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Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa Versilia 7-8 ottobre 2011 Dal territorio alla preservazione della funzione.

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Presentazione sul tema: "Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa Versilia 7-8 ottobre 2011 Dal territorio alla preservazione della funzione."— Transcript della presentazione:

1 Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa Versilia 7-8 ottobre 2011 Dal territorio alla preservazione della funzione ventricolare

2

3 Importance of Prompt Treatment Prompt treatment increases the likelihood of survival for patients with myocardial infarction with ST-segment elevation (Berger et al., 1999; Cannon et al., 2000, McNamara et al., 2006). McNamara et al., JACC, 2006

4 Mortality and Doorn to Balloon Time Ting HH, et al. Circulation 2007;116:

5 Beyond a D2B of 90 minutes…. Every 15-min delay adds mortality (Nallamothu 2007 NEJM 357:1631)

6 2008 ESC STEMI GUIDELINES Key Messages remain unchanged: Early diagnosis Reperfusion therapy as soon as possible Optimal secondary prevention

7 (tempo decisionale) Ritardo extraospedaliero sanitario Ritardo extraospedaliero NON sanitario Ritardo intraospedaliero Ritardo Evitabile Campagne educazionali Percorsi extraospedalieri Percorsi intraospedalieri

8 Fonti di possibili ritardi tra comparsa sintomi e inizio terapia riperfusiva ProblemaSoluzione Ritardo del paziente: Tempo tra la comparsa sintomi e chiamata 118 Educazione del paziente Ritardo nel trasporto Strategia organizzativa 118 Ritardo inizio del trattamento Strategia organizzativa Inter-intraospedaliera

9 Strategia concordata:

10 Modello di Rete per lemergenza coronarica Favorire una diagnosi precoce, un trasporto rapido ed un ottimale trattamento riperfusivo a tutti i pazienti Obiettivi

11 Documento di consenso La rete interospedaliera per lemergenza coronarica IHJ Nov Vol.6/Suppl.6 FIC SICI SIMEU SIS 118 La realtà italiana: la Rete

12 E. H. Bradley, N Engl J. Med 13, 2006; Hospitals

13 32 Items 28 Key hospital strategies Six strategies associated with a faster door to balloon time

14 Door to Balloon Times: Achieving 90 Minutes and Less W. Douglas Weaver, MD President-Elect ACC November 2007

15 Strategies that Reduce Treatment Delays 1.ED physician activates the cath lab 2.Single call activates the cath lab 3.Cath lab team ready in minutes 4.Prompt data feedback for case review 5.Pre-hospital ECG to activate the cath lab while patient is en route 6.Having attending cardiologist always on site

16 D2B Alliance Goal Goal: To achieve a door-to-balloon time of 90 minutes for at least 75% of non-transfer primary PCI patients with STEMI

17 D2B Alliance Participants Over 900 hospitals currently participating Representing 45 states and 8 countries 15.6West 12.7Southwest 27.5Midwest 26.8Southeast 16.2Northeast %Region

18 Salvare il miocardio dei Pazienti con SCA ottimizzando tempi e modalità di soccorso ottimizzando tempi e modalità di soccorso e di intervento medico RITARDO EVITABILE In tutte le Regioni la Campagna ha coinvolto Cardiologi, 118, Medicina Urgenza, Assessorati e Agenzie CAMPAGNA RITARDO EVITABILE COORDINAMENTO F. Chiarella L. Oltrona Visconti A. Di Chiara La Campagna presentata in tutte le Regioni ha proposto una semplice scheda di automisurazione dei dati Disponibili i dati dei Centri che hanno accettato di centralizzare i dati

19 Obiettivo: Ottenere nel 75% dei pazienti: D2B entro 90 minuti D2N entro 30 minuti Un intervento mirato ai singoli Ospedali ed alla rete.

