazione miocardica e terapia trombolitica: Rivascolarizzazione miocardica e terapia trombolitica:
scelte antitetiche o integrate?scelte antitetiche o integrate?
M T bMarco Tubaro
UTIC – Dipartimento CardiovascolareOspedale San Filippo Neri - Roma
mt
ParamedicParamedic--diagnosed STEMIdiagnosed STEMI
1.00
ality (%
)
P=0.017
e survival 0.95
0.90C t l
Paramedic‐referred primary PCI group(n=108)
morta
lumulative
0. 85
Control group(n=225)
n=2 n=20n=20
Cu
0.800 10 20 30
Days
MTLe May MR. Am J Cardiol 2006;98:1329–1333
BLITZ: hospital presentationBLITZ: hospital presentation
1959 pts, 65% STEMI n° pts %
26 %26 %
time from onset of symptoms ‐ median 120 min (IQR 60‐300)to hospital arrival ‐ 48 % pts < 2 h
‐ 76 % pts < 6 h
MTDi Chiara A. Eur Heart J 2003
field vs. interhospital transferfield vs. interhospital transfer
MTLe May, N Engl J Med 2008
primary PCI vs fibrinolysis: equipoiseprimary PCI vs fibrinolysis: equipoise
Tarantini G. EHJ 2010
MT
primary PCI vs thrombolytic therapy-short term outcomes -
25
21
20
25 PTCA
Lysis
p<0.0001
1415
20
p<0.0001
cy (%
)
76 6.8
89
7 6.810
p=0.0002
p=0.0003 p<0.0001 p=0.032
Freq
uenc
5
2.5
6
12
0 05
5.3
1.1
5p=0.0004
p<0.0001
0.050
Death Death excludingshock
Non fatal MI
Recurrent ischaemia
Total CVA
Haem‐rrhagic CVA
Major bleeds
Death/ CVA/AMI
MT
shock
Keeley EC, et al. Lancet 2003;361:13–20
Danchin N. Circulation 2008
Danchin N. Circulation 2008
Local System of Care: The Vienna modelall cath labs active between 7.00 and 16:00 h
General HospitalGeneral Hospital
permanent availability of cath labs and teams during non-official catheter times
General HospitalGeneral HospitalUniversity of ViennaUniversity of ViennaMon - Fri (on call), Sa-Sun
VienneseHospital RudolfstiftungHospital Rudolfstiftung Hanusch HospitalHanusch Hospital
Viennese Ambulance Systemcall 144
Mon FriFri
call 144
Donau HospitalDonau Hospital
Tue
Wilhelminen HospitalWilhelminen Hospital
ThuThuTue
Hospital HietzingHospital HietzingHospital HietzingHospital Hietzing
WedWedCourtesy K. Huber
networking in Czech Republic
equitable access to careequitable access to care
PCI centers
community H(no cath lab)
networking in Czech Republic
1997-99 2005(no cath lab)
MT
STEMI in-hospital mortality
primary PCI in Europeprimary PCI in Europe
Widimski P, EHJ 2010
MT
NORDISTEMI: thrombolysis and immediate PCI in STEMINORDISTEMI: thrombolysis and immediate PCI in STEMI
MTBohmer, JACC 2009
f i th 58 4% 76 3 %
Bologna networkBologna network
• reperfusion therapy: 58.4% 76.3 %• in‐hospital mortality: 17.0% 12.3 %
Saia Heart 2009
MT
reti per lo STEMI reti per lo STEMI -- conclusioniconclusioni
chiara definizione delle aree di interesse
protocolli scalari a seconda della stratificazione del rischio
trasporti sicuri con ambulanze appropriatamente equipaggiate in termini
di macchinari e personale
stretta organizzazione di riduzione dei ritardi: < 10 min trasmissione ECG,
< 5 min teleconsulto, < 30 min D2N, < 30 min D2B (in ospedale)
lli di d li h b i li d li protocolli di trasporto pre-ospedaliero che bypassino gli ospedali senza
emodinamica h 24
b ss d l DEA d ll'UTIC i s di PCI i ibypass del DEA e dell UTIC in caso di PCI primaria
stretta cooperazione tra 118, cardiologi e centri ospedalieri
utilizzare la trombolisi pre ospedaliera ogniqualvolta sia indicatautilizzare la trombolisi pre-ospedaliera ogniqualvolta sia indicata
utilizzare tutte le strategie terapeutiche per migliorare l'esito della
PCI primaria
MT
PCI primaria
Rokos IC. Am Heart J 2006;152:55.
