From interventional cardiology to cardio-neurology. A new subspeciality in the future? Prof. Andrejs Erglis, MD, PhD Pauls Stradins Clinical University Hospital University of Latvia Riga, LATVIA
Disclosure Speaker name: ANDREJS ERGLIS I have the following potential conflicts of interest to report: Consulting (Abbott Vascular, Biosensors, Biotronik, Bostons Scientific) Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
Causes of death in Europe Deaths by cause, males, latest available year, Europe Deaths by cause, females, latest available year, Europe European Cardiovascular Disease Statistics 2017 http://www.ehnheart.org/cvd-statistics.html
History of STEMI and ischemic stroke treatment Catanese L et al. Circ Res. 2017 Feb 3;120(3):541-558. EVT, endovascular therapy TNK, tenecteplase; TPA, tissue-type plasminogen activator; STK, streptokinase
Death Death, excl. SHOCK data Non-fatal MI Recurrent ischemia Stroke Haemorrhagic stroke Major bleed Death, non-fatal MI, or stroke Primary angioplasty vs thrombolytic therapy in STEMI: review of 23 RCT 23 trials, 7739 patients with STEMI randomised to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. % 25 20 15 10 5 0 Short-term outcomes: Events after 4-6 weeks after thrombolysis or PCI P=0.0002 7 9 P=0.0003 5 7 7 P<0.0001 3 6 22 P<0.0001 P=0.0004 1 2 0,05 1 N=7739 P<0.0001 7 P=0.032 6 P<0.0001 8 14 PCI Thrombolysis Keeley EC et al. Lancet. 2003 Jan 4;361(9351):13-20.
Interventional cardiology in Latvia 1990: PTCA 2 PCI centres with 24/7 service (1 per million) 2 PCI centres without 24/7 service 1 only angio centre 1996: BMS 2002: DES 2012: BVS Total population: 1.97 million (in 2016) Total area: 64 589 km 2
Hospitals Providing Care to ACS Patients in Latvia 35 2005 33 2006 32 2007 29 2008 25 2009 18 2010 16 2011 8 2012-2016
Network of emergency services
Patients (%) STEMI treatment in Latvia 2015: 565 PCI per million 90 80 70 60 50 40 30 20 10 0 76 72 73 74 76 78 71 74 69 64 65 71 68 55 59 55 49 44 36 30 36 33 30 32 29 28 21 26 22 23 20 21 12 18 13 14 16 13 15 1 0 1 1 2 3 4 4 2 3 5 11 12 3 48 1 2001 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 PPCI Rescue PCI Total PCI Fibrinolysis No reperfusion
STEMI - in-hospital mortality 18 16 14 12 10 8 6 4 2 0 Overall in-hospital mortality (%) 17 16 13 16 15 14 9 9 7 In-hospital mortality accoring to treatment strategy (%) 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 40 35 32 30 27 28 28 25 24 25 20 18 19 20 16 15 12 13 11 11 9 10 6 7 8 7 4 4 5 0 8 10 5 7 4 55 5 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 38 31 32 TL PPCI No reperfusion
Patients(n) 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 9028 7222 Latvian registry of ACS: Annual incidence of ACS 7752 5936 1806 1816 6648 5155 6176 4577 5747 5752 4223 4217 5301 3714 1493 1599 1524 1535 1587 4778 STEMI 47% 3378 1400 2015 3221 2086 3564 2330 1135 1234 3071 1629 1442 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 NSTEMI/ UA 53% ACS NSTEMI/UA STEMI
Meta-analysis: Endovascular treatment vs. i.v. thrombolysis alone for ischaemic stroke 8 RCT and 2423 participants Non-stent retriever systems: 3 studies (IMS III, MR RESCUE, SYNTHESIS Expansion) EVT: intra-arterial fibrinolysis or first-generation mechanical embolectomy devices, alone or in combination vs. intravenous t-pa Stent retriever systems: 5 studies (EXTEND-IA, MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME) EVT: stent retrievable systems, with some studies permitting the use of salvage intra-arterial fibrinolytic drugs (i.e., MR CLEAN, ESCAPE, SWIFT PRIME), while other studies did not allow this use (EXTEND-IA, REVASCAT). vs. intravenous t-pa Ferrante G et al. EuroIntervention. 2016 Jun 12;12(2):e271-81.
