Decision for fibrinolysis or primary PCI in the prehospital phase

Transcription

1 Decision for fibrinolysis or primary PCI in the prehospital phase Nicolas Danchin, Hôpital Européen Georges Pompidou, Paris, France

2 Disclosures Research grants: Astrazeneca, Eli-Lilly, GSK, Merck, Novartis, Pfizer, Sanofi-aventis, Servier, The MedCo Fees for giving lectures and/or consulting: Astrazeneca, BMS, Boehringer-Ingelheim, GSK, Lilly, MSD-Schering, Novartis, Novo-Nordisk, Pfizer, sanofi-aventis, Servier, The MedCo

3 Background: fibrinolysis vs ppci in STEMI Randomised controlled trials have shown the superiority of primary PCI over fibrinolysis. 16 Lysis PCI Death Re-MI Stroke Death, MI, stroke Keeley et al. Lancet 2003

4 Overall, there is an about 40% reduction in ischemic events with ppci, compared with lytic treatment But

5 Real life may be different from RCTs: times to PCI are often very long Old trials all compared primary PCI with stand-alone fibrinolytic treatment: DANAMI-2: clear benefits of PPCI even in transfer patients 10% 8% Death P= % 6.6% DANAMI-2: Results 8% 6% Recurrent MI P< % 8% 6% Stroke P=0.15 6% Rescue PCI: 1.9% 4% 2% 4% 2% 1.6% 4% 2% 2.0% 1.1% Any PCI: 16.4% 0% 0% Lytic Primary PCI 0% Lytic Primary PCI Lytic Primary PCI N Engl J Med 2003; 349:

6 Management of STEMI in the real world: time delays

7 % of Patients Time Delays for PPCI in Non-Transfer Patients NCDR , ,6 23, ,8 3,2 4,2 2 1,1 1,7 < Rathore et al. BMJ 2009 Total Door-to-Balloon Time (minutes)

8 % of Patients Time Delays in Transfer Patients for Primary PCI <1 1 to <2 2 to <3 3 to <4 4 to <5 5 to <6 6 to <7 >=7 Total Door-to-Balloon Time (Hours) Nallamothu et al. Circulation 2005.

9 GRACE: Trends in time delays Door to reperfusion PCI only 75 (45-125) Fibrinolytic therapy only 35 (21-62) (45-119) 34 (17-62) Eagle et al. EHJ 2008

10 Fibrinolysis should not be used as a stand-alone procedure

11 REACT trial: rescue PCI 427 patients <50% ST resolution 90 min after lysis R'dom: rescue PCI repeat lysis conservative NEJM 2005; 353:

12 Ischaemic event rate (%) Routine early invasive approach after lysis Time from fibrinolysis to routine early PCI (hr) Verheugt FWA. N Engl J Med 2009;360:

13 266 patients randomised NORwegian study on District treatment of ST-Elevation Myocardial Infarction NORDISTEMI 30-day outcome Death, MI, or stroke Bohmer et al., JACC 2010

14 Overall, comparisons of a pharmaco-invasive strategy including both rescue PCI and routine, semi-urgent PCI with stand-alone fibrinolysis show a 50% reduction in the risk of combined CV ischemic events

15 Fibrinolysis vs ppci: real-world data

16 FAST-MI 2005 and 2010: in-hospital mortality ,7 4,7 1,7 4,1 3,0 3,0 6,1 0 Primary PCI Lysis PH lysis 0,0 IH lysis Lysis ppci Initial TIMI flow 2 or 3 50% 29% Final LVEF 53.1 ± ± 12.6

17 Three French surveys, 5 years apart USIK month death if admission 3 hrs: 7.7% vs 12.0% PHT PPCI IHT No reperf USIC yr death in pts calling 120 min 5.3 vs 9.4 vs 10.7% FAST-MI 2005 Adjusted HR 0.49 [ ] Circulation 1999; Circulation 2004; Circulation 2008

18 Pros and cons of fibrinolysis in the specific context of OHCA

19 Pros of fibrinolysis Fibrinolysis is more efficacious when the patients are seen very early Aborted MI with PH-fibrinolysis Boersma, 1996; Lamfers PHT 4 IHT

20 Cons of fibrinolysis Intrinsic bleeding risk: specific risk in OHCA? Cannot confirm diagnosis of STEMI: Initial series of Spaulding et al. (NEJM 1997) In a recent series of 158 OHCA with ST elevation after resuscitation, 97% had CAD; in 54 pts with ST-T changes without ST elevation, 41% had no CAD (Radsel et al, Am J Cardiol 2011)

21 Cons of fibrinolysis: the TROICA trial Specific context of ongoing resuscitation and failed defibrillation attempts. About 70% presumed AMIs No benefit of fibrinolytic treatment (tenecteplase mg, weight-adjusted): Similar death rate and cerebral function recovery 30-day survival Increased risk of intracranial bleeding (2.7 v. 0.4) Böttiger et al. NEJM 2008

22 Primary PCI in OHCA: the PROCAT registry 435 patients with CAG after OHCA CAD present in 96% with ST-elevation and 58% without ST-elevation PCI associated with improved survival (OR= 2.06) Dumas et al. Circ CV Interv 2010

23 Summary After OHCA, fibrinolysis is a potentially valid option if: ST-elevation is present on ECG Expected time to primary PCI is too long Followed by semi-urgent coronary angiography In the absence of ST-segment elevation, coronary angiography is warranted if there is no other obvious cause for cardiac arrest