Presentazione sul tema: "(Dalle Linee Guida alla Realtà Clinica) Nazario Carrabba"— Transcript della presentazione:
1TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica)Nazario CarrabbaCardiologia 1 - Dipartimento del Cuore e dei Vasi,Azienda Ospedaliera - Universitaria di Careggi, FirenzeFirenze, 15 Marzo 2008EDUCATORIO del FULIGNO“Difendiamo il cuore”Campagna Educazionale Regionale ANMCO Toscana
2Primary PTCA vs Thrombolysis for AMI: Review of 23 Randomized Trials Primary PTCA vs Thrombolysis for AMI: Review of 23 Randomized Trials. Long- term Outcome%PTCA n= 3872 Pzp<Thrombolysis n= 3867 Pzp<p=p=p<Ormai è noto come la angioplastica primaria abbia mostrato la sua superiorità sulla fibrinolisi come confermato dalla celebre metaanalisi di 23 studi randomizzati.DeathDeathexcludingShockNon FatalMIRecurrentIschemiaDeath,Non FatalMI or StrokeKeeley EC, Lancet 2003; 361: 13-20
3The Transfer for Primary Angioplasty: The Evidences According to ESC guidelines (and AHA/ACC guidelines too) when primary angioplasty is available in a “timely fashion” and procedure can be performed by an “experienced” operator in a “large volume centre”, primary PCI should be considered the preferred reperfusion strategyHowever, which is the best modality of reperfusion treatment for patients admitted to community hospitals without invasive facilities is less clear
4The Importance of Time to Transfer The time delay for transferring patients to PCI centers could reduce or even nullify the potential benefit of reperfusionGersh, B. J. et al. JAMA 2005;293:
5ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)Writing Committee Members: Elliott M. Antman, MD, FACC, FAHA, Chair; Daniel T. Anbe, MD, FACC, FAHA; Paul Wayne Armstrong, MD, FACC, FAHA; Eric R. Bates, MD, FACC, FAHA; Lee A. Green, MD, MPH; Mary Hand, MSPH, RN, FAHA; Judith S. Hochman, MD, FACC, FAHA; Harlan M. Krumholz, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Gervasio A. Lamas, MD, FACC; Charles J. Mullany, MB, MS, FACC; Joseph P. Ornato, MD, FACC, FAHA; David L. Pearle, MD, FACC, FAHA; Michael A. Sloan, MD, FACC; Sidney C. Smith, Jr, MD, FACC, FAHATuttavia, dal 1990, la commissione di esperti delle 2 principali associazioni di cardiologi americani ha fornito periodicamente alla comunità scientifica delle rasserenanti raccomandazioni che tenessero di conto i numerosi progressi realizzati nel campo della diagnosi e del trattamento dell’IMA.Nel luglio 2004 sono state aggiornate le linee guida compilate nel 1999.(Circulation. 2004;110: )
6ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction Class I. If immediately available, primary PCI should be performed in patients with STEMI (including true posterior MI) or MI with new or presumably new LBBB who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed in a timely fashion (balloon inflation within 90 minutes of presentation) by persons skilled in the procedure (individuals who perform more than 75 PCI procedures per year). The procedure should be supported by experienced personnel in an appropriate laboratory environment (performs more than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and has cardiac surgery capability). (Level of Evidence: A)Per quanto riguarda le indicazioni all’angioplastica primaria,(Circulation. 2004;110: )
7ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction Strict performance criteria must be mandated for primary PCI programs so that long door-to-balloon times and performance by low- volume or poor-outcome operators/laboratories do not occur. Interventional cardiologists and centers should strive for outcomes to include:(1) door-to-balloon times less than 90 minutes;(2) TIMI 2/3 flow rates obtained in more than 90% of patients;(3) emergency CABG rate less than 2%;Le linee guida americane oltre alla quantità si preoccupano anche della qualità delle procedure dei singoli centri.Vengono quindi elencati criteri minimi da raggiungere. Tali criteri includono:Un tempo intercorso tra la presentazione e la riperfusione inferiore a 90’Un flusso epicardico TIMI 2-3 in almeno 90% dei pazienti.La necessità di intervento cardiochirurgico d’urgenza in meno del 2%Il realizzo effettivo della angioplastica in almeno l’85% dei pazientiUna mortalità intraospedaliera inferiore al 7%(4) actual performance of PCI in >85% of patients brought to the lab;(5) risk-adjusted in-hospital mortality rate less than 7% in patients without cardiogenic shock.
11Iter Diagnostico-Terapeutico? Ricovero nell’UTIC più vicina per eseguire fibrinolisi2. Fibrinolisi in ambulanza (pre-ospedaliera)3. PCI facilitata (trombolitici/inibitori IIb/IIIa prima del trasferimento per PCI - 2 ambulanze -)4. Trasferimento diretto in sala di emodinamica per una PCI (2-ambulanze)
12Trasferimento per una PCI una scelta appropriata?