20 Liguria Valle d'Aosta Piemonte Veneto Bolzano Trento Toscana Lombardia Abruzzo FVG Emilia Romagna Lazio Basilicata Campania Puglia Umbria Sicilia Calabria Sardegna Marche Ascoli Piceno - Pesaro Avezzano - Pescara Teramo - Vasto Catanzaro - Cosenza Crotone - Vibo Valentia Andria – Bari - Gallipoli – Scorrano - Terlizzi Cagliari – Olbia Carbonia Siracusa – Ragusa Roma Centri N.6 AlbanoTerme Rieti Salerno Vallo della Lucania Nocera Inferiore Pozzuoli Lagonegro - Matera Policoro - Potenza Ivrea - Novara Torino Centri N.2 Moncalieri Genova Centri N. 2 Pietra Ligure - Sanremo Empoli - Grosseto – Lucca – Massa - Piombino - Pisa Rimini - Sassuolo Bolzano – Merano Rovereto - Trento Pordenone - Trieste – Udine – Gorizia - Tolmezzo - San Daniele - Palmanova Latisana - San Vito al Tagliamento Città di Castello - Foligno Gubbio - Perugia - Terni Milano Centri N. 4 - Treviglio – Lecco – Tradate - Pavia – Saronno - Varese - Lodi - Gravendona – Sondrio - Desenzano - Gallarate Treviso -Castelfranco Veneto - Mestre Cardiologie aderenti alla raccolta dati n = 78

21 Zona Apuane-Versilia

22 Zona Lunigiana

23 Triage diretto Paziente con IMA Unità PS I° LIV TELECONSULTO FTGM Ospedale del Cuore ECG normale o ST PS - UTIC IMA ST Protocollo Terapeutico Concordato SALA DI EMODINAMICA

24 MobiMed System HWS SERVER Hospital 1 La Trasmissione ECG Hospital 2

25

26 Matrix Network STEMI 1227 Pazienti

27 p< n= n= n= n= n=247 D 2 B (1227 Pz) Network STEMI Zona Apuane-Versilia

28 (34.9%) 80 (36.4%) 81 (40.0%) 89 (46.3%) 104 (72.3%) p< % pazienti con DtB 90 min (1227 Pz) Network STEMI Zona Apuane-Versilia

29 1227 pts DtB (minutes) EF% 72.3%

30 1227 pts Network STEMI Zona Apuane-Versilia

31 How Effective is the Hub?

32 Reperfusion Therapy: Primary PCI Preferred reperfusion treatment if performed by an experienced team as soon as possible after FMC I A RecommendationsClassLoE

33 Physician Volume and Hospital Volume and Mortality during Primary PCI Srinivas VS J Am Coll Cardiol 2009: 53:574-9

34 Physicians High Volume Low Volume (N=92) (N= 174) Odds Ratio (95% CI) Mortality 3.25% 4.9% 0.66 ( ) Physician Volume and Hospital Volume and Mortality during Primary PCI

35 Hospitals High Volume Low Volume (N=23) (N= 18) Odds Ratio (95% CI) Mortaliy 3.4% 5.4% 0.58 ( )

36 PCI for STEMI Less Safe, Effective When Performed Off-Hours Glaser R J Am Coll Cardiol Intv 2008;1:681-8 Off HoursRoutine Hoursp Device use Stent76%82.4%0.04 IVUS0.8%4.6%0.005 Thrombectomy1.9%6.3%0.007 Periprocedural Clopidogrel48.2%58.2% 0.01 Major Dissections10.3%5.2%0.2

37 PCI for STEMI Less Safe, Effective When Performed Off-Hours Glaser R J Am Coll Cardiol Intv 2008;1:681-8 Combined End Point: In HospitalDeath, MI, Target Vessel Revascularization: Off Hours: 16.2% p=0.002 Routine Hours 6.8%

38 Mechanical strategies to prevent distal embolization

39 P < Patients (%) Thrombus aspirationConventional PCI TAPAS Trial Primary endpoint: Myocardial Blush Grade Svilaas T, et al N Engl J Med 2008;358:557

40 TAPAS : 1,071 pts with STEMI undergoing PCI randomized to thrombus aspiration vs control Vlaar P et al. Lancet 2008; 371:1915

41 Cardiac Magnetic Resonance Imaging Results Thrombus aspiration during Primary Percutaneous Coronary Intervention: myocardial reperfusion and infarct size The EXPIRA (Thrombectomy With Export Catheter in Infarct-Related Artery During Primary Percutaneous Coronary Intervention) Prospective, Randomized Trial G Sardella, MD, M Mancone, MD, C Bucciarelli-Ducci, MD et al; JACC Vol. 53, No. 4, 2009

