Prof. Adel El Etriby Ain Shams Faculty of Medicine

Transcription

1 Prof. Adel El Etriby Ain Shams Faculty of Medicine Reperfusion Options for STEMI Patients Step One: Assess Time and Risk. Time Since Symptom Onset Risk of STEMI Risk of Fibrinolysisi i Time Required for Transport to a Skilled PCI Lab 2 1

2 Reperfusion Options for STEMI Patients Step 2: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. Fibrinolysis generally preferred Early presentation ( 3 hours from symptom onset and delay to invasive strategy) Invasive strategy not an option Cath lab occupied or not available Vascular access difficulties No access to skilled PCI lab Delay to invasive strategy Prolonged transport Door-to-balloon more than 90 minutes > 1 hour vs fibrinolysis (fibrin-specific agent) now 3 Reperfusion Options for STEMI Patients Step 2: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. Invasive strategy generally preferred Skilled PCI lab available with surgical backup Door-to-balloon < 90 minutes High Risk from STEMI Cardiogenic shock, Killip class 3 Contraindications to fibrinolysis, including increased risk of bleeding and ICH Late presentation > 3 hours from symptom onset Diagnosis of STEMI is in doubt 4 2

3 PCI vs Lysis: Additional Data Mortality advantage of PCI diminishes: As risk with lytic decreases: PCI = Lysis at 3% With increasing delay: PCI = Fibrin spec lytic with 60 min delay RR = 1.08 for every 30 min from onset of sx The earlier patient is seen: PCI = Lysis in < 3 h from sx Outcomes with PCI are influenced by time of day and operator/institution volume and experience Trials of transfer for PCI: Had very short transport and D-B times PCI mortality higher than prehospital lysis in pts treated early (2h) JACC 2004;44: 671 Circ 2004;110: Treatment Delayed is Treatment Denied Symptom Recognition Call to Medical System PreHospital ED Cath Lab Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy 6 3

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5 We are different! Patient awareness of the magnitude of the problem is deficient. Proper education and training of ER personnel is needed to improve services for the management of ACS. We are different! Marked difficulties in transportation facilities and lack of inter hospital communication. Because of financial restrains the basic lab works for the diagnosis of ACS are lacking. 5

6 We are different! Computer database and electronic filing are deficientinmostifnotall2 ry as well as 3 ry hospitals. Despite the marked rise in cathlabs all over Egypt, still in some parts of Egypt cathlabsare not available. We are different! Despite governmental support, state of art therapy is not available in all hospitals specifically IIb/IIIa inhibitors and Thienopyridenes and even if available, not all forms are there e.g. Reopro. 6

7 We are different! Medical insurance covers only fraction of the population and difficulties are faced when expensive therapy is needed specially long term treatment with statins and Clopidogrel. 7

8 Improve patient awareness by heart attack symptoms. Improvement of patient transfer (EMS). Map of PCI capable hospitals all over Egypt. Training of ER personnel for rapid and accurate triage of patients with chest pain. Building communications ways between hospitals. Data Collection and analysis. Monitoring of performance of each center. Highly skilled PCI capable centers 24/7. 8

9 What was done between the Medical Insurance and Ain Shams Cardiology Department A Pilot Multidisciplinary National Program for optimal STEMI management in Egypt The initiative was done by Dr. Essam Anwar Head of The Medical Insurance Cairo District & Prof. Ayman Saleh Ain Shams University Agreement between Ain Shams University Hospital & Sednawy Insurance Hospital for the proper management of AMI Ain Shams Duties: Primary PCI Cathlab available 24/7. Skilled devoted team 24/7. Free telephone line for the PCI team. 9

10 Agreement between Ain Shams University Hospital & Sednawy Insurance Hospital for the proper management of AMI Medical linsurance Duties: Ambulance available 24/7, stationed in the hospital. Training of the ER personnel for rapid triage of patients with chest pain. Rapid data acquisition and transfer of the data to Ain Shams Hospital. Financial coverage to assure best service to the patient including IIb/IIIa inhibitors when needed. The program started one month ago. 16 patients enrolled. Short and long term success of this program depends on the number of cases referred, the duration of transfer and the status of the patient upon arriving to Ain Shams Hospital. 10

11 Future directions Including more hospitals in greater Cairo to cover more regions: Nasr City & Heliopolis. 6 th October Hospital to cover Mohandiseen, Dokki & Agouza. Kasr Ainy Hospital. And more. Including more governorates. 11