components of total delay in STEMI reperfusioncomponents of total delay in STEMI reperfusion
MTFox KAA, Nat Clin Pract CV Med 2008
REACT trial: rescue PCI in STEMIREACT trial: rescue PCI in STEMI
MTGershlick AH. N Engl J Med 2005;353:2758.
STEMI: routine early PCI after thrombolysisSTEMI: routine early PCI after thrombolysis
Halvorsen S, Thromb & Haemost 2011 MT
prepre--hospital ECG & SRC networkshospital ECG & SRC networks
MTRokos IC. JACC Intv 2009
PHPH--ECG and ED bypass in STEMIECG and ED bypass in STEMI
Baran, Circ CQO 2010 MT
bypass emergency roombypass emergency room
USIC 2000 Registry
direct admission to ICCU/cath lab
admission via ER
t t t d i i ( i ) 244 *** 292symptom onset to admission (min) 244 *** 292symptom onset to thrombolysis (min) 204 ** 258symptom onset to PCI (min) 292 ** 402symptom onset to PCI (min) 292 402mortality at 5 days (%) 4.9 * 8.6
admission via ER independently predicts mortality: OR 1.67 (1.01-2.75)
MTSteg PG, Heart 2006
high risk pts (DANAMI‐2)high risk pts (DANAMI‐2)
3 yrs mortality (%)
fibrinolysis primary PCI
low risk # 5.6 8.0
high risk § 36.2 25.3 *
3 yrs event rate¶ (%)
fibrinolysis primary PCI
low risk # 15.7 13.7
high risk § 45 9 32 3 *
# TIMI risk score 0-4; § TIMI risk score > 5¶ d th i f ti di bli t k
high risk § 45.9 32.3
MT
¶ death, reinfarction, disabling stroke
Thune JJ, Circulation 2005;112:2017
primary PCI in Europeprimary PCI in Europe
Widimski P, EHJ 2010
MT
time to treatment and mortalitytime to treatment and mortality-- Vienna STEMI Registry Vienna STEMI Registry --
MTKalla K, Circulation 2006;113:2398
longlong--term mortality in a regionalized STEMI system of careterm mortality in a regionalized STEMI system of careBologna
mortality
cardiac card ac mortality
MT
6 strategies significantly associated with a reduced D2B time
strategies to reduce D2B timestrategies to reduce D2B time6 strategies significantly associated with a reduced D2B time
1. cath lab activation by the EMS physician2. single call to a central page operator3 ED i h l b hil i i 3. ED activates cath lab while patient is en route4. cath lab staff arrival within 20 min from page5. attending cardiologists always on site6 l ti d t f db k t ED d th l b t ff6. real-time data feedback to ED and cath lab staff
Bradley EH, NEJM 2006
MT
FINESSE: facilitated PPCI in STEMIFINESSE: facilitated PPCI in STEMI
Ellis SG. N Engl J Med 2008
MT
back-up slidesback-up slides
SMALL COUNTRY, HIGHWAYS, ACCEPTABLE TRAFIC, HELICOPTER FOR REMOTE AREAS....
AustriaAustriaHungary
50 km
91 km
73 km
61 km
106km
78 km32 km
••Area 20.273 kmArea 20.273 km••Population 2 053 470Population 2 053 470115 km ••Population 2.053.470Population 2.053.470••PCI centers (5)PCI centers (5)
••--“24“24--7” (2)7” (2)••No “24No “24--7” (3)7” (3)
ItalyItaly
No 24No 24--7 (3)7 (3)••35003500--4000 PCI/year4000 PCI/year••1100 PPCI for STEMI1100 PPCI for STEMICroatiaCroatia
STEMI reperfusion treatment in EuropeSTEMI reperfusion treatment in Europe
Widimski P, EHJ 2010 MT
EMS use for STEMI in EuropeEMS use for STEMI in Europe
Widimski P, EHJ 2010
MT
emergency number emergency number
7878Mantova 1st period
4646
3737
2nd period
118 EMS
138138Territory 1st period
9191
66
2nd period
118 EMS
MTZanini R, Ital Heart J Suppl 2003
Milan STEMI networkMilan STEMI network
e (m
in)
tim
advanced advanced basic self-presentersb l b l b lambulance ambulance ambulance
+ ECG
Marzegalli M. G Ital Cardiol 2008
MT
prepre--hospital managementhospital management
MT
prepre--hospital emergency cardiac carehospital emergency cardiac care
MT
pre‐hospital triage
12 leads pre-hospital ECGmeta analysis
cardiogenic shockBologna Italy - meta-analysis - - Bologna, Italy -
MTBrainard AH, Am J Emerg Med 2005 Ortolani P, Eur Heart J 2006
EGYPT: early GPI in PEGYPT: early GPI in P--PCIPCI-- abciximab data abciximab data --
d l pre-procedural TIMI 3 flow
post procedural post-procedural TIMI 3 flow
ST segment resolution
late abcx better early abcx betterDe Luca, Heart 2008
MT
EUROTRANSFER: early abciximab in PEUROTRANSFER: early abciximab in P--PCIPCI-- European multicentre registry European multicentre registry --
Dudek D, Am Heart J 2008
MT
ONON--TIME 2: preTIME 2: pre--hospital tirofiban in PPCI in STEMIhospital tirofiban in PPCI in STEMI
ST resolution death – reMI – uTVR ‐ bailout tirofiban
van't Hof AWJ, Lancet 2008
MT
OnOn--TIMETIME--2: pre2: pre--hospital highhospital high--dose tirofiban and early stent thrombosisdose tirofiban and early stent thrombosis
Heestermans AACM, J Thromb Haemost 2009
MT
organizzazione per la PCI primaria in Europaorganizzazione per la PCI primaria in Europa
condizione strutturale ottimale:200-800 pPCI/centro/annop50-100 pPCI/operatore/anno0.3-1.1 milioni abitanti/centro pPCI
criticitàpersonale scarsoattitudine conservatrice dei cardiologi clinicimotivazione insufficiente dei cardiologi interventistimancanza di programmi di trainingmancanza di programmi di trainingmancanza di sostegno economico per i progetti di rete("pay for performance")
Widimski P, EHJ 2010
MT
ischaemic time and mortality in Pischaemic time and mortality in P--PCIPCI
MTDe Luca G. Circulation 2004
guidelines applied in practice (GAP) projectsguidelines applied in practice (GAP) projects
40
baseline
post‐GAP
35
30
p**
25
20ality
(%)
20
15
10
morta
**
***
10
5
00
in hospital 30 days 1 year
Eagle KA. JACC 2005;46:1242)
MT
TRANSFERTRANSFER--AMI AMI
End-point Standard (%)
Pharmacoinvasive (%) p
Primary end point 16.6 10.6 0.0013Death 3.6 3.7 0.94R i f ti 6 0 3 3 0 044Reinfarction 6.0 3.3 0.044Recurrent ischemia 2.2 0.2 0.019Death/MI/ischemia 11 7 6 5 0 004Death/MI/ischemia 11.7 6.5 0.004New/worsening CHF 5.2 2.9 0.069Cardiogenic shock 2.6 4.5 0.11
Cantor WJ. ACC 2008 Scientic Sessions/i2 Summit-SCAI Annual Meeting; March 30, 2008; Chicago, IL.
p. miechowski51,5 tys.p. miechowski51,5 tys.
p. olkuski114,7 tys.
p. proszowicki43,6 tys. p. dąbrowski
58,6 tys.Kraków + p.
p. olkuski114,7 tys.
p. proszowicki43,6 tys.
