Primary Percutaneous Coronary Intervention

Transcription

1 The big 5 in PCI Primary Percutaneous Coronary Intervention W. Wijns (Aalst, BE)

2 Disclosures Consulting Fees: on my behalf go to the Cardiovascular Research Center Aalst Contracted Research between the Cardiovascular Research Center Aalst and several pharmaceutical and device companies Ownership Interest: Cardiovascular Research Center Aalst is co-founder of Cardio³BioSciences (cell-based regeneration cardiovascular therapies) Chairman of PCR / EuroPCR, the annual Course of EAPCI

3 Primary Percutaneous Coronary Intervention for STEMI The evidence The procedure The network

4 1 ary PCI for STEMI: historical landmarks Late 70 ies Intracoronary streptokinase 1980 Wiring and first balloon attempts 80 ies Zwolle and PAMI studies 1993 Illusion of reperfusion (Lincoff, Topol) 2002 First meta-analyses PCI vs lysis 2003 PPCI recommended by ESC Guidelines 2008 Aspiration catheters (TAPAS) 2010 New antiplatelet drugs for PCI 2012 Implementation projects (SFL, NIAP)

5 Reperfusion Therapy for STEMI 23 Randomized Trials (n=7739) Pooled Analysis - Outcome at 30 days DEATH PCI Better Lysis Better n = 3872 n = % 9% 12 9 Pooled Analysis: PCI vs Lytics Mortality (%) at 30 days Lytics PCI 12.1 Re-MI STROKE COMBINED 3% 7% 1% 2% 8% 14% OR (95% C.I) P< Early <2h Medium 2-4h Late >4h Keeley et al. Lancet 2003 Zijlstra et al. Eur Heart J 2002 Courtesy dr. H. Suryapranata

6 Symptom-To-Balloon and One-year Mortality (%) Every minute delay counts both for thrombolysis and primary PCI < 2 h 2-4 h 4-6 h > 6 h P = P = NS De Luca et al JACC 2003 De Luca et al Circulation 2004 Courtesy dr. H. Suryapranata P = All Patients Low-Risk High-Risk n=1791 n=545 n= Adjusted RR [95% CI] [ ] RR death increased by 7.5% for each 30-min 60 Y = 2.86 (+ 1.46) X X 2 p < Ischemic Time (min) 360

7 PCI Volume and Outcome In 2003, patients at 67 non-university hospitals: ALKK PCI registry In Hospital Mortality for PCI No MI STEMI / NSTEMI Zahn et al. Heart 2008;94:329 35

8 Primary Percutaneous Coronary Intervention for STEMI The evidence The procedure The network

9 7 Leads for improved procedural outcomes after Primary PCI Adjunctive pharmacotherapy Thrombus management Access site selection Reduction in bleeding complications Stent choices Strategies for multivessel management Myocardial preservation

10 Available data with 1 st generation & newer DES Long-term safety and efficacy of DES vs BMS in pts with STEMI (Piccolo et al. Atherosclerosis 2011;217:149) 10 studies, pts, follow-up 3.6 years Stent thrombosis OR 1.06 p = 0.66 Very late ST OR 1.71 p = 0.03 TVR OR 0.51 p < Performance of newer generation DES is superior, especially in terms of deliver-ability and safety Examination Everolimus-DES vs BMS Comfortable AMI Biolimus-DES vs BMS

11 MACE (%) COMFORTABLE AMI Primary Endpoint 1 Year yr HR 0.49 ( ) P=0.004 BMS 8.7 % 4 2 BES 4.3 % 0 No at risk BMS BES Days since index procedure MACE* = Cardiac death + TVR-MI + ischemic TLR L. Räber et al. JAMA 2012;308:777

12 Multivessel PCI during Primary PCI for STEMI PRO Aiming at complete revascularisation Convenience (no need for repeat procedures) Few positive studies including undersized RCT CONTRA Increased procedural risk Acute ischemic risk / prothrombotic milieu Acute dysfunction Closing the door for surgery Benefit uncertain (contradictory metanalyses)

13 FFR in ACS V. B. 83-y-o man, acute anterior MI, Chronic Renal Failure

14 FFR in ACS V. B. 83-y-o man, acute anterior MI, Chronic Renal Failure Possible Stategies 1. Stent the non culprit distal RCA and the LCx in the same setting? 2. Bring the patient back to the cath lab in 4 to 8 days? 3. Elective non-invasive assessment in the next coming days?

15 FFR in ACS FFR in Non-Culprit Stenoses During the Acute Phase of a Myocardial Infarction patients with acute MI 112 non-culprit stenoses FFR - acute phase AND - 1 month later In 2/112 stenoses, the FFR value was >0.80 at the acute phase but <0.75 at follow-up ACUTE FOLLOW-UP p=ns Ntalianis A et al JACC interv 2010

16 FFR in ACS V. B. 83-y-o man, acute anterior MI, Chronic Renal Failure Non Culprit 1 Non Culprit 2

17 Primary Percutaneous Coronary Intervention for STEMI The evidence The procedure The network

18 Reperfusion Therapy for STEMI 25 % STEMI Mortality Rates in The Netherlands Cardiovascular Mortality Europe (From: Closing the health gap in European Union. Ed. by W. Zatonski) Thrombolysis P-PCI Pre-CCU CCU Reperfusion Era Central Bureau of Statistics Courtesy dr. H. Suryapranata

19 Widimsky et al, Eur Heart J, 2010;31: Reperfusion therapy in Europe 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO P-PCI Thrombolysis No reperfusion

20 Primary PCI per million vs Gross Domestic Product NO relationship between Country GDP & Primary PCI rate

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22 Sremska Kamenica (2 cath labs) Belgrade (8 + 4) Arrival to cath lab <90 minutes for large infarctions and young patients ` Kragujevac (1) < 120 minutes for others STEMI Guidelines (Van de Werf at al, EHJ 2008) Not able to arrive to cath lab in 120 min: inhab. (12 %) Niš (2) ACC/AHA 2007 STEMI Guideline Focused Update Not able to arrive to cath lab in 90 min: inhab. (20 %) 2002 census

23 Organization of STEMI patient disposal describing pre- and in-hospital management, and reperfusion strategies within 12 h of First Medical Contact (FMC) Symptoms of STEMI EMS GP / Cardiologist Self referral Pre-hospital diagnosis & care Ambulance to Cath Primary PCI capable centre Private transportation Non-primary PCI capable centre PCI possible < 2 h Primary PCI no Rescue PCI 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 Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

24 NORWAY Prehospital treatment 4.8 mill with people fibrinolysis is used in areas with long transfer delays to PCI km km from N to S 7 PCI hospitals Long transfer times to PCI (>2 h) in: Mountains Islands Fjords Sparsely populated areas Unstable weather conditions PCI-hospital

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26 1 ary PCI for STEMI: Take Home Don t miss the detailed presentation of the new 2012 ESC Guidelines for STEMI Aug 27, 8:30 1 ary PCI for STEMI is life-saving 1 ary PCI procedures ~ 30% of cathlab workload in good networks Among the big 5 Primary PCI for STEMI is the biggest!