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1 Guidelines for PCI in late STEMI presenters 2010 Sameh Sabet Assistant Professor of Cardiology Ain Shams University

2 29% of MI patients have STEMI. NRMI 4 (Fourth National Registry of Myocardial Infarction), 47% of ACS patients present with STEMI European survey, the EHS ACS II (Second Euro Heart Survey on Acute Coronary Syndromes)

3 Under treatment In the era preceding the widespread use of primary PCI Registry Reperfusion Therapy German MITRA (STEMI) registry 57.8% the FrenchACS registry 53% EHS study 56%

4

5

6 40% 33%

7 Factors Related to No reperfusion Therapy Age >75 years Prior congestive heart failure Prior myocardial infarction i (MI) Female gender Diabetes Systolic pressure <100 mm Hg Delayed presentation Global Registry of Acute Coronary Events (GRACE) Lancet 2002;359:

8 Late Presenters Late Presentation >12 h from Onset of Symptoms has a great impact on the decision making to whether/not a reperfusion based strategy in STEMI has to be chosen. Late Presenters > 12 hours have undergone extensive research.

9 Reperfusion therapy is indicated in all patients with chest pain < 12hours with ST elevation or new left bundle branch block Class Ia PCI should be considered if there is clinical and / or ECG evidence of ongoing ischemia if symptoms started > 12 hours before Class IIa PCI in stable patients presenting >12 to 24 hours after symptom onset Class IIb PCI of totally occluded infarct artery in stable patients without signs of ischemia > 24 hours after symptom onset Class III

10

11 Animal studies After 12 hours

12 In OAT (Occluded Artery Trial), 2,166 stable patients with a total occlusion of the infarct related artery (IRA) that was found 3 to 28 days post STEMI 4 Years PCI Conservative P Value primary composite end point 17.2% 15.6% 0.18 of death, re infarction, or NYHA class IV HF mortality 9.1% 9.4% NS Occluded Artery Trial Investigators Coronary intervention for persistent occlusion after myocardial infarction N Engl J Med 2006;355:

13 OAT Trial 5 years follow up Risk Tertile High PCI n = 1,101 Medical Therapy n = 1,100 P Value 33.9% 27.3% 0.10 Medium 13.1% 13.8% 0.82 Low 10.2% 7.3% 0.57 Results from the OAT (Occluded Artery Trial) study. J Am Coll Cardiol Intv 2008;1:

14

15 Gaps in the evidence? Nobody knows what symptom duration means in the human setting symptom onset may not represent coronary occlusion and the course of ischemia is unknown. Recanalization and reocclusion may occur keeping the myocardium viable for prolonged intervals compared with animal ischemiareperfusion studies.

16 Gaps in the evidence? STEMI within hours interval? Are we concerned only about clinical benefits or myocardial salvage as well. Age of patients. Echocardiographic parameters ( stunned full thickness myocardial segments at jeopardy, or thinned out scar ). Results of viability study (reliability of its interpretation)

17 ` Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction Eur Heart J 2006;27:

18 396 patients with STEMI Early presenters (n = 341), PCI < 12 hours after symptom onset, late presenters (n = 55) PCIbetween 12and72hours hours. Myocardial perfusion imaging with Tc 99m sestamibi SPECT to assess myocardial salvage. LVEF, EDV, ESD. 1 year mortality. Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for < 12 h vs h. Eur Heart J

19 Early (n = 341) Late (n = 55) P value AAR (%) 28 (18 40) 31 (22 45) 0.04 Salvage Index (%) 69 (45 91) 53 (27 89) 0.05 LVEF (%) 52 (47 59) 48 (44 58) 0.04 LV EDV (ml) 115 (92 138) 121 (99 146) LV ESV (ml) 53 (39 70) 57 (45 80) year mortality Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for < 12 h vs h. Eur Heart J

20 TIMI flow 0 early presenters TIMI flow 0 Late presenters P value Myocardial 57% 44% Salvage Index

21 In the BRAVE 2 trial 365 patients with STEMI 12 and 48 hours after symptom onset Invasive strategy Conservative (n = 182) management (n = 183) 4 year MACCE Schömig A et al. Beyond 12 Hours Reperfusion Alternative Evaluation (BRAVE 2) Trial Investigators. : A randomized controlled trial. JAMA. 2005;293(23):

22 Conservative (n = 183) Invasive (n =182) P value Death 18.9% 11.1% 0.04 Reinfarction 5.6% 6.8% 0.66 Stroke 1.1% 1.6% 0.65 Revascularization of 69.1% 25.8% <0.001 the Infarct-Related Artery Schömig A et al. Beyond 12 Hours Reperfusion Alternative Evaluation (BRAVE 2) Trial Investigators. : A randomized controlled trial. JAMA. 2005;293(23):

23 Late Presenters hours after STEMI Worse? Better? Myocardial Salvage Mortality

24 Take Home Message For the treatment of late presenting gpatients with STEMI (beyond the first 12 h after onset of symptoms), clinical evaluation and risk stratificationrepresentthe represent the crucial elements guiding the choice of therapeutic intervention ( Guidelines ). In the presence of hemodynamic or electrical instability, and/or if the patient continues to experience symptoms, a primary PCI is recommended ( Guidelines ).

25 Substantial ti salvage can be achieved in a considerable percentage of late presenters despitetotal total occlusion of the infarct related related artery. The 12 hour limit is totally arbitrary and has failed to identify which patients have the potential ti lfor myocardial salvage.

26 Until evaluating large scale randomized trials, late presenters with STEMI should be offered primary angioplasty on a relatively liberal basis. Time Matters, but Should Not absolutely Preclude PCI.

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