Strategie terapeutiche nell'infarto miocardico acuto. acuto. Rivascolarizzazione miocardica e terapia trombolitica: Rivascolarizzazione miocardica e terapia trombolitica:

scelte antitetiche o integrate?scelte antitetiche o integrate?

M T bMarco Tubaro

UTIC – Dipartimento CardiovascolareOspedale San Filippo Neri - Roma

mt

ParamedicParamedic--diagnosed STEMIdiagnosed STEMI

1.00

ality (%

)

P=0.017

e survival 0.95

0.90C t l

Paramedic‐referred primary PCI group(n=108)

morta

lumulative

0. 85

Control group(n=225)

n=2 n=20n=20

Cu

0.800 10 20 30

Days

MTLe May MR. Am J Cardiol 2006;98:1329–1333

BLITZ: hospital presentationBLITZ: hospital presentation

1959 pts, 65% STEMI n° pts             %

26 %26 %

time from onset of symptoms ‐ median 120 min (IQR 60‐300)to hospital arrival ‐ 48 % pts < 2 h

‐ 76 % pts < 6 h

MTDi Chiara A. Eur Heart J 2003

field vs. interhospital transferfield vs. interhospital transfer

MTLe May, N Engl J Med 2008

primary PCI vs fibrinolysis: equipoiseprimary PCI vs fibrinolysis: equipoise

Tarantini G. EHJ 2010

MT

primary PCI vs thrombolytic therapy-short term outcomes -

25

21

20

25 PTCA

Lysis

p<0.0001

1415

20

p<0.0001

cy (%

)

76 6.8

89

7 6.810

p=0.0002

p=0.0003 p<0.0001 p=0.032

Freq

uenc

5

2.5

6

12

0 05

5.3

1.1

5p=0.0004

p<0.0001

0.050

Death Death excludingshock

Non fatal MI

Recurrent ischaemia

Total CVA

Haem‐rrhagic CVA

Major bleeds

Death/ CVA/AMI

MT

shock

Keeley EC, et al. Lancet 2003;361:13–20

Danchin N. Circulation 2008

Danchin N. Circulation 2008

Local System of Care: The Vienna modelall cath labs active between 7.00 and 16:00 h

General HospitalGeneral Hospital

permanent availability of cath labs and teams during non-official catheter times

General HospitalGeneral HospitalUniversity of ViennaUniversity of ViennaMon - Fri (on call), Sa-Sun

VienneseHospital RudolfstiftungHospital Rudolfstiftung Hanusch HospitalHanusch Hospital

Viennese Ambulance Systemcall 144

Mon FriFri

call 144

Donau HospitalDonau Hospital

Tue

Wilhelminen HospitalWilhelminen Hospital

ThuThuTue

Hospital HietzingHospital HietzingHospital HietzingHospital Hietzing

WedWedCourtesy K. Huber

networking in Czech Republic

equitable access to careequitable access to care

PCI centers

community H(no cath lab)

networking in Czech Republic

1997-99 2005(no cath lab)

MT

STEMI in-hospital mortality

primary PCI in Europeprimary PCI in Europe

Widimski P, EHJ 2010

MT

NORDISTEMI: thrombolysis and immediate PCI in STEMINORDISTEMI: thrombolysis and immediate PCI in STEMI

MTBohmer, JACC 2009

f i th 58 4% 76 3 %

Bologna networkBologna network

• reperfusion therapy:  58.4%    76.3 %• in‐hospital mortality:  17.0%   12.3 %

Saia Heart 2009

MT

reti per lo STEMI reti per lo STEMI -- conclusioniconclusioni

chiara definizione delle aree di interesse

protocolli scalari a seconda della stratificazione del rischio

trasporti sicuri con ambulanze appropriatamente equipaggiate in termini

di macchinari e personale

stretta organizzazione di riduzione dei ritardi: < 10 min trasmissione ECG,

< 5 min teleconsulto, < 30 min D2N, < 30 min D2B (in ospedale)

lli di d li h b i li d li protocolli di trasporto pre-ospedaliero che bypassino gli ospedali senza

emodinamica h 24

b ss d l DEA d ll'UTIC i s di PCI i ibypass del DEA e dell UTIC in caso di PCI primaria

stretta cooperazione tra 118, cardiologi e centri ospedalieri

utilizzare la trombolisi pre ospedaliera ogniqualvolta sia indicatautilizzare la trombolisi pre-ospedaliera ogniqualvolta sia indicata

utilizzare tutte le strategie terapeutiche per migliorare l'esito della

PCI primaria

MT

PCI primaria

Rokos IC. Am Heart J 2006;152:55.

components of total delay in STEMI reperfusioncomponents of total delay in STEMI reperfusion

MTFox KAA, Nat Clin Pract CV Med 2008

REACT trial: rescue PCI in STEMIREACT trial: rescue PCI in STEMI

MTGershlick AH. N Engl J Med 2005;353:2758.

STEMI: routine early PCI after thrombolysisSTEMI: routine early PCI after thrombolysis

Halvorsen S, Thromb & Haemost 2011 MT

prepre--hospital ECG & SRC networkshospital ECG & SRC networks

MTRokos IC. JACC Intv 2009

PHPH--ECG and ED bypass in STEMIECG and ED bypass in STEMI

Baran, Circ CQO 2010 MT

bypass emergency roombypass emergency room

USIC 2000 Registry

direct admission to ICCU/cath lab

admission via ER

t t t d i i ( i ) 244 *** 292symptom onset to admission (min) 244 *** 292symptom onset to thrombolysis (min) 204 ** 258symptom onset to PCI (min) 292 ** 402symptom onset to PCI (min) 292 402mortality at 5 days (%) 4.9 * 8.6

admission via ER independently predicts mortality: OR 1.67 (1.01-2.75)

MTSteg PG, Heart 2006

high risk pts (DANAMI‐2)high risk pts (DANAMI‐2)

3 yrs mortality (%)

fibrinolysis primary PCI

low risk # 5.6 8.0

high risk § 36.2 25.3 *

3 yrs event rate¶ (%)

fibrinolysis primary PCI

low risk # 15.7 13.7

high risk § 45 9 32 3 *

# TIMI risk score 0-4; § TIMI risk score > 5¶ d th i f ti di bli t k

high risk § 45.9 32.3

MT

¶ death, reinfarction, disabling stroke

Thune JJ, Circulation 2005;112:2017

primary PCI in Europeprimary PCI in Europe

Widimski P, EHJ 2010

MT

time to treatment and mortalitytime to treatment and mortality-- Vienna STEMI Registry Vienna STEMI Registry --

MTKalla K, Circulation 2006;113:2398

longlong--term mortality in a regionalized STEMI system of careterm mortality in a regionalized STEMI system of careBologna

mortality

cardiac card ac mortality

MT

6 strategies significantly associated with a reduced D2B time

strategies to reduce D2B timestrategies to reduce D2B time6 strategies significantly associated with a reduced D2B time

1. cath lab activation by the EMS physician2. single call to a central page operator3 ED i h l b hil i i 3. ED activates cath lab while patient is en route4. cath lab staff arrival within 20 min from page5. attending cardiologists always on site6 l ti d t f db k t ED d th l b t ff6. real-time data feedback to ED and cath lab staff

Bradley EH, NEJM 2006

MT

FINESSE: facilitated PPCI in STEMIFINESSE: facilitated PPCI in STEMI

Ellis SG. N Engl J Med 2008

MT

back-up slidesback-up slides

SMALL COUNTRY, HIGHWAYS, ACCEPTABLE TRAFIC, HELICOPTER FOR REMOTE AREAS....

