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CARDIOLOGIA 1 AO CAREGGI - FIRENZE TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica)

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Presentazione sul tema: "CARDIOLOGIA 1 AO CAREGGI - FIRENZE TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica)"— Transcript della presentazione:

1 CARDIOLOGIA 1 AO CAREGGI - FIRENZE TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica) Nazario Carrabba Cardiologia 1 - Dipartimento del Cuore e dei Vasi, Azienda Ospedaliera - Universitaria di Careggi, Firenze Firenze, 15 Marzo 2008 EDUCATORIO del FULIGNO Difendiamo il cuore Campagna Educazionale Regionale ANMCO Toscana

2 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Primary PTCA vs Thrombolysis for AMI: Review of 23 Randomized Trials. Long- term Outcome PTCA n= 3872 Pz Death excluding Shock Non Fatal MI Recurrent Ischemia Thrombolysis n= 3867 Pz p= p= p< % Keeley EC, Lancet 2003; 361: Death, Non Fatal MI or Stroke p<

3 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 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 strategy However, which is the best modality of reperfusion treatment for patients admitted to community hospitals without invasive facilities is less clear The Transfer for Primary Angioplasty: The Evidences

4 CARDIOLOGIA 1 AO CAREGGI - FIRENZE The Importance of Time to Transfer The time delay for transferring patients to PCI centers could reduce or even nullify the potential benefit of reperfusion Gersh, B. J. et al. JAMA 2005;293:

5 CARDIOLOGIA 1 AO CAREGGI - FIRENZE ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial InfarctionExecutive Summary A 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, FAHA (Circulation. 2004;110: )

6 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 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) ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (Circulation. 2004;110: )

7 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 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: ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (5) risk-adjusted in-hospital mortality rate less than 7% in patients without cardiogenic shock. (4) actual performance of PCI in >85% of patients brought to the lab; (3) emergency CABG rate less than 2%; (2) TIMI 2/3 flow rates obtained in more than 90% of patients; (1) door-to-balloon times less than 90 minutes;

8 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Caso clinico numero 1 Nazario Carrabba, MD

9 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 1.Maschio, 59 anni 2.Fattori di rischio cardiovascolare: Fumatore, Ipercolesterolemia, Diabete 3.Riferisce da circa 5 ore dispnea e dolore toracico posteriore 4.Killip class: 1 Caratteristiche Cliniche del Paziente Nazario Carrabba, MD

10 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Primo ECG eseguito

11 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 1.Ricovero nellUTIC più vicina per eseguire fibrinolisi 2. 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) Iter Diagnostico-Terapeutico?

12 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Trasferimento per una PCI una scelta appropriata?

13 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Coronaria destra

14 CARDIOLOGIA 1 AO CAREGGI - FIRENZE ECG post-angioplastica primaria

15 CARDIOLOGIA 1 AO CAREGGI - FIRENZE The Florence Reperfusion Experience Spontaneous organization with Spoke centers

16 CARDIOLOGIA 1 AO CAREGGI - FIRENZE FLORENCE DISTRICT REGISTRY Location of the Participating Hospitals * Historic area Urban area Chianti area Mugello area N Florence District 2,205 Kmq residents 33 municipalities Careggi Hospital: 2 PCI centers 5 community hospitals Distance range: 5-33 Km NSGD 7 km/4 miles Careggi 2 PCI centers Mugello H 33 km/20 miles SMN 5 km/3 miles OSMA 12 km/7 miles Figline H 33 km/20 miles

17 CARDIOLOGIA 1 AO CAREGGI - FIRENZE No reperfusion treatment n=274 (36.7 %) Reperfusion treatment n=472 (63.3 %) 7.4% with thrombolysis (n°35 patients) 1.1% rescue PCI (n°5 patients) 91.5% with P- PCI (n°432 patients) 746 reperfusion treatment eligible patients (<12h) Use of Reperfusion Treatment: March 1, 2000 to February 28, 2001 Buiatti E. Eur Heart J. 2003;24:

18 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Underuse of Reperfusion Therapy in Registry Studies 60 % No Reperfusion Delay (h) Period NRMI-2 24 < MITRA-MIR 36.8 <12h FRENCH 34 <6h nov GRACE < 12h AMI-Florence 36.7 < 12h BLITZ 35 <6h oct. 01

