AARHUSUNIVERSITET

Når biomarkører bidragertil præhospital diagnostik

Christian Juhl Terkelsen,Overlæge, Dr.med., PhD,

Hjertesygdomme,Aarhus Universitetshospital.

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Aarhus University Hospital, Denmark

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STEMI NSTEMIOHCA

Bedre overlevelseOptimale patientforløb

Kortere indlæggelse / Undgå indlæggelseUndgå dobbeltundersøgelser

Mere sundhed for samme midler

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Kilde: En ”Helhjertet indsats”,

Hjerteforeningen

NSTEMI

STEMI

AARHUSUNIVERSITET

Kilde: En ”Helhjertet indsats”,

Hjerteforeningen

AARHUSUNIVERSITET

Overlevelse blandt patienter med præhospitalthjertestop for de enkelte regioner

Kilde: En ”Helhjertet indsats”,

Hjerteforeningen

AARHUSUNIVERSITET

STEMI NSTEMIOHCA

AARHUSUNIVERSITET

ESC guidelines

Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS) treatment strategy and timing according to initial risk stratification.2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

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KAG < 2 timer

KAG < 24 timer

KAG < 72 timer

ESC guidelines

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STEMI NSTEMIOHCAKan vi ikke bare diagnosticere dem iambulancen og køre direkte til center ?

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NONSTEMI-I

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Design:

500 patients, randomized,

open labelled, intention to treat,

prehospital/acute hospital randomization

Primary endpoint:

Composite of death, re-infarction and

readmission with congestive heart

failure within one year from

randomization

NONSTEMI trial

Either Point-of-care

Troponin-T ≥ 50 ng/L

orSignificant ST-

segment depression

Randomization

Acute

angiography

Conventional

therapy

Acute

chest pain

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Final diagnosis

Acute coronary syndrome 86.5%

NSTEMI 66.9%

STEMI 9.5%

STEMI visible at

inclusion7.7%

STEMI after inclusion 1.8%

BBB myocardial infarction 1.0%

Unstable angina pectoris 9.1%

Other 13.5%

NSTEMI

STEMI

BBBMI

Unstable AP

Other

0%

10%

90%

70%

80%

100%

60%

50%

40%

20%

30%

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99.7

90.6

51.1

1.3

47.8

1.0

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NONSTEMI-II

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NONSTEMI-2: Data from all-comers

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Cases in total 18,712

POC-cTnT ≥ 50 ng/L 2,150(11,5%)

POC-cTnT< 50 ng/L 16,562(88,5%)

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Prehospital POC-cTnT measurementsN = 18,712

POC-cTnT ≥ 50 ng/LN = 2,150

AMIN = 966

No AMIN = 1,184

POC-cTnT < 50 ng/LN = 16,562

AMIN = 1,221

No AMIN = 15,341

Diagnostic properties

POC-cTnT ≥ 50 ng/L

(N=2,150)

Sensitivity 44.2

Positive predictive value 44.9

POC-cTnT < 50 ng/L

(N=16,562)

Specificity 92.8

Negative predictive value 92.6

POC-cTnT measurements performed

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Mortality

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Mortality

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NONSTEMI-III

Routine use of “NONSTEMI”- algorithm: All suspected high-risk NST-ACS patients triaged for tertiary PCI capable center. Acute/subacute CAG.

Støttet af Hjerteforeningen

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24

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25

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Case – ”Gunnars”story

›61years old, active life

›AMI x 2 (last 2007), normal LVEF

28km

116km

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Case – ”Gunnars”story

28

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KAG

Før Efter

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Case – ”Gunnars”story

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NONSTEMI-III

Routine use of “NONSTEMI”- algorithm: All suspected high-risk NST-ACS patients triaged for tertiary PCI capable center. Acute/subacute CAG.

Aktuelt omvisiteres ca. 350 patienter med NSTEMI direkte til AarhusUniversitetshospital hvert år.

Sparer vi 700 indlæggelsesdage ?

Kan det kopieres til øvrige regioner ?

Støttet af Hjerteforeningen

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AROMI

Kan vi helt undgå indlæggelse ?

90% med brystsmerter jo ikke AMI !

Accelerated Rule Out of acute Myocardial Infarction

- using prehospital Copeptin and in-hospital hs-Troponin

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Biomarker kinetics in AMI:copeptin + troponin

• Copeptin rises early- covers blind period

• Copeptin is optimally bemeasured early – troponin late

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AROMI

Randomization

Standard rule-out:In-hospital hs-cTn at arrival

+ In-hospital hs-cTn at 3 hours

Suspected AMI

Accelerated rule-out:Pre-hospital copeptin

+ In-hospital hs-cTn at arrival

In both groups:- AMI is ruled out if both biomarkers are normal

- Further diagnostics, incl. hs-troponin in discretion of the attending physician

Design:RCT, N=4800 (ca. 4000 inkluderet)

Aim:To evaluate:

1. Length of stay2. MACE-rate.

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AROMI

Kan vi helt undgå indlæggelse ?

Hvis normal Copeptin + Troponin i ambulance ?

Accelerated Rule Out of acute Myocardial Infarction

- using prehospital Copeptin and in-hospital hs-Troponin

AARHUSUNIVERSITET

STEMI NSTEMIOHCA

Bedre overlevelseOptimale patientforløb

Kortere indlæggelseUndgå indlæggelse

Undgå dobbeltundersøgelserMere sundhed for samme midler