Updates in Emergency Management of Stroke / AMI. Dr Daniel Chor Associate Consultant, NUH EMD MBBS (S pore), MCEM (UK), M.

Transcription

1 Updates in Emergency Management of Stroke / AMI Dr Daniel Chor Associate Consultant, NUH EMD MBBS (S pore), MCEM (UK), M.Med (EM) (S pore)

2 Emergency Management Outline of today s talk Stats on Stroke Part 1: Stroke Goals of Treatment What is new? What we do at NUH

3 Emergency Management Outline of today s talk Stats on AMI Part 2: Acute Myocardial Infarction STEMI equivalents Management and update in therapies What we do at NUH

4 Part 1: Stroke

5 Outline Statistics on Stroke in Singapore Goals of treatment What is new? Early imaging Early intervention What we do at NUH

6 Some Statistics on Stroke ~80% Ischaemic Overall increasing trends in number of stroke cases from Average duration of admission: 8 to 10 days National Registry of Disease Office.

7 Medical cost of stroke Study published in 2015 in International Journal of Stroke Random sampling of patients with stroke Annual mean cost of a patient with ischaemic stroke ~$9000 Ng CS, Toh MPHS, Ng J, et al. Direct medical cost of stroke in Singapore. Int J Stroke 2015; 10:

8 Goals of treatment Time is essential Early Suspicion Assessment Stabilisation Early imaging Early intervention What is new?

9 Early Suspicion FAST: Sensitivity 83% Specificity 68% CPSS: Sensitivity 85% Specificity 69% Higher the sensitivity, the more effective the screening tool! Purrucker JC, Hametner C, Engelbrecht A et al. Comparison of stroke recognition and stroke severity scores for stroke detection in a single cohort. J Neurol Neurosurg Psychiatry Sep; 86(9):1021-8

10 Early Assessment Time of onset Nature of symptoms Ruling out potential mimics Migraine / SAH / ICH Bell s palsy Hypoglycaemia Syncope Seizure Drug toxicity

11 Early Assessment Loss of higher functions such as changes in behavior, aphasia, memory impairment and neglect usually suggest major vessel involvement

12 Early Assessment

13 Early Assessment Bedside tests Hypocount ECG Lab tests Full Blood Count Troponin Renal Panel Coagulation profile Other labs for differentials

14 Early Stablisation Assessing vitals signs Stabilise ABC Reversal of potential mimics eg hypoglycaemia Fluid resuscitation / reversal of dehydration

15 Early imaging In acute setting: Exclude haemorrhage Assess extent of injury to brain Identify site of vascular occlusion Assess infarct core, salvageable brain tissue and degree of collateral circulation

16 Early imaging Non-contrast CT (NCCT) CT Angriogram / CT perfusion MRI Pros Readily available Rapid acquisition of images Very sensitive at evaluating for haemorrhage Evaluate vasculature (occlusion / collaterals) Evaluation of infarct core and salvageable brain tissue Detects more acute ischaemic strokes Cons Not sensitive in detecting acute ischaemic stroke Less readily available than NCCT Takes longer than NCCT Contrast required Many contraindications Less tolerable Less available More costly Takes more time

17 Early imaging Alberta Stroke Program Early CT Score (ASPECTS) method Method of assessing ischaemic changes on a CT brain Helps identify patients unlikely to benefit from thrombolysis Using 2 standard axial CT cuts Essentially divides MCA territory into 10 regions 1 point subtracted for an early ischaemic change Score of 7 associated with poorer outcomes Barber PA, Demchuk AM, Zhang J et al. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000;355(9216):1670.

18 Early Intervention Reperfusion therapy: Aim to restore blood flow to parts of brain that are ischaemic Need to present early enough 2 main modalities Intravenous Thrombolysis (1 st line) Mechanical Thrombectomy

19 Early Intervention IV Thrombolysis Main agent used: Alteplase (or recombinant Tissue Plasminogen Activator - rtpa) Initiates local fibrinolysis Converts plasminogen to plasmin -> breaks down fibrinogen and fibrin in the clot

20 Early Intervention IV Thrombolysis Given if occurring within 4.5 hours of symptom onset Symptom onset taken as time last seen well Benefits are time dependent Benefits Within 3 hours of onset: Good outcome seen in 33% of patients vs 23% given placebo Treated between 3 to 4.5 hours: Proportion of good outcomes was 35% vs 30% Risks risk of symptomatic ICH (6.8% vs 1.3%) and fatal ICH within 7 days (2.7% vs 0.4%) Allergy / angioedema Emberson J, Lees KR, Lyden P et al. Effect of treatment delay, age and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014 Nov 29;384(9958):

