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Management dell’Infarto Miocardico Acuto a presentazione “sopralivellamento del tratto ST” STEMI Linee Guida ESC 2012.

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Presentazione sul tema: "Management dell’Infarto Miocardico Acuto a presentazione “sopralivellamento del tratto ST” STEMI Linee Guida ESC 2012."— Transcript della presentazione:

1 Management dell’Infarto Miocardico Acuto a presentazione “sopralivellamento del tratto ST” STEMI Linee Guida ESC 2012

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12 Time to Reperfusion and Outcome % Extent of salvage (% of area at risk) Mortality reduction (%) D A-B – no benefit Potential outcomes A-C – benefit D-C – harm C B A B-C – benefit ? Gersh JAMA 2005 Time to treatment is critical Opening the IRA PPCI>lysis

13 13 Tcheng J Am Coll Cardiol 48:1336, 2006

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19 System delay

20 Patient Delay

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22 Protocollo condiviso Monitoraggio continuo Direttamente in sala emodinamica Bypass DEA

23 FMC Diagnosi Ecg teletrasmesso Cardiologo UTIC Emodinamista reperibile & staff : infermiere/TRS 1 accesso diretto sala Accesso diretto sala per 1PTCA Percorso+ attivazione sala Trasporto monitoraggio Ritardo di sistema Percoso STEMI pistoia

24 STEMI ENTRO 12 ORE ANNO 2012 N.TOTALE PAZIENTI POST-TL RESCUE PCI PRIMARIA 64 37% 26 15% 83 48% DIRETTA AL CL TRASFERITA DA SPOKE AMMESSA AD HUB 173

25 N. PAZIENTI 173 – MEDIANA D2B: 90 MINUTI D2B TOTALE PAZIENTI N. 173 MINUTI PAZIENTI

26 N. PAZIENTI 64 – MEDIANA D2B: 84 MINUTI D2B AMMISSIONE DIRETTA 118

27 N. PAZIENTI 47 – MEDIANA D2B: 90 MINUTIN. PAZIENTI 47 – MEDIANA D2B: 90 MINUTI D2B AMMISSIONE PS PO PISTOIA

28 N. PAZIENTI 45 – MEDIANA D2B: 100 MINUTIN. PAZIENTI 45 – MEDIANA D2B: 100 MINUTI D2B AMMISSIONE PS PO PESCIA MINUTI

29 N. PAZIENTI 26 – MEDIANA D2B: 125 MINUTI PCI di trasferimento tra PO MINUTI PAZIENTI

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36 36 Motality benefit of primary PCI declines with “PCI-related time delay” Favors PCI Favors fibrinolysis with a fibrin-specific agent 13 RCTs N = 5494 P = 0.04 Absolute Risk Difference in Death (%) PCI-Related Time Delay (minutes) 10 − 5 − 0 − -5 − ┬ ┬ ┬┬ ┬ ┬ Nallamothu and Bates. Am J Cardiol 2003;92:824. Mortality equipose: 60 min

37 F. Van de Werf, ACC 2013

38 Large contemporary international registries continue to demonstrate persisting delays to primary PCI in STEMI patients first presenting to EMS or non-cath capable hospitals Subsequent transfer for primary PCI commonly results in reperfusion times exceeding current guideline recommendations These delays are associated with commensurate increases in morbidity and mortality BACKGROUND

39 F. Van de Werf, ACC 2013 A strategy of early fibrinolysis followed by coronary angiography within 6-24 hours or rescue PCI if needed was compared with standard primary PCI in STEMI patients with at least 2 mm ST-elevation in 2 contiguous leads presenting within 3 hours of symptom onset and unable to undergo primary PCI within 1 hour. STUDY AIM

40 F. Van de Werf, ACC 2013 no lytic STUDY PROTOCOL RANDOMIZATION 1:1 by IVRS, OPEN LABEL Ambulance/ER Primary endpoint: composite of all cause death or shock or CHF or reinfarction up to day 30 ECG at 90 min: ST resolution ≥ 50% Standard primary PCI Aspirin Clopidogrel: LD 300 mg + 75 mg QD Enoxaparin: 30 mg IV + 1 mg/kg SC Q12h Aspirin Clopidogrel: LD 300 mg + 75 mg QD Enoxaparin: 30 mg IV + 1 mg/kg SC Q12h Antiplatelet and antithrombin treatment according to local standards Antiplatelet and antithrombin treatment according to local standards angio >6 to 24 hrs PCI/CABG if indicated angio >6 to 24 hrs PCI/CABG if indicated immediate angio + rescue PCI if indicated YE S NONO Strategy A: pharmaco-invasive Strategy B: primary PCI Aspirin Clopidogrel: 75 mg QD Enoxaparin: 0.75 mg/kg SC Q12h Aspirin Clopidogrel: 75 mg QD Enoxaparin: 0.75 mg/kg SC Q12h PCI Hospital STEMI <3 hrs from onset symptoms, PPCI <60 min not possible, 2 mm ST-elevation in 2 leads ≥75y: ½ dose TNK <75y:full dose After 20% of the planned recruitment, the TNK dose was reduced by 50% among patients ≥75 years of age.

41 F. Van de Werf, ACC Sx onset 1st Medical contact 61 1 Hour 2 Hours n= Randomize IVRS 9 Rx TNK 3186 Sx onset Rx PPCI 100 min 178 min MEDIAN TIMES TO TREATMENT (min) 1st Medical contact 78 min difference Randomize IVRS

42 F. Van de Werf, ACC Sx onset 61 1 Hour 2 Hours 299 Rx TNK 3186 Sx onset Rx PPCI 100 min 178 min MEDIAN TIMES TO TREATMENT (min) 36% Rescue PCI at 2.2h n= % non-urgent cath at 17h 1st Medical contact Randomize IVRS 1st Medical contact Randomize IVRS

43 F. Van de Werf, ACC 2013 PRIMARY ENDPOINT TNK 12.4% PPCI 14.3% TNK vs PPCI Relative Risk 0.86, 95%CI ( ) p=0.24 Dth/Shock/CHF/ReMI (%) The 95% CI of the observed incidence in the pharmaco-invasive arm would exclude a 9% relative excess compared with PPCI

44 F. Van de Werf, ACC 2013 STROKE RATES

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48 Bleeding Risk Subgroups Therapeutic Considerations Significant Net Clinical Benefit with Prasugrel 80% MD 10 mg Reduced MD Guided by PK Age > 75 or Wt < 60 kg 16% Avoid Prasugrel Prior CVA/TIA 4%

49 HR 0.82 P=0.01 HR 0.80 P= Days Primary Endpoint (%) Prasugrel Clopidogrel Prasugrel Clopidogrel Loading DoseMaintenance Dose Timing of Benefit (Landmark Analysis)

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51 Time-related Kaplan–Meier estimates of the time to first occurrence of the primary end point (incidence of MI, stroke, or vascular death; HR, 0.87; 95% CI, 0.75 to 1.01; P=0.07) PLATO - STEMI substudy - Outcomes Steg P.G., et al. Circulation 2010;122:

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