SHOULD A REGIONAL STEMI CENTRE ONLY OFFER PRIMARY PCI?

Transcription

1 SHOULD A REGIONAL STEMI CENTRE ONLY OFFER PRIMARY PCI? Kurt Huber, MD 3 Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria

2 Disclosures DISCLOSURE STATEMENT OF FINANCIAL INTEREST Kurt Huber, MD, FESC, FACC Research Grants from Bristol-Myers Squibb, Eli Lilly, Medtronic, Sanofi-Aventis Consulting Fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Fibrex, Eli Lilly, Portola, Sanofi-Aventis, Schering-Plough, and The Medicines Company Lecture Fees from AstraZeneca, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cordis / Johnson&Johnson, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Pfizer, Sanofi- Aventis, and The Medicines Company

3 STEMI (all comers, all treatment): In-hospital mortality Vienna Mortality (%) % TT CCU/ICU 17% Formation of network 2013 TT was only offered to <3% of STEMI patients % 8.7% 7.6% 7.2% 5.2% Any reperfusion Data partially based on Kalla et al. Circulation 2006;113: ; & Lanschuetzer et al. Unpublished. TT, thrombolytic therapy; CCU, coronary care unit; ICU, intensive care unit; STEMI, ST-elevation myocardial infarction

4 Case report: 66-year-old female Ongoing chest pain for 1 hour Called 144 (Vienna STEMI network), was seen by an emergency physician (ambulance) within 15 min Risk factors: Hypertension, DM-Type 2 (NIDDM) History of TIA 2 years ago Recent medication: Beta-blocker, Aspirin, Glucophage STEMI, ST-elevation myocardial infarction; DM, diabetes mellitus; NIDDM, non-insulin dependent diabetes mellitus; TIA, transient ischaemic attack

5 ECG in the ambulance I V II V III V avr V V avl V avf

6 Q1: What to do? (FMC to balloon is 80 min on average in Vienna) 1. Pre-hospital fibrinolytic therapy UFH, aspirin IV, clopidogrel, TNK-tPA 2. Pre-hospital therapy and rush to the cath lab UFH, aspirin IV, P2Y12-inhibitor 3. Rush to the cath lab without pre-treatment FMC, first medical contact; IV, intravenous; TNK-tPA, tenecteplase-tissue plasminogen activator; UFH, unfractionated heparin

7 Organisation of STEMI patient disposal describing pre- and in-hospital management, and reperfusion strategies within 12 h of FMC EMS Pre-hospital diagnosis & care Ambulance to Cath Lab Primary PCI capable centre Primary PCI Rescue PCI Symptoms of STEMI GP / Cardiologist Immediate transfer to Cath Lab Self referral Private transportation Non-primary PCI capable centre PCI possible <2h yes no no yes Successful fibrinolysis? Transfer to ICU of PCI-capable centre Immediate fibrinolysis Coronary angiography 3 to 24 h after FMC Delayed PCI as required Steg et al. Eur Heart J 2012;33: EMS, emergency medical services; GP, general practitioner; PCI, percutaneous coronary intervention; FMC, first medical contact; ICU, intensive care unit; STEMI, ST-elevation myocardial infarction

8 We decided Pre-hospital fibrinolytic therapy UFH, aspirin IV, clopidogrel, TNK-tPA Pre-hospital therapy plus rush to the cath lab UFH, aspirin IV, clopidogrel Rush to the cath lab without pre-treatment However, due to unexpected traffic jam, transfer to the hospital was prolonged and time from FMC to PPCI was 160 minutes!

9 Coronary angiography The patient survived but LVEF after successful PPCI was only 36%

10 Logistics for networks ESC STEMI guidelines Table 8. Logistics of pre-hospital care Recommendations Class a Level b Ref c Ambulance teams must be trained and equipped to identify STEMI (with use of ECG recorders and telemetry as necessary) and administer initial therapy, including thrombolysis where applicable. The prehospital management of STEMI patients must be based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make primary PCI available to as many patients as possible. Primary PCI-capable centres must deliver a 24/7 service, be able to start primary PCI as soon as possible and within 60 min from the initial call. I B (43) I B (47) I B (6,52,55) Steg et al. Eur Heart J 2012;33: ECG, electrocardiogram; STEMI, ST-elevation myocardial infarction; PCI, percutaneous coronary intervention

11 FAST-MI 2005: early mortality according to reperfusion therapy % None PHT PPCI IHT 5-day 30-day Danchin et al. Circulation 2008;118: PHT, pre-hospital thrombolysis; IHT, in-hospital thrombolysis; PPCI, primary percutaneous coronary intervention

12 Vienna STEMI registry Reperfusion strategies, time delay and mortality Pain-to-first contact <120 min Inhospital mortality p= <60 min (n=190) min (n=265) tt (n=357) p=0.013 p= min (n=106) 17.6 >180 min (n=51) 74.3% of STEMI patients referred for PPCI were treated <120 min Landsteiner et al. 2010; unpublished. However 8.3% of STEMI patients referred for PPCI received first balloon inflation >3 h later TT, thrombolytic therapy; PPCI, primary percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction

13 Vienna STEMI network ( ) FMC-to-PPCI time intervals TT recommended, if FMC-to-PPCI expected to exceed 90 min Patient 60% 20% 20% min 144* Self PCI Self non-pci min min 30 min 144* min FMC-to-PPCI: min *144 = emergency medical services number, Austria FMC = DG by 12-lead ECG Landsteiner et al. 2010; unpublished. PPCI FMC-to-PPCI in self-comers to a non-pci centre: min TT, thrombolytic therapy; FMC, first medical contact; PPCI, primary percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction

14 Cardiac mortality: STREAM trial 15 Cuumulative incidence (%) Gray s Test p= p=0.927 RR 0.98 ( ) PPCI 4.1% TNK 4.0% Number at risk Months since randomisation TNK PPCI Sinnaeve et al. Presented at AHA 2013; Accepted for publication in Circulation 09/2014. PPCI, primary percutaneous coronary intervention; TNK, tenecteplase; RR, relative risk

15 Kaplan-Meier curves for primary endpoint 20 Probability of all-cause death/shock/chf/remi (%) Primary PCI 14.3% Tenecteplase 12.4% p= Days since randomisation Number at risk Tenecteplase Primary PCI Adapted from Armstrong et al. N Engl J Med 2013;368: PCI, percutaneous coronary intervention; CHF, congestive heart failure; remi, subsequent myocardial infarction

16 Danish registry Impact of time delay FMC-to-PCI on long-term mortality p<0.01 FMC to PCI Median FU: 3.4 years ( years) (2092) (275) 25 (2643) % Mortality (43) Time delay (minutes) Terkelsen et al. JAMA 2010;304: FMC, first medical contact; FU, follow-up; PCI, percutaneous coronary intervention

17 SUMMARY Keep pre-hospital thrombolysis in your network for patients with short onset of pain and a low risk of intracerebral bleeding in whom FMC to balloon is expected to be prolonged (Vienna 2014: anterior wall MI, <75 years, onset of pain <3 h; <3% of all STEMIs) FMC, first medical contact; MI, myocardial infarction; STEMI, STelevation myocardial infarction

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