21 Early Intervention IV Thrombolysis Overall percentage of patients receiving thrombolysis from 0.5% in 2005 to 6.5% in

22 Early Intervention IV Thrombolysis

23 Early Intervention IV Thrombolysis Recommended Door-to-needle time of 60 minutes Evaluation by Dr within 10 minutes of ED arrival Activation of stroke specialist 15 minutes Imaging 25 minutes Interpretation 45 minutes Start of therapy by 60 minutes Powers WJ, Rabinstein AA, Ackerson T, et al Guidelines for the Early Management of Patients with Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association / American Stroke Association. Stroke. 2018;49(3):e46-e110

24 Early Intervention IV Thrombolysis Some other points rtpa dose: 0.9mg/kg over 60 minutes with 10% as a bolus over 1 minute May require BP control prior should be <185/110 Neurological deficits should be measurable and persistent Close neurologic and cardiac monitoring in a stroke unit required Powers WJ, Rabinstein AA, Ackerson T, et al Guidelines for the Early Management of Patients with Acute Ischemic Stroke: a Guideline for Healthcare Professionals From the American Heart Association / American Stroke Association. Stroke. 2018;49(3):e46-e110

25 Early Intervention Mechanical Thrombectomy Main indication: Large arterial occlusion in the anterior circulation Treated within 24 hours of symptom onset Can (and should) receive IV rtpa if eligible Some grey indications: Posterior circulation occlusions eg affecting Vertebral / Basilar Arteries

26 Early Intervention Mechanical Thrombectomy 5 multicenter, open label RCTs published in 2015 Evaluating mechanical thrombectomy within 6 hours of symptom onset Early intra-arterial treatment with 2 nd generation mechanical thrombectomy devices were: Safe and effective for reducing disability Superior to IV thrombolysis alone for ischaemic strokes 2 to a large artery occlusion in the proximal anterior circulation NNT for functional independence: 3 to 8

27 Early Intervention Mechanical Thrombectomy Meta-analysis of the trials showed: Rate of functional independence in the intervention group significantly greater Significantly reduced disability at 90 days NO significant difference in: rates of symptomatic ICH 90-day mortality Goyal M, Menon BK, van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723.

28 Early Intervention Mechanical Thrombectomy Meta-analysis of the trials also showed: Beneficial across wide range of patient subgroups including: Age 80 years old High initial stroke severity Those not treated with IV rtpa NNT to reduce disability by at least 1 point: 2.6 Goyal M, Menon BK, van Zwam WH et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723.

29 Early Intervention Mechanical Thrombectomy Benefits of later treatment Possible benefits beyond 6 hours for selected patients who have disproportionately severe clinical deficit relative to volume of infarction on imaging. May benefit patients with wake-up strokes

30 Early Intervention Mechanical Thrombectomy Findings of both studies Primary outcome Adverse events DAWN trial 1 DEFUSE 3 trial 2 Rate of functional independence at 90-days: 49% vs 13% NNT: 3 No significant difference in: Rate of symptomatic intracranial hemorrhage (6% vs 3%) 90-day mortality (19% vs 18%) Rate of functional independence at 90-days: 45% vs 17% NNT: 3.6. Trend to lower mortality with intervention (14% versus 26%). No significant difference in: Rate of symptomatic intracranial hemorrhage (7% vs 4%) Serious adverse events (43% vs 53%). 1 Nogueira RG, Jadhav AP, Haussen DC et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018;378(1):11. 2 Albers GW, Marks MP, Kemp S et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018:378(8):708.

31 Early Intervention Mechanical Thrombectomy Adverse events include: Symptomatic ICH Distal embolisation Dissection Vasospasm Bleeding from puncture Technical success without clinical improvement

32 What we do at NUH Systemic interventions Stroke Nurses, Dedicated Stroke Dr and Neuro-interventionist on Call 24/7 Pre-notified Stroke cases from SCDF ambulance directly into CT room Stroke team also on standby Weighing bed outside CT room CT brain with angiogram perfusion scans available 24/7

33 What we do at NUH Systemic interventions (continued) IV rtpa started in EMD and continued to Neurology HD NUH serving as a hub for stroke management Acute interventions: <4.5 hours: IV rtpa 4.5 up to 6 hours: Mechanical Thrombectomy 6 to 16 hours: KIV Mechanical Thrombectomy

34 Take Homes Early Suspicion Time of onset Nature of symptoms Call SCDF ambulance Allows resource mobilisation Patients presenting within 4.5 hours of symptoms may be eligible for IV Thrombolysis Patients up to 16 hours may still benefit from acute interventions Even wake-up strokes may undergo mechanical thrombectomy

35 Part 2: Acute Myocardial Infarction

36 Outline Statistics on AMI in Singapore STEMI equivalents Management Update in therapies What we do in NUH

37 Some statistics on AMI 1 of the top 3 causes of death in Singapore Common symptoms: chest pain, SOB and diaphoresis National Registry of Disease Office.

38 STEMI equivalents Classical STEMI definition: ST-elevation at the J Point in 2 contiguous leads

39 STEMI equivalents Posterior MI Lt Main Coronary Artery (LMCA) Occlusion De Winter s T Waves Sgarbossa s Criteria Wellens Syndrome Life In The Fast Lane.