15The Florence Reperfusion Experience Andando ad analizzare l’esperienza ormai decennale conseguita a Firenze……Spontaneous organization with Spoke centers
16FLORENCE DISTRICT REGISTRY Location of the Participating Hospitals AMI-FlorenceFlorence District2,205 Kmqresidents33 municipalitiesCareggi Hospital: 2 PCI centers5 community hospitalsDistance range: 5-33 KmNMugello H33 km/20 milesCareggi2 PCI centersOSMA12 km/7 milesNSGD7 km/4 miles*SMN5 km/3 milesHistoric areaUrban areaFigline H33 km/20 milesChianti areaMugello area
17Use of Reperfusion Treatment: AMI-FlorenceUse of Reperfusion Treatment:March 1, 2000 to February 28, 2001746 reperfusion treatment eligible patients (<12h)No reperfusion treatmentn=274 (36.7 %)Reperfusion treatmentn=472 (63.3 %)91.5% with P- PCI(n°432 patients)7.4% with thrombolysis(n°35 patients)1.1% rescue PCI(n°5 patients)Buiatti E. Eur Heart J. 2003;24:
18Underuse of Reperfusion Therapy in Registry Studies60%5040MITRA-MIR36.8<12h94-98No ReperfusionFRENCH34<6hnov. 95AMI-Florence36.7<12h00-01BLITZ35<6hoct. 0130GRACE<12h99-0130NRMI-224<694-962010Delay (h)Period
19AMI-Florence Registry In-hospital and 6-month Mortality 30P<.0002520P<.000%1514.924.4109.155.7In hospital6 monthsReperfusiontherapyNo reperfusiontherapy
20Factors Influencing the use of Reperfusion AMI-FlorenceFactors Influencing the use of Reperfusionby Multivariate Regression AnalysisHR % CIAge (years)Previous CHFPrevious MITime delay>6 hNon anterior MIKillip >IINon-office hoursHospitals with P-PCI facilities0.51369Reduced probabilityIncreased probability
24Iter Diagnostico-Terapeutico? Ricovero nell’UTIC più vicina per eseguire fibrinolisi2. Fibrinolisi in ambulanza (pre-ospedaliera)3. PCI facilitata (trombolitici/inibitori IIb/IIIa prima del trasferimento per PCI - 2 ambulanze -)4. Trasferimento diretto in sala di emodinamica per una PCI (2-ambulanze)
25Trasferimento per una PCI una scelta appropriata?
29Study Population 746 Patients AMI-FlorenceStudy Population746 PatientsAdmitted to hospitals with PCI facilitiesn=351 (47%)Admitted to hospitals without PCI facilities n=395 (53%)On-site P-PCIn=286 (81.5%)Transf. for P-PCIn=146 (37%)Presented ESC-2006
30Kaplan-Meier Survival Curves by Hospital of Admission AMI-FlorenceKaplan-Meier Survival Curvesby Hospital of Admission%10091.3%On-site P-PCI89.7%Transf. P-PCI755025Log – rank test p = 0.305246Time (months)Presented ESC-2006
31Kaplan Meyer survival curves after 3 years: comparison between on-site and after transferal primary PCI.AMI-Florencelog-rank test: p<0.20Variables independently associated with the risk of death at 3 years.VariableHR195%CIp valueAge in years (continuous variable)1.07<0.001Killip class > 1 (reference: class 1)3.20Use of Glycoprotein IIb/IIIa inhibitors0.570.024Paper submitted
32Angioplasty: Evidences Transfer for PrimaryAngioplasty: EvidencesMetanalysis considering five randomized Trials (n=2909) (+ CAPTIM, n=3750) showed a benefit of transfer for primary PCI compared to on-site fibrinolysis in term of combined endpoint (death, reinfarction, stroke)Dalby, M. et al. Circulation 2003;108:
33Asymptomatic patients with STEMI and symptom onset > 12 h BRAVE-2 Trial:Asymptomatic patients with STEMIand symptom onset > 12 h%13%Final Infarct size8%InvasivestrategyConservativestrategySchömig, A. et al. JAMA 2005;293:
34Should patients with STEMI and symptom onset > 12 h be treated with PCI? Schömig, A. et al. JAMA 2005;293:
35Practical MessagesThe policy of transferring STEMI patients with symptom onset <12 h initially admitted to community hospitals to centres which offer primary PCI seem feasible and safe, with the “useful window for transfer of 90 min”.For patients with STEMI and symptom onset 12 h (8-31% of all patients with STEMI), the transfer from community hospitals to PCI centres could represent a “missed opportunity”. However, more trials are needed to confirm this policy.
36CONCLUSIONEIndipendentemente dal tipo di “rete interospedaliera” che si viene a realizzare,deve essere perseguito l’obiettivo di garantire il trattamento riperfusivo più rapido ed efficace al “maggior numero possibile di pazienti”.
37AHA Consensus Statement Recommendation to Develop Strategies to Increase the Number of ST-Segment–Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary InterventionThe American Heart Association’s Acute Myocardial Infarction (AMI) Advisory Working GroupAlice K. Jacobs, MD, FAHA, Chair; Elliott M. Antman, MD, FAHA; Gray Ellrodt, MD; David P. Faxon, MD, FAHA; Tammy Gregory; George A. Mensah, MD, FAHA; Peter Moyer, MD; Joseph Ornato, MD, FAHA; Eric D. Peterson, MD, FAHA; Larry Sadwin; Sidney C. Smith, MD, FAHA(Circulation. 2006;113: )AHA Policy Recommendations
38Guiding Principles Patient-centered care as the No. 1 priority High-quality care that is safe, effective, and timelyStakeholder consensus on systems infrastructureIncreased operational efficienciesAppropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality"Measurable patient outcomesAn evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelinesA role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health careA reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines
39Guiding Principles Patient-centered care as the No. 1 priority High-quality care that is safe, effective, and timelyStakeholder consensus on systems infrastructureIncreased operational efficienciesAppropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality"Measurable patient outcomesAn evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelinesA role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health careA reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines