lysis and beyond: esc guidelines and reality j n townend queen elizabeth hospital birmingham
TRANSCRIPT
Lysis and Beyond: ESC Guidelines and Reality
J N Townend
Queen Elizabeth Hospital Birmingham
NO CONFLICT OF INTEREST TO DECLARE
Lytic Therapy: Class I recommendation when PPCI cannot be performed within 2 hours (or 90 minutes)
NB must be <90 mins if present early with a large amount of viable myocardium
Lytic Therapy: Not Yet Redundant in the UK
Beyond Lysis: ESC Guidelines
• The pharmaco-invasive strategy:
– “Rescue PCI should be considered when there is evidence of failed fibrinolysis…or if there is uncertainty”Class IIa recommendation, level of evidence B
– “If it is likely that fibrinolysis was successful angiography is recommended… time window of 3-24 hours”Class IIa recommendation, level of evidence A
Rescue PCI: REACT
• Rescue PCI vs. repeat lytic
vs. conservative therapy
for failed reperfusion @ 90
mins
• N = 427
• Primary end point:– Death, re-MI, CVA,CHF
reduced by >50%
• Mortality reduced by 50%
Gershlick et al. NEJM 2005
How Often is Rescue PCI Required?
• CAPTIM (n=419) 26%• CARESS-in-AMI (n=300) 30%• TRANSFER AMI (n=522) 34%?
At least 1 in 4 cases
Trials demonstrating efficacy of routine early angiography and PCI after STEMI
Trial Date N
SIAM III 2003 197
GRACIA-1 2004 500
CAPITAL AMI 2005 170
CARESS-in -AMI 2008 600
TRANSFER-AMI
NORDISTEMI
2009
2009
1059
266
RR = 0.64, p=0.004
Death, re-MI, CHF, shock
Days from randomization
PCI Rate after Lytic Therapy
PCI rates in studies of routine post lytic
angiography/PCI after STEMI:
• GRACIA 1 80%
• CARESS 86%
• TRANSFER AMI 85%
• FAST MI registry 84%
According to treatment Propensity matched
Circulation 2008
How to Avoid Bleeding Associated with PCI Following Lytic Therapy
REALITY
Angiography and PCI rates following lytic therapy in 12297
cases in 2008 in England and Wales
• MINAP: data on STEMI cases from all acute hospitals in
England and Wales
• BCIS: data on (almost) all UK centres performing PCI
– Rescue PCI
– PCI within one month of lytic therapy
Rescue 14%
Protocol driven 20%
Not performed 32%
Angiography rate after STEMI = 62%
Reality according to MINAP: Angiography Rates in England and Wales
after Lytic Therapy in 2008
Symptom driven 21%
Post discharge 7% Unclear 4% Indication unclear 2%
N=12297
Interval: Admission to AngiographySTEMI admitted to Interventional Hospitals
Reality according to BCIS: PCI Rates after Lytic Therapy in 2008
Rescue = 18%
Recent lytic therapy 22%
The rest - No PCI(?) = 60%
England and Wales PCI rate early after STEMI was 40%
N=12297
In Conclusion
In England and Wales, rescue PCI performance is quite good (about 70% predicted)
The rest of post STEMI invasive angiographic / interventional care for lytic treated patients is too little and too late
Could do better
Admission to a non-PCI Centre After Lytic Therapy : Wrong Place, Wrong Time