40 STEMI equivalents Posterior MI Suggests occlusion of distal Lt Cx or PDA of RCA Findings in V1-V3: Flat ST-Depression Upright T-wave Prominent R wave

41 STEMI equivalents LMCA Occlusion Findings: ST elevation in avr ST elevation in avr V1 Widespread ST depression, esp I, II, V4-V6

42 STEMI equivalents De Winter s T Waves Suggests plad artery occlusion Findings mainly in V1-V4: Upsloping ST segment depression at J-point Tall, symmetric T waves in precordial leads

43 STEMI equivalents Sgarbossa s Criteria Used to identify STEMI in the setting of LBBB or pacemaker Score of 3: > 90% specific for AMI

44 STEMI equivalents Wellens Syndrome Suggests critical plad stenosis In the setting of chest pain, will benefit from early PCI Findings in V1-V4: Biphasic T-waves (Type A) OR Deep symmetric T-waves (Type B)

45 STEMI equivalents Wellens Syndrome (Type A)

46 STEMI equivalents Wellens Syndrome (Type B)

47 Management Focus of therapy Relieve pain ECG and Appropriate monitoring Stabilise haemodynamics Reduce ischaemia MONA? Early PCI

48 Update in therapies Morphine Generally avoided now unless severe pain Large retrospective observational study of >50,000 patients with NSTEMI / ACS Use of morphine associated with higher mortality Meine TJ, Roe MT, Chen AY et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J Jun;149(6):

49 Update in therapies Oxygen May be given if SpO2 <90% or clear respiratory distress No added benefit from giving O2 in patients who had SpO2 >90% - does not decrease All-cause mortality Recurrent ischaemia / AMI Heart failure Occurrences of arrhythmias Abuzaid A, Fabrizio C, Felpel K et al. Oxygen Therapy in Patients with Acute myocardial Infarction: A Systematic Review and Meta-Analysis. Am J Med. 2018;131(6):693.

50 Update in therapies Oxygen 2015 AVOID study RCT where STEMI patients with normoxia given 8L/min vs no supplementation No improvement in infarct size In fact, there was increase in: Rate of recurrent MI Frequency of cardiac arrhythmia Infarct size on cardiac MRI at 6 months Stub D, Smith K, Bernard S et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015;131(24):2143.

51 Update in therapies Nitrates Sublingual easily administered IV given if: Persistent chest pain after x3 SL doses Hypertension / Heart failure Avoided if: Hypotensive / risk of hypotension RV infarction Severe Aortic Stenosis Use of phosphodiesterase inhibitors in last 24 hours

52 Update in therapies Antiplatelet Therapy 3 main types (based on mechanism): COX inhibitors: Aspirin Platelet P2Y12 receptor blockers: Clopidogrel, Ticagrelor, Prasugrel GPIIb/IIIa inhibitors: Abciximab, eptifibatide, tirofiban

53 Update in therapies Antiplatelet Therapy (continued) Usually DAPT regardless of subsequent treatment modality but esp for PCI Aspirin Back bone of therapy 300mg as a loading dose 2 nd agent usually P2Y12 inhibitor 3 main ones used now: Clopidogrel, Ticagrelor and Prasugrel

54 Update in therapies Antiplatelet Therapy (continued) Clopidogrel previously mainstay (PCI-CLARITY) Ticagrelor (PLATO) / Prasugrel (Triton-TIMI) preferred now Faster onset More intense platelet inhibition compared to Clopidogrel

55 Update in therapies Antiplatelet Therapy (continued)

56 Update in therapies Antiplatelet Therapy (continued)

57 Update in therapies Early PCI PCI being the mainstay if available Aim for Door-to-Balloon (D2B) time <90 minutes associated with reduced mortality If at a non-pci site, to aim D2B <120 minutes by transfer to a PCI-capable site Stenting preferred over balloon angioplasty Drug Eluting Stents preferred over Bare-metal stents but requires 1 year of DAPT Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13. Borja Ibanez, Stefan James, Stefan Agewall et al ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) Eur Heart J Jan 7;39(2):

58 What we do at NUH Systemic interventions Cardiology Interventionist on duty 24/7 Pre-hospital transmission of ECGs by SCDF Facilitates activation of Interventionist Mobilise team and preparation of facility ECG within 10 minutes of arrival Target D2B <90 minutes DAPT: Aspirin + Ticagrelor / Prasugrel Regular audits of performance and adjustment of processes

59 What we do at NUH Some NUH Stats

60 What we do at NUH Some NUH Stats

61 Take Homes Early ECG Look for the STEMI equivalents Call SCDF ambulance Facilitates ECG transmission Allows resource mobilisation Morphine and Oxygen may not be helpful Load Aspirin DAPT = Aspirin + Ticagrelor/Prasugrel/Clopidogrel Reinforce compliance to DAPT

62 Questions?

63 Thank You