AustriaAustriaHungary

50 km

91 km

73 km

61 km

106km

78 km32 km

••Area 20.273 kmArea 20.273 km••Population 2 053 470Population 2 053 470115 km ••Population 2.053.470Population 2.053.470••PCI centers (5)PCI centers (5)

••--“24“24--7” (2)7” (2)••No “24No “24--7” (3)7” (3)

ItalyItaly

No 24No 24--7 (3)7 (3)••35003500--4000 PCI/year4000 PCI/year••1100 PPCI for STEMI1100 PPCI for STEMICroatiaCroatia

STEMI reperfusion treatment in EuropeSTEMI reperfusion treatment in Europe

Widimski P, EHJ 2010 MT

EMS use for STEMI in EuropeEMS use for STEMI in Europe

Widimski P, EHJ 2010

MT

emergency number emergency number

7878Mantova 1st period

4646

3737

2nd period

118 EMS

138138Territory 1st period

9191

66

2nd period

118 EMS

MTZanini R, Ital Heart J Suppl 2003

Milan STEMI networkMilan STEMI network

e (m

in)

tim

advanced advanced basic self-presentersb l b l b lambulance ambulance ambulance

+ ECG

Marzegalli M. G Ital Cardiol 2008

MT

prepre--hospital managementhospital management

MT

prepre--hospital emergency cardiac carehospital emergency cardiac care

MT

pre‐hospital triage

12 leads pre-hospital ECGmeta analysis

cardiogenic shockBologna Italy - meta-analysis - - Bologna, Italy -

MTBrainard AH, Am J Emerg Med 2005 Ortolani P, Eur Heart J 2006

EGYPT: early GPI in PEGYPT: early GPI in P--PCIPCI-- abciximab data abciximab data --

d l pre-procedural TIMI 3 flow

post procedural post-procedural TIMI 3 flow

ST segment resolution

late abcx better early abcx betterDe Luca, Heart 2008

MT

EUROTRANSFER: early abciximab in PEUROTRANSFER: early abciximab in P--PCIPCI-- European multicentre registry European multicentre registry --

Dudek D, Am Heart J 2008

MT

ONON--TIME 2: preTIME 2: pre--hospital tirofiban in PPCI in STEMIhospital tirofiban in PPCI in STEMI

ST resolution death – reMI – uTVR ‐ bailout tirofiban

van't Hof AWJ, Lancet 2008

MT

OnOn--TIMETIME--2: pre2: pre--hospital highhospital high--dose tirofiban and early stent thrombosisdose tirofiban and early stent thrombosis

Heestermans AACM, J Thromb Haemost 2009

MT

organizzazione per la PCI primaria in Europaorganizzazione per la PCI primaria in Europa

condizione strutturale ottimale:200-800 pPCI/centro/annop50-100 pPCI/operatore/anno0.3-1.1 milioni abitanti/centro pPCI

criticitàpersonale scarsoattitudine conservatrice dei cardiologi clinicimotivazione insufficiente dei cardiologi interventistimancanza di programmi di trainingmancanza di programmi di trainingmancanza di sostegno economico per i progetti di rete("pay for performance")

Widimski P, EHJ 2010

MT

ischaemic time and mortality in Pischaemic time and mortality in P--PCIPCI

MTDe Luca G. Circulation 2004

guidelines applied in practice (GAP) projectsguidelines applied in practice (GAP) projects

40

baseline

post‐GAP

35

30

p**

25

20ality

 (%)

20

15

10

morta

**

***

10

5

00

in hospital             30 days                1 year

Eagle KA. JACC 2005;46:1242)

MT

TRANSFERTRANSFER--AMI AMI

End-point Standard (%)

Pharmacoinvasive (%) p

Primary end point 16.6 10.6 0.0013Death 3.6 3.7 0.94R i f ti 6 0 3 3 0 044Reinfarction 6.0 3.3 0.044Recurrent ischemia 2.2 0.2 0.019Death/MI/ischemia 11 7 6 5 0 004Death/MI/ischemia 11.7 6.5 0.004New/worsening CHF 5.2 2.9 0.069Cardiogenic shock 2.6 4.5 0.11

Cantor WJ. ACC 2008 Scientic Sessions/i2 Summit-SCAI Annual Meeting; March 30, 2008; Chicago, IL.

p. miechowski51,5 tys.p. miechowski51,5 tys.

p. olkuski114,7 tys.

p. proszowicki43,6 tys. p. dąbrowski

58,6 tys.Kraków +            p. 

p. olkuski114,7 tys.

p. proszowicki43,6 tys.

