iamsest en el 2019 ¿cuándo debemos intervenir? · •insuficiencia cardiaca con angina...

$: IAMSEST en el 2019 ¿Cuándo debemos intervenir? · •Insuficiencia cardiaca con angina refractaria o desvío del segmento ST. •Cambios dinámicos recurrentes del segmento ST u$
IAMSEST en el 2019¿Cuándo debemos intervenir?

LUIS ALBERTO URNA HERBAS, MD. MSc.

2019

Ciudad de Panamá, Panamá Santa Cruz, Bolivia

DECLARACIÓN DE CONFLICTOS DE INTERÉS

• Sin conflictos de interés.

[email protected][email protected] @LuisAlbertoUrna

GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013

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Gregory A. Roth et al. Circulation. 2015;132:1667-1678

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¿CUÁNDO DEBERÍAMOS INTERVENIR UN IAMSEST?

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¿En qué momentodeberíamos intervenir?


¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?

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Revista Argentina de Cardiología Vol. 82, Supl. 1, Octubre 2014Sociedade Brasileira de Cardiologia Vol 102, Nro. 3, Supl. 1, Marzo 2014Sociedade Brasileira de Cardiologia Vol 109, Nro. 1, Supl. 1, Julho 2017

2017: DIRETRIZ DA SBC E DA SBHCI SOBRE INTERVENÇÃO CORONÁRIA PERCUTÂNEA

2014: DIRETRIZ DA SBC SOBRE ANGINA INESTÁVEL E INFARTO AGUDO DO MIOCÁRDIO SEM SUPRADESNIVEL DO SEGMENTO ST

2014: CONSENSO PARA EL MANEJO DE PACIENTES CON SCA SIN SUPRADESNIVEL DEL SEGMENTO ST



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JACC Vol. 64, Nº 24, e139-228, December 23 2014European Heart Journal (2016) 37, 267-315European Heart Journal (2018) 00, 1-96

2018: ESC/EACTS GUIDELINES ON MYOCARDIAL REVASCULARIZATION

2015: GUIDELINES FOR THE MANAGEMENT OF ACS IN PATIENTS PRESENTING WITHOUT PERSISTENT ST-SEGMENT ELEVATION

2014: GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH NON-ST-ELEVATION ACUTE CORONARY SYNDROMES



• < 2 Horas: ESTRATEGIA INVASIVA INMEDIATA (I-C)

• Shock cardiogénico o inestabilidad hemodinámica.

• Angina recurrente o refractaria a tratamiento médico.

• Paro cardiaco o arritmias que amenacen la vida.

• Insuficiencia cardiaca con angina refractaria o desvío del segmento ST.

• Cambios dinámicos recurrentes del segmento ST u ondaT, principalmente con supradesnivel intermitente del segmento ST.

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European Heart Journal (2016) 37, 267-315



• < 24 Horas: ESTRATEGIA INVASIVA TEMPRANA (I-A)

• Incremento o descenso de la troponina.

• Cambios dinámicos del segmento ST u onda T, sean sintomáticos o silentes.

• GRACE Score >140 puntos.

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• < 72 Horas: ESTRATEGIA INVASIVA (I-A)

• Diabetes mellitus.

• Insuficiencia renal (eGFR <60 mL/min/1.73 m2).

• FEVI <40% o insuficiencia cardiaca aguda.

• APIAM.

• Angioplastia reciente.

• CRM previa.

• GRACE Score >109 puntos, y <140 puntos.

• Sintomas recurrentes o evidencia de isquemia.

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European Heart Journal (2016) 37, 267-315Neth Heart J (2017) 25:181–185



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J Nucl Cardiol. 2018 Jun;25(3):769-776


PREDICTORS OF IN-HOSPITAL MORTALITY IN PATIENTS ADMITTED WITH AMI IN A DEVELOPING COUNTRY

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Cardiol Res. 2018 Oct;9(5):293-299. doi: 10.14740/cr772w. Epub 2018 Oct 7

Multivariate predictors of mortality


IMPACT OF AN INVASIVE STRATEGY IN THE ELDERLY HOSPITALIZED WITH ACS WITH EMPHASIS ON THE NONAGENARIANS

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Catheter Cardiovasc Interv. 2018 Sep 30. doi: 10.1002/ccd.27877

Adjusted risk for in-hospital all-cause and cardiovascular mortality stratified by the revascularization strategy

DEATH CARDIOVASCULAR DEATH


PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014

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Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]

Temporal trends in utilisation of percutaneous coronary angioplasty



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Percentage of percutaneous coronary angioplasty in age groups



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Temporal trends of in-hospital mortality



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Temporal trends of 12-month mortality


INVASIVE TREATMENT OF NSTEMI PATIENTS IN GERMAN CHEST PAIN UNITS

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Int J Cardiol. 2018 Mar 15;255:15-19. doi: 10.1016/j.ijcard.2017.11.018

Kaplan-Meier survival curves for HIGHER (A) and LOWER (B) risk group


- Mortality.- Myocardial infarction.- Recurrent angina.