42 *p 0.05 vs. control patientsp 0.05 compared to 24 h In thrombus-aspiration patients, at each time point, ejection fraction was significantly better compared with control patients, and it further improved at 1 week and 6 months Thrombus Aspiration Reduces Microvascular Obstruction After Primary Coronary Intervention A Myocardial Contrast Echocardiography Substudy of the REMEDIA Trial L Galiuto, MD, PHD, B Garramone, MD, F Burzotta, MD, PHD et al, JACC Vol. 48, No. 7, 2006

43 Illusion of reperfusion In 1993, at the peak of the thrombolytic era, Lincoff and Topol wrote a provocative editorial wondering whether reperfusion was just an illusion. At that time, they estimated that only 25% or less of patients treated by thrombolysis had an optimal reperfusion. Lincoff AM, Topol EJ. Illusion of reperfusion. Does anyone achieve optimal reperfusion during acute myocardial infarction? Circulation 1993;88:1361–74.

44 The no-reflow phenomenon is the inability to reperfuse a portion of the myocardium after re-establishment of patency of previously occluded epicardial coronary artery The No-Reflow Phenomenon: Defining the Problem

45 The no-reflow phenomenon is the inability to reperfuse a portion of the myocardium after re-establishment of patency of previously occluded epicardial coronary artery The No-Reflow Phenomenon: Defining the Problem

46 Agents studied to reduce reperfusion injury Agent Mechanism proposed Trial FluosolNeutr.inhib., O 2 deliveryTAMI 9 Magnesium Membrane stabilisation ISIS4,MAGIC RheothRX O 2 deliveryCORE Trimetazidine H +, free radicals, neutr.EMIP-FR hSODPrevent free radicalsFlaherty CylexinInhib.p-selectin, neutr.CALYPSO AdenosineNeutr.inhib, vasodil, metab.AMISTAD I,II ANTI CD-18Neutr.inhib.HALT, LIMIT EniporideNa + /H + exchange inhib.ESCAMI

47 Agents studied to reduce reperfusion injury TrialN°Primary endpointResult TAMI 9 430Infarct size, EF (22 v.17%) ISIS4 58,05035 d. mortality (7.6 v. 7.2%) CORE pilot 114Infarct size (16 v.26%) CORE 2,607Death, shock, reMI (14 v. 26%) EMIP-FR 19,66535 d.mortality (12.2 v.12.3%) CALYPSO 153Infarct size (larger) AMISTAD I 236Infarct size (ant. 20 v.13%) AMISTAD II 2,11830-d.death, CHF (18 v. 16%) ISz + HALT MI 420Infarct size (no effect) LIMIT MI 413Patency, infarct size (no effect) ESCAMI 1389Infarct size (no effect)

48 Ormoni tiroidei ed IMA: evidenze cliniche Wiersinga WM et al. Thyroid hormones in acute myocardial infarction. Clin Endocrinol 1981; 14: Friberg L et al. Association between increased levels of reverse triiodothyronine and mortality after acute myocardial infarction. Am J Med. 2001; 111: Friberg L et al. Rapid down-regulation of thyroid hormones in acute myocardial infarction: is it cardioprotective in patients with angina? Arch Intern Med. 2002; 162:

49 Tiride e Cuore Nei pazienti con STEMI la riduzione dei livelli di fT3 durante la degenza correla con un peggiore recupero funzionale delle aree infartuali, come ben evidenziato dallo scarso recupero in termini di WMSI alla dimissione

50 Recommended Logistics Pre-hospital triage/care: – EMS unique telephone number tele-consultation – Ambulance 12-ECG recorder/defibrillator staff able to provide basic and advanced life support

51 Recommended Logistics Pre-hospital triage/care: – EMS unique telephone number tele-consultation – Ambulance 12-ECG recorder/defibrillator staff able to provide basic and advanced life support Networks: – implementation of a network of hospitals with different levels of technology connected by an efficient ambulance service using the same protocol Targets: – < 10 min ECG transmission – < 5 min tele-consultation – < 120 min to first balloon inflation – < 30 min start fibrinolytic therapy

52 Mille ragioni per vivere, Dom Helder Camara (Profeta del Terzo Mondo)

53 Sergio Berti Fondazione CNR-Reg. Toscana G. Monasterio Ospedale del Cuore, Massa Versilia 7-8 ottobre 2011 Dal territorio alla preservazione della funzione ventricolare


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