STEMI Linee guida ESC Maddalena Lettino, Italy

Transcription

1 STEMI Linee guida ESC 2017 Maddalena Lettino, Italy

2 Disclosure Speaker fee: Aspen, Astra Zeneca, BMS, Boehringer, Eli Lilly, DaichiiSankio, Bayer, Pfizer, Sanofi Advisory board member: Astra Zeneca, Eli Lilly, Daiichi Sankyo, BMS, Pfizer, Sanofi Speaker

3 Class I Classes of recommendations Classes Definition Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective. Suggested wording Recommended/ is indicated. 159 recommendations IIb 13 8% III 16 10% Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy. Should be considered. Class III Class IIb Usefulness/efficacy is less well established by evidence/ opinion. Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful. May be considered. Not recommended. IIa 38 24% 92 58% I Speaker guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal doi: / eurheartj/ ehx095)

4 A B C Level of evidence 21% Data derived from multiple randomized clinical trials or meta-analyses. Data derived from a single randomized clinical trial or large non-randomized studies. Consensus of opinion of the experts and/or small studies, retrospective studies, registries. 159 recommendations based on 477 references guidelines 2017 ESC Guidelines for the Management Speaker of AMI-STEMI (European Heart Journal doi: / eurheartj/ ehx095) C 78 49% 37 23% 44 28% B A 7

5 Gaps in the evidence and areas for future research 1. Public awareness and emergency care 2. Reduction of ischaemia/ reperfusion injury 3. Refinement of (acute and long-term)antithrombotic regimes) 4. Beta-blockers and ACE inhibitors 5. Post-STEMI risk stratification 6. Shock and left ventricular assist devices 7. Myocardial repair/ rescue 8. Need for observational data and real-world evidence 9. Need for pragmatic real-life clinical trials Speaker

6 The pre-hospital phase. Speaker

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8 O 2 therapy in the early phase DETO 2 X-AMI HR % CI, P=0.8 Stub D et al Circulation 2015; 131: 2143 Hofmann et al, ESC 2017 Speaker

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13 Reperfusion: strategies & timing. Speaker

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17 Relationship between PCI-related delay and in-hospital mortality Pinto et al. Circulation guidelines 2017 ESC Guidelines for the Management Speaker of AMI-STEMI (European Heart Journal doi: / eurheartj/ ehx095) 6

18 Strategic Reperfusion Early after Myocardial Infarction (STREAM) study p=0.21 Median PCI-related delay 78 min Armstrong et al. N Engl J Med 2013;368: Speaker guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal doi: / eurheartj/ ehx095) 7

19 Complete revascularization (non-ira PCI) Speaker

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21 Recommended therapies in the subacute & and long term phases Speaker

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23 Myocardial infarction with non-obstructive coronary arteries Speaker

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25 Flow-chart n Eur Heart J. 2017;38: guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal doi: / eurheartj/ ehx095)

26 Car d iac m ag n et ic r eso n an ce im ag in g ( w it h in 6 w eek s af t er t h e ev en t ) Pasupathy et al Circulation 2015 Speaker

27 MI & Quality indicators Speaker

28 Rationale: Why new quality indicators? Focus of the analysis Human Material Financial Resources Interaction HC professionals - patients Health outcomes Structure Process Results Structural conditions Adequacy with standards Outcome improvement Speaker

29 Definition of Quality indicators Speaker

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31 Quality indicators (continued) Type of indicator and process Performance measures for reperfusion therapy Quality indicator 1) Proportion of STEMI patients arriving in the first 12 h receiving reperfusion therapy 2) Proportion of patients with timely reperfusion therapy, defined as: For patients attended to in the pre-hospital setting: 90 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI, <10 min from STEMI diagnosis to lytic bolus for reperfusion with fibrinolysis For patients admitted to PCI centres: <60 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI, For transferred patients: <120 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI <30 min door-in-door-out for patients presenting in a non-pci centre (en route to a PCI centre) Speaker 14

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35 Acute Cardiovascular Care Congress: NOW IN SPRING WORKING TOGETHER FOR ACUTE CARDIOVASCULAR PATIENTS >100 international expert faculty >60 sessions, workshops and virtual case presentations >1100 participants from >80 countries