Kraków + p. p. dąbrowski58,6 tys.
p. chrzanowski128,7 tys.
a ó p.krakowski998,8 tys.
p. bocheński99,7 tys.
p. chrzanowski128,7 tys.
a ó p.krakowski998,8 tys.
p. bocheński99,7 tys.
558 5001 808 800
p. wadowicki153,4 tys.
p. oświęcimski153,1 tys.
p. brzeski89,7 tys.
Tarnów + p. tarnowski310,5 tys.
p. wielicki102,5 tys.p. oświęcimski
153,1 tys.p. wielicki102,5 tys.
p. brzeski89,7 tys.
Tarnów + p. tarnowski310,5 tys.
p. limanowski120,2 tys.
p. suski81,5 tys.
p. myślenicki114,9 tys.p. myślenicki114,9 tys.
p. limanowski120,2 tys.
506 000
p. nowotarski
, y
Nowy Sącz + p. nowosądecki
p. gorlicki106,4 tys.
120,2 tys.
Nowy Sącz + p. nowosądecki
p. gorlicki106,4 tys.
p. nowotarski179,9 tys. 279,4 tys.
p. tatrzański65,3 tys.
ą279,4 tys.261 400
FOURFOUR NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENTNETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENTFOURFOUR NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT OF ACUTE CORONARY SYNDROMESOF ACUTE CORONARY SYNDROMES
PPCI IN LJUBLJANA‐SLOVENIA
Also STEMI’s from remote
•6709 STEMI“24‐7”call for
areas
•4813 PPCIPPCI
20001990
Modified from Am J Cardiol 2008;101:162‐168
MT
Mayo Clinic STEMI protocolMayo Clinic STEMI protocol
MTTing HH, Circulation 2007
NRMI‐2: pre‐hospital ECG in AMINRMI‐2: pre‐hospital ECG in AMINRMI‐2: pre‐hospital ECG in AMI
PH‐ECG (n=3,786)
P<0.001 for both comparisons
No PH‐ECG (n=66,989)
Lytic Rx (n=26,559)Percentiles(25th, 75th)
20, 53
26, 54
ts
65 33
P<0.001 for both comparisons
Primary PCTA (n=4932)
% of p
atient
84, 64
65, 33%
Time (median, minutes)
Canto JG. J Am Coll Cardiol 1997;29:498–505
MT
barriers for networksbarriers for networks
lack of public awarenessp
different technological levels of emergency vehicles
mandate to deliver to the nearest hospital
inter-hospital transfer with the "next available" ambulance
ED diversion
need to restructure payments
MTJacobs AR, Circulation 2007
prepre--hospital triage in STEMI pts. with cardiogenic shockhospital triage in STEMI pts. with cardiogenic shock
MTOrtolani P. Am J Cardiol 2007
ECG & triageECG & triage
pre-hospital ED pp p psymptoms onset to balloon (median) (min) 154 249 < 0.001
k CK i l ( / ) 1435 2320 0 009peak CK in early presenters (U/L) 1435 2320 = 0.009mortality in PCI-treated pts (%) 1.1 8.2 =0.025overall mortality (%) 1 9 7 3 =0 046overall mortality (%) 1.9 7.3 =0.046
MTCarstensen S. Eur Heart J 2007
regional system of care: Mayo Clinic STEMI protocolregional system of care: Mayo Clinic STEMI protocol
D2B time < 90 min:- 75% pts group A- 12% pts group B
D2N time < 30 min:- 70% pts group Cp g p
MTTing HH, Circulation 2007
French nationwide surveys on STEMIFrench nationwide surveys on STEMI
MTDanchin N. Eur Heart J 2010
courtesy of P.Widimsky
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