KCS Congress: Impact through collaboration

Transcription

1 STEMI IN A NEW INTERVENTIONAL ENVIRONMENT Harun A Otieno, FACC June 29th, 2017 KCS Congress: Impact through collaboration

2 Disclosures I have no conflicts of interest for this talk I have no relationships to disclose

3 OBJECTIVES 1.Approaches to adjunctive pharmacology in STEMI 2.Review strategies for Multivessel CAD in STEMI 3.Improving safety and outcomes in Kenya

4 Adjunctive Pharmacology in STEMI Clopidogrel ASPIRIN Aspirin therapy has been the cornerstone of STEMI treatment New agents bring new benefits, but also risks Rationale for drug selection Ticagrelor Prasugrel

5 ISIS 2: 10 year survival The early survival advantages produced by fibrinolytic therapy and one month of aspirin started in acute myocardial infarction seem to be maintained for at least 10 years. Baigent. BMJ. 1998;316(7141):

6 Dual Anti-Platelet Therapy in STEMI The ACCF/AHA supports the use of all P2Y 12 receptor inhibitors with similar levels of recommendation (clopidogrel, prasugrel, and ticagrelor all receive Class I, Level of Evidence: B) The ESC prefers prasugrel or ticagrelor to clopidogrel, unless they are not available or contraindicated Bainey KR. J Am Coll Cardiol 2016; 67:

7 Ticagrelor vs Clopidogrel in patients with ACS Ticagrelor provides faster, more consistent reversible platelet inhibition Lower rate of death/mi/stroke More non-cabg (4.5% vs 3.8%), More fatal intracranial bleeding (0.1% vs. 0.01%) Wallentin L. N Engl J Med 2009:361:

8 TRITON-TIMI 38: Net Clinical Benefit Mainly PCI ACS patients Prasugrel- similar platelet inhibition in 30 mins as clopidogrel in 6 hours Prasurgel 60mg load, then 10mg

9 OBJECTIVES 1.Approaches to adjunctive pharmacology in STEMI Aspirin is the cornerstone of therapy with balancing risk between different P2Y12 inhibitors - clopidogrel, ticagrelor & prasugrel 2.Strategies in multivessel CAD in STEMI 3.Improving safety and outcomes in the Kenya

10 Multivessel CAD in STEMI: 30-50% A 48 year old Male, presents with substernal crushing chest discomfort for 2 hours. Prior history of dyslipidemia. He receives tenecteplase within 30 mins or arrival and goes for angiography in 6 hours, stable - 90% lesion in LAD, 75-90% in LCx

11 Question: What is your strategy? A.PCI only of the Infarct related artery, LAD & stress testing in a 4-6 weeks B.PCI of the LAD and FFR of the LCx, & stent if <0.80 C.PCI of the LAD and LCx at the same setting D.PCI of the LAD and re-admit patient in days to a few weeks for intervention to the LCx

12 STEMI Guidelines: Multivessel CAD ACCF/AHA guidelines PCI should NOT be performed in a noninfarct artery at the time of primary PCI in hemodynamically stable patients (III B). PCI of the non- IRA at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia (I C).

13 The CvLPRIT Trial 296 patients randomized to complete revascularization or IRA only PCI. Death/MI/HF/Revasc - 12 months 10% vs 21.2% HR 0.45 ( , p<0.009) Gershlick T. J Am Coll Cardiol 2015;65:

14 Assessment of non-ira lesions in STEMI? One year MACCE, 7.8% in the complete revascularization group vs 20.5% in the IRA-only group. HR, 0.35, 95%{CI]

15 OBJECTIVES 1.Approaches to adjunctive pharmacology in STEMI Aspirin is the cornerstone of therapy with balancing risk between different P2Y12 inhibitors - clopidogrel, ticagrelor & prasugrel 2.Strategies in multivessel CAD with STEMI Complete revascularization in primary PCI should be considered Physiologic assessment of non-ira is safe and beneficial during P-PCI 3.Improving safety and outcomes in Kenya

16 Radiation safety in the Cath lab Operator & Cath Lab Personnel Left-sided brain tumors Cataracts Thyroid disease? CV effects Reproductive system effects

17 STEMI in Kenya What do we know? A. Patients present late, 12.9 hours after symptom onset in STEMI B. Only 27% of hospitals have ECG C. 7 cath labs in Nairobi & latest one in Mombasa D. Guideline based care, but optimal reperfusion in <50%

18 Hub-and-Spoke Model: Lessons for Kenya Strategies to Improve Care 1. STEMI Kit = ECGs with Vital signs monitor, Telemedicine 2. Health care financing (NHIF) 3. Integrated ambulance & emergency services 4. Pharmaco-invasive & P-PCI JAMA Cardiol. 2017; ;2:

19 Impact through Collaboration ORGANIZATION Ministry of Health Kenya Cardiac Society NHIF, AKGH Kenya Red Cross, AMREF, Philips, GE Healthcare, FLARE Safaricom, Web & Mobile based app designers Stent - Save a Life, Heart Attack Concern Kenya AfricaSTEMI Live Teaching, Public and Private Hospitals PARTICIPATING PARTNER ROLE National Strategic Policy in NCDs Clinical care, Coordination Health care financing, Ambulance and emergency services 12 lead ECG, Data collection, Integration of Health Information Systems Professional and Patient Advocacy Professional Medical Education & Conferences Capacity building, Systems of care

20 STEMI IN A NEW INTERVENTONAL ENVIRONMENT 1.Approaches to adjunctive pharmacology in STEMI Aspirin is the cornerstone of therapy with balancing risk between different P2Y12 inhibitors - clopidogrel, ticagrelor & prasugrel 2.Strategies in multivessel CAD with STEMI Complete revascularization in primary PCI should be considered Physiologic assessment of non-ira is safe and beneficial during P-PCI 3.Improving safety and outcomes in Kenya We need more data, more collaboration Promote Hub-and-spoke model system of care