cardiologia 1 ao careggi - firenze trattamento in rete interospedaliera di un infarto miocardico...

CARDIOLOGIA 1AO CAREGGI - FIRENZE

TRATTAMENTO in RETE INTEROSPEDALIERA di un TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATOINFARTO MIOCARDICO ACUTO ST ELEVATO

(Dalle Linee Guida alla Realtà Clinica)(Dalle Linee Guida alla Realtà Clinica)

Nazario CarrabbaNazario Carrabba

Cardiologia 1 - Dipartimento del Cuore e dei Vasi, Cardiologia 1 - Dipartimento del Cuore e dei Vasi, Azienda Ospedaliera - Universitaria di Careggi, FirenzeAzienda Ospedaliera - Universitaria di Careggi, Firenze

Firenze, 15 Marzo 2008Firenze, 15 Marzo 2008EDUCATORIO del FULIGNOEDUCATORIO del FULIGNO

“Difendiamo il cuore”

Campagna Educazionale Regionale ANMCO Toscana


Primary PTCA vs Thrombolysis for AMI: Review of 23 Randomized Trials. Long- term Outcome

0

10

20

30

40

50

PTCA n= 3872 Pz

Death Death excluding

Shock

Non Fatal MI

Recurrent Ischemia

Thrombolysis n= 3867 Pz

p= 0.0019 p= 0.0053 p< 0.0001

p< 0.0001%

Keeley EC, Lancet 2003; 361: 13-20

Death, Non Fatal

MI or Stroke

p< 0.0001


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


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;293:979-986


ACC/AHA Guidelines for the Management of Patients With

ST-Elevation Myocardial Infarction—Executive 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;110:588-636.)


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;110:588-636.)


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;


Caso clinico numero 1

Nazario Carrabba, MD


• Maschio, 59 anni

• Fattori di rischio cardiovascolare: Fumatore, Ipercolesterolemia, Diabete

• Riferisce da circa 5 ore dispnea e dolore toracico posteriore

• Killip class: 1

Caratteristiche Cliniche del Paziente



Primo ECG eseguito


1. Ricovero nell’UTIC 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?


Trasferimento per una PCI una scelta appropriata?


Coronaria destra


ECG post-angioplastica primaria


The Florence Reperfusion Experience

Spontaneous organization with Spoke centers


FLORENCE DISTRICT REGISTRYLocation of the Participating Hospitals

*

Historic area

Urban area

Chianti area

Mugello area

NFlorence District

2,205 Kmq

798.000 residents

33 municipalities

Careggi Hospital: 2 PCI centers

5 community hospitals

Distance range: 5-33 Km

NSGD7 km/4 miles

Careggi2 PCI centers

Mugello H33 km/20 miles

SMN5 km/3 miles

OSMA12 km/7 miles

Figline H33 km/20 miles


No reperfusion treatmentn=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;24:1195-203


Underuse of Reperfusion Therapy in Registry Studies

60%

0

10

20

30

40

50

No

R

eper

fusi

on

Delay (h)

Period

NRMI-2

24

<6

94-96

MITRA-MIR

36.8

<12h

94-98

FRENCH

34

<6h

nov. 95

30

GRACE

<12h

99-01

AMI-Florence

36.7

<12h

00-01

BLITZ

35

<6h

oct. 01


AMI-Florence Registry In-hospital and 6-month Mortality

In hospital 6 months

Reperfusion therapy

No reperfusion therapy

0

5

10

15

20

25

30

%

5.79.1

14.9 24.4

P<.000

P<.000


Factors Influencing the use of Reperfusion by Multivariate Regression Analysis

HR 95% CI 0.97 0.96 - 0.99 0.26 0.11 - 0.65 0.55 0.33 - 0.93 0.91 0.84 - 0.99 0.32 0.21 - 0.50 0.44 0.24 - 0.83 0.59 0.39 - 0.88 7.8 5.1 - 11.8

Age (years)Previous CHFPrevious MITime delay>6 hNon anterior MIKillip >IINon-office hoursHospitals with P-PCI facilities

0 3 61

Increased probabilityReduced probability

90.5


Caso clinico numero 2



• Donna, 62 anni

• Fattori di rischio cardiovascolare: Ipertensione arteriosa, ipercolesterolemia,

• Riferisce da >12 ore fastidio epigastrico,

• Killip class: 3

Caratteristiche Cliniche del Paziente



Primo ECG eseguito


1. Ricovero nell’UTIC 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?


Trasferimento per una PCI una scelta appropriata?


Coronaria Destra


Coronaria Sinistra


ECG post-angioplastica primaria


Admitted to hospitals with PCI facilitiesn=351 (47%)

746 Patients

Admitted to hospitals without PCI facilities

n=395 (53%)

On-site P-PCIn=286 (81.5%)

Transf. for P-PCIn=146 (37%)

Study Population

Presented ESC-2006


Time (months)0 2 4 6

0

25

50

75

100On-site P-PCI

Transf. P-PCI

Kaplan-Meier Survival Curves by Hospital of Admission

Log – rank test p = 0.305

% 91.3%

89.7%

Presented ESC-2006


Kaplan Meyer survival curves after 3 years:

comparison between on-site and after transferal primary PCI.

0.00

0.25

0.50

0.75

1.00

surv

iva

l

0 10 20 30 40mounts of follow-up

primary PCI after transferral primary PCI on-site

log-rank test: p<0.20

Variables independently associated with the risk of death at 3 years. Variable HR1 95%CI p value

Age in years (continuous variable) 1.07 1.05-1.10 <0.001

Killip class > 1 (reference: class 1) 3.20 1.94-5.26 <0.001

Use of Glycoprotein IIb/IIIa inhibitors 0.57 0.35-0.93 0.024 Paper submitted


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;108:1809-1814


BRAVE-2 Trial: Asymptomatic patients with STEMI

and symptom onset > 12 h

0

2

4

6

8

10

12

14

16

Invasive strategy

Conservativestrategy

Fin

al I

nfa

rct s

ize

%

Schömig, A. et al. JAMA 2005;293:2865-2872

8%

13%


Schömig, A. et al. JAMA 2005;293:2865-2872

Should patients with STEMI and symptom onset > 12 h be treated with

PCI?


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.


Indipendentemente 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”.

CONCLUSIONE


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 Association’s 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;113:2152-2163)


Guiding Principles1. 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


Grazie

cardiologia 1 ao careggi - firenze trattamento in rete interospedaliera di un infarto miocardico...

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