From interventional cardiology to cardio-neurology. A new subspeciality

Transcription

1 From interventional cardiology to cardio-neurology. A new subspeciality in the future? Prof. Andrejs Erglis, MD, PhD Pauls Stradins Clinical University Hospital University of Latvia Riga, LATVIA

2 Disclosure Speaker name: ANDREJS ERGLIS I have the following potential conflicts of interest to report: Consulting (Abbott Vascular, Biosensors, Biotronik, Bostons Scientific) Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest

3 Causes of death in Europe Deaths by cause, males, latest available year, Europe Deaths by cause, females, latest available year, Europe European Cardiovascular Disease Statistics

4 History of STEMI and ischemic stroke treatment Catanese L et al. Circ Res Feb 3;120(3): EVT, endovascular therapy TNK, tenecteplase; TPA, tissue-type plasminogen activator; STK, streptokinase

5 Death Death, excl. SHOCK data Non-fatal MI Recurrent ischemia Stroke Haemorrhagic stroke Major bleed Death, non-fatal MI, or stroke Primary angioplasty vs thrombolytic therapy in STEMI: review of 23 RCT 23 trials, 7739 patients with STEMI randomised to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. % Short-term outcomes: Events after 4-6 weeks after thrombolysis or PCI P= P= P< P< P= ,05 1 N=7739 P< P= P< PCI Thrombolysis Keeley EC et al. Lancet Jan 4;361(9351):13-20.

6 Interventional cardiology in Latvia 1990: PTCA 2 PCI centres with 24/7 service (1 per million) 2 PCI centres without 24/7 service 1 only angio centre 1996: BMS 2002: DES 2012: BVS Total population: 1.97 million (in 2016) Total area: km 2

7 Hospitals Providing Care to ACS Patients in Latvia

8 Network of emergency services

9 Patients (%) STEMI treatment in Latvia 2015: 565 PCI per million PPCI Rescue PCI Total PCI Fibrinolysis No reperfusion

10 STEMI - in-hospital mortality Overall in-hospital mortality (%) In-hospital mortality accoring to treatment strategy (%) TL PPCI No reperfusion

11 Patients(n) Latvian registry of ACS: Annual incidence of ACS STEMI 47% NSTEMI/ UA 53% ACS NSTEMI/UA STEMI

12 Meta-analysis: Endovascular treatment vs. i.v. thrombolysis alone for ischaemic stroke 8 RCT and 2423 participants Non-stent retriever systems: 3 studies (IMS III, MR RESCUE, SYNTHESIS Expansion) EVT: intra-arterial fibrinolysis or first-generation mechanical embolectomy devices, alone or in combination vs. intravenous t-pa Stent retriever systems: 5 studies (EXTEND-IA, MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME) EVT: stent retrievable systems, with some studies permitting the use of salvage intra-arterial fibrinolytic drugs (i.e., MR CLEAN, ESCAPE, SWIFT PRIME), while other studies did not allow this use (EXTEND-IA, REVASCAT). vs. intravenous t-pa Ferrante G et al. EuroIntervention Jun 12;12(2):e

13 Meta-analysis: Endovascular treatment vs. i.v. thrombolysis alone for ischaemic stroke Eight RCT enrolling 2,423 participants were included. Ferrante G et al. EuroIntervention Jun 12;12(2):e

14 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

15 Impact of Onset-to-Reperfusion Time on Stroke Mortality In a collaborative pooled analysis of 7 endovascular databases (480 cases), the impact of onset- to-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes was analyzed. Successful reperfusion was defined as complete or partial restoration of blood ow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modi ed Rankin Scale score, 0 2), 90-day excellent outcome (modi ed Rankin Scale score, 0 1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. Mazighi M et al. Circulation May 14;127(19):

16 Higher volume faster times better outcomes Retrospective analysis of 442 consecutive patients treated with endovascular therapy at 9 tertiary stroke centers (USA) from September 2009 to July High volume centers = performing more than 50 endovascular intra-arterial stroke interventions annually. Good clinical outcome: a modified Rankin score of 2 between 90 and 120 days were. considered to have a good clinical outcome. Gupta R et al. J Neurointerv Surg Jul;5(4):294-7.

17 Neuro-cardiology or cardio-neurology Stroke prevention: Cardiologists should broadly cooperate with neurologists in stroke prevention (both primary and secondary) due to the fact that most strokes occur as a complication of another cardiovascular disease (e.g., atrial fibrillation, hypertension, endocarditis, intracardiac shunts, etc.). STROKECLOSE a Nordic randomized clinical trial Prevention of STROKE by Left Atrial Appendage CLOSurE in Atrial Fibrillation Patients after Intracerebral Hemorrhage - A Multicenter Randomized Clinical Trial Endovascular treatment in acute ischemic stroke: associated with improved reperfusion, early neurologic recovery and functional outcomes, but unfortunately there are not enough neurovascular interventionists and limited 24/7 acute stroke centers in many countries. Multidisciplinary approach: Endovascular treatment could be performed with the close cooperation of cardiologists, neurologists and radiologists Interventional cardiologists already have experience with carotid interventions

18 Prospective registry PRAGUE-16 The role of direct catheter-based thrombectomy in acute stroke and the feasibility and safety of interventions performed in an interventional cardiology center was investigated in 115 patients with acute ischemic stroke. Angiographic success was 69-81%. Neurologic recovery was achieved in 40% patients. Direct thrombectomy lead to neurologic recovery in 36%, while bridging thrombolysis in 52%. Symptomatic intracranial bleeding was present in 3.6% (direct) and 6.5% (bridging). Acute stroke interventions performed in close cooperation of cardiologists, neurologists and radiologists were feasible and safe. Widimsky P et al. EuroIntervention May 15;13(1):

19 Green corridor for STEMI and ischaemic stroke ischaemic stroke

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21 From interventional cardiology to cardio-neurology. A new subspeciality in the future? Prof. Andrejs Erglis, MD, PhD Pauls Stradins Clinical University Hospital University of Latvia Riga, LATVIA

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24 Geographic distribution of relative mortality from stroke and ischemic heart disease World Health Organization Global Burden of Disease Program, 2004 Kim AS et al. Circulation Jul 19;124(3):

25 Geographic distribution of relative mortality from stroke and ischemic heart disease Mortality from stroke relative to ischemic heart disease World Health Organization Global Burden of Disease Program, 2004 Kim AS et al. Circulation Jul 19;124(3):