COMPARISON OF THE PREDICTIVE ROLES OF RISK SCORES OF IN-HOSPITAL MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH NSTEMI UNDERGOING PCI

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Med Princ Pract. 2018;27(5):459-465. doi: 10.1159/000489399. Epub 2018 Apr 19

Independent predictors of MACE: logistic regression analysis


KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE

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Am J Cardiol. 2018 Jun 1;121(11):1285-1292. doi: 10.1016/j.amjcard.2018.01.051. Epub 2018 Mar 1

Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI <2 vs. ≥ 2 hours after admission



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Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI 2 - 24 hours (< 24) vs. ≥ 24 hours after admission



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Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI 24 - 72 hours (< 72) vs. ≥ 72 hours after admission


PERCUTANEOUS CORONARY INTERVENTION VERSUS CONSERVATIVE TREATMENT FOR NSTEMI IN PATIENTS ABOVE 80 YEARS OF AGE

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Int J Cardiol. 2018 Sep 15;267:57-61. doi: 10.1016/j.ijcard.2018.05.078. Epub 2018 May 24

Age-adjusted Kaplan Meier Survival curves comparing survival functions of patients undergoing PCI vs conventional treatment

PCI

Conservative Treatment


EARLY VERSUS DELAYED PCI IN PATIENTS WITH NSTEACS

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Coron Artery Dis. 2016 Aug;27(5):344-9. doi: 10.1097/MCA.0000000000000374

Clinical outcomes at 30 days and 12 months in stable high risk patients who went for EARLY PCI (<24 hours) or DELAYED PCI (>24 hours)


EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT

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Heart Lung Circ. 2017 Nov;26(11):1142-1159. doi: 10.1016/j.hlc.2017.02.031. Epub 2017 Apr 11

Forest plot for recurrent myocardial infarction



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Forest plot for early mortality



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Forest plot for recurrent ischaemia


SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI

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Eur Heart J Qual Care Clin Outcomes. 2017 Jan 1;3(1):53-60. doi: 10.1093/ehjqcco/qcw044

One-day cut-off—Outcomes for All-cause death (A) and Myocardial infarction (B)

Delay PCI

Early PCI

Delay PCI

Early PCI


SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI

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Eur Heart J Qual Care Clin Outcomes. 2017 Jan 1;3(1):53-60. doi: 10.1093/ehjqcco/qcw044

Outcomes at 1 year in relation to delay of percutaneous coronary intervention procedure


REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI

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Circ Cardiovasc Qual Outcomes. 2016 May;9(3):197-205. doi: 10.1161/CIRCOUTCOMES.115.002084. Epub 2016 May 10.

Trends in use of PCI, CABG, and medical management in NSTEMI patients with diabetes mellitus and multivessel coronary artery disease. 2008 - 2014

PCI rate

CABG rate

No Intervention


REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI

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Circ Cardiovasc Qual Outcomes. 2016 May;9(3):197-205. doi: 10.1161/CIRCOUTCOMES.115.002084. Epub 2016 May 10.

Proportional use of different revascularization strategies across patient subgroups stratified by the angiographic severity of CAD. 2008 - 2014

P

C

I

P

C

I

P

C

I

P

C

I


CABG

No Intervention

SMILE: SINGLE-STAGED COMPARED WITH MULTI-STAGED PCI IN MULTIVESSEL NSTEMI PATIENTS

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J Am Coll Cardiol. 2016 Jan 26;67(3):264-72. doi: 10.1016/j.jacc.2015.10.082

1-Year Clinical Events According to Randomized Allocation


CONCLUSIONES

• ¿Cuándo deberíamos intervenir un IAMSEST?

• Siempre.

• ¿En qué momento deberíamos hacerlo?

• Dependerá de la estratificación de riesgo del paciente.

• Recordar que el IAMSEST es el infarto que se presenta con más frecuencia.

[email protected][email protected] @LuisAlbertoUrna

Ciudad de Panamá, Panamá Santa Cruz, Bolivia

Gracias…

iamsest en el 2019 ¿cuándo debemos intervenir? · •insuficiencia cardiaca con angina...

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