Kraków +            p. p. dąbrowski58,6 tys.

p. chrzanowski128,7 tys.

a ó p.krakowski998,8 tys.

p. bocheński99,7 tys.

p. chrzanowski128,7 tys.

a ó p.krakowski998,8 tys.

p. bocheński99,7 tys.

558 5001 808 800

p. wadowicki153,4 tys.

p. oświęcimski153,1 tys.

p. brzeski89,7 tys.

Tarnów +            p. tarnowski310,5 tys.

p. wielicki102,5 tys.p. oświęcimski

153,1 tys.p. wielicki102,5 tys.

p. brzeski89,7 tys.

Tarnów +            p. tarnowski310,5 tys.

p. limanowski120,2 tys.

p. suski81,5 tys.

p. myślenicki114,9 tys.p. myślenicki114,9 tys.

p. limanowski120,2 tys.

506 000

p. nowotarski

, y

Nowy Sącz +         p. nowosądecki

p. gorlicki106,4 tys.

120,2 tys.

Nowy Sącz +         p. nowosądecki

p. gorlicki106,4 tys.

p. nowotarski179,9 tys. 279,4 tys.

p. tatrzański65,3 tys.

ą279,4 tys.261 400

FOURFOUR NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENTNETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENTFOURFOUR NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT OF ACUTE CORONARY SYNDROMESOF ACUTE CORONARY SYNDROMES

PPCI IN LJUBLJANA‐SLOVENIA

Also STEMI’s from remote 

•6709 STEMI“24‐7”call for 

areas

•4813 PPCIPPCI

20001990

Modified from Am J Cardiol 2008;101:162‐168

MT

Mayo Clinic STEMI protocolMayo Clinic STEMI protocol

MTTing HH, Circulation 2007

NRMI‐2: pre‐hospital ECG in AMINRMI‐2: pre‐hospital ECG in AMINRMI‐2: pre‐hospital ECG in AMI

PH‐ECG (n=3,786)

P<0.001 for both comparisons

No PH‐ECG (n=66,989)

Lytic Rx (n=26,559)Percentiles(25th, 75th)

20, 53

26, 54

ts

65 33

P<0.001 for both comparisons

Primary PCTA (n=4932)

% of p

atient

84, 64

65, 33%

Time (median, minutes)

Canto JG. J Am Coll Cardiol 1997;29:498–505

MT

barriers for networksbarriers for networks

lack of public awarenessp

different technological levels of emergency vehicles

mandate to deliver to the nearest hospital

inter-hospital transfer with the "next available" ambulance

ED diversion

need to restructure payments

MTJacobs AR, Circulation 2007

prepre--hospital triage in STEMI pts. with cardiogenic shockhospital triage in STEMI pts. with cardiogenic shock

MTOrtolani P. Am J Cardiol 2007

ECG & triageECG & triage

pre-hospital ED pp p psymptoms onset to balloon (median) (min) 154 249 < 0.001

k CK i l ( / ) 1435 2320 0 009peak CK in early presenters (U/L) 1435 2320 = 0.009mortality in PCI-treated pts (%) 1.1 8.2 =0.025overall mortality (%) 1 9 7 3 =0 046overall mortality (%) 1.9 7.3 =0.046

MTCarstensen S. Eur Heart J 2007

regional system of care: Mayo Clinic STEMI protocolregional system of care: Mayo Clinic STEMI protocol

D2B time < 90 min:- 75% pts group A- 12% pts group B

D2N time < 30 min:- 70% pts group Cp g p

MTTing HH, Circulation 2007

French nationwide surveys on STEMIFrench nationwide surveys on STEMI

MTDanchin N. Eur Heart J 2010

courtesy of P.Widimsky