19 CARDIOLOGIA 1 AO CAREGGI - FIRENZE AMI-Florence Registry In-hospital and 6-month Mortality In hospital6 months Reperfusion therapy No reperfusion therapy % P<.000

20 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Factors Influencing the use of Reperfusion by Multivariate Regression Analysis HR 95% CI Age (years) Previous CHF Previous MI Time delay>6 h Non anterior MI Killip >II Non-office hours Hospitals with P-PCI facilities 0361 Increased probabilityReduced probability 90.5

21 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Caso clinico numero 2 Nazario Carrabba, MD

22 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 1.Donna, 62 anni 2.Fattori di rischio cardiovascolare: Ipertensione arteriosa, ipercolesterolemia, 3.Riferisce da >12 ore fastidio epigastrico, 4.Killip class: 3 Caratteristiche Cliniche del Paziente Nazario Carrabba, MD

23 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Primo ECG eseguito

24 CARDIOLOGIA 1 AO CAREGGI - FIRENZE 1.Ricovero nellUTIC più vicina per eseguire fibrinolisi 2. 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) Iter Diagnostico-Terapeutico?

25 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Trasferimento per una PCI una scelta appropriata?

26 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Coronaria Destra

27 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Coronaria Sinistra

28 CARDIOLOGIA 1 AO CAREGGI - FIRENZE ECG post-angioplastica primaria

29 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Admitted to hospitals with PCI facilities n=351 (47%) 746 Patients Admitted to hospitals without PCI facilities n=395 (53%) On-site P-PCI n=286 (81.5%) Transf. for P-PCI n=146 (37%) Study Population Presented ESC-2006

30 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Time (months) On-site P-PCI Transf. P-PCI Kaplan-Meier Survival Curves by Hospital of Admission Log – rank test p = % 91.3% 89.7% Presented ESC-2006

31 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Kaplan Meyer survival curves after 3 years: comparison between on-site and after transferal primary PCI. log-rank test: p<0.20 Variables independently associated with the risk of death at 3 years. VariableHR 1 95%CIp value Age in years (continuous variable) <0.001 Killip class > 1 (reference: class 1) <0.001 Use of Glycoprotein IIb/IIIa inhibitors Paper submitted

32 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Transfer for Primary Angioplasty: Evidences Metanalysis 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:

33 CARDIOLOGIA 1 AO CAREGGI - FIRENZE BRAVE-2 Trial: Asymptomatic patients with STEMI and symptom onset > 12 h Invasive strategy Conservative strategy Final Infarct size % Schömig, A. et al. JAMA 2005;293: % 13%

34 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Schömig, A. et al. JAMA 2005;293: Should patients with STEMI and symptom onset > 12 h be treated with PCI?

35 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Practical Messages The 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.

36 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Indipendentemente dal tipo di rete interospedaliera che si viene a realizzare, deve essere perseguito lobiettivo di garantire il trattamento riperfusivo più rapido ed efficace al maggior numero possibile di pazienti. CONCLUSIONE

37 CARDIOLOGIA 1 AO CAREGGI - FIRENZE AHA Policy Recommendations AHA Consensus Statement Recommendation to Develop Strategies to Increase the Number of ST-Segment–Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention The American Heart Associations Acute Myocardial Infarction (AMI) Advisory Working Group Alice 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: )

38 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Guiding Principles 1. Patient-centered care as the No. 1 priority 2. High-quality care that is safe, effective, and timely 3. Stakeholder consensus on systems infrastructure 4. Increased operational efficiencies 5. Appropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality" 6. Measurable patient outcomes 7. An evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelines 8. A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health care 9. A reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines

39 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Guiding Principles 1. Patient-centered care as the No. 1 priority 2. High-quality care that is safe, effective, and timely 3. Stakeholder consensus on systems infrastructure 4. Increased operational efficiencies 5. Appropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality" 6. Measurable patient outcomes 7. An evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelines 8. A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health care 9. A reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines

40 CARDIOLOGIA 1 AO CAREGGI - FIRENZE Grazie


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