Meta-analysis: Endovascular treatment vs. i.v. thrombolysis alone for ischaemic stroke Eight RCT enrolling 2,423 participants were included. Ferrante G et al. EuroIntervention. 2016 Jun 12;12(2):e271-81.
2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
Impact of Onset-to-Reperfusion Time on Stroke Mortality In a collaborative pooled analysis of 7 endovascular databases (480 cases), the impact of onset- to-reperfusion time in large-artery occlusion (internal carotid artery or middle cerebral artery) on outcomes was analyzed. Successful reperfusion was defined as complete or partial restoration of blood ow within 8 hours from symptom onset. Primary outcome was 90-day all-cause mortality. Secondary outcomes included 90-day favorable outcome (modi ed Rankin Scale score, 0 2), 90-day excellent outcome (modi ed Rankin Scale score, 0 1), and occurrence of any intracerebral hemorrhage within 24 to 36 hours after treatment. Mazighi M et al. Circulation. 2013 May 14;127(19):1980-5.
Higher volume faster times better outcomes Retrospective analysis of 442 consecutive patients treated with endovascular therapy at 9 tertiary stroke centers (USA) from September 2009 to July 2011. High volume centers = performing more than 50 endovascular intra-arterial stroke interventions annually. Good clinical outcome: a modified Rankin score of 2 between 90 and 120 days were. considered to have a good clinical outcome. Gupta R et al. J Neurointerv Surg. 2013 Jul;5(4):294-7.
Neuro-cardiology or cardio-neurology Stroke prevention: Cardiologists should broadly cooperate with neurologists in stroke prevention (both primary and secondary) due to the fact that most strokes occur as a complication of another cardiovascular disease (e.g., atrial fibrillation, hypertension, endocarditis, intracardiac shunts, etc.). STROKECLOSE a Nordic randomized clinical trial Prevention of STROKE by Left Atrial Appendage CLOSurE in Atrial Fibrillation Patients after Intracerebral Hemorrhage - A Multicenter Randomized Clinical Trial Endovascular treatment in acute ischemic stroke: associated with improved reperfusion, early neurologic recovery and functional outcomes, but unfortunately there are not enough neurovascular interventionists and limited 24/7 acute stroke centers in many countries. Multidisciplinary approach: Endovascular treatment could be performed with the close cooperation of cardiologists, neurologists and radiologists Interventional cardiologists already have experience with carotid interventions
Prospective registry PRAGUE-16 The role of direct catheter-based thrombectomy in acute stroke and the feasibility and safety of interventions performed in an interventional cardiology center was investigated in 115 patients with acute ischemic stroke. Angiographic success was 69-81%. Neurologic recovery was achieved in 40% patients. Direct thrombectomy lead to neurologic recovery in 36%, while bridging thrombolysis in 52%. Symptomatic intracranial bleeding was present in 3.6% (direct) and 6.5% (bridging). Acute stroke interventions performed in close cooperation of cardiologists, neurologists and radiologists were feasible and safe. Widimsky P et al. EuroIntervention. 2017 May 15;13(1):131-136.
Green corridor for STEMI and ischaemic stroke ischaemic stroke
From interventional cardiology to cardio-neurology. A new subspeciality in the future? Prof. Andrejs Erglis, MD, PhD Pauls Stradins Clinical University Hospital University of Latvia Riga, LATVIA
Geographic distribution of relative mortality from stroke and ischemic heart disease World Health Organization Global Burden of Disease Program, 2004 Kim AS et al. Circulation. 2011 Jul 19;124(3):314-23.
Geographic distribution of relative mortality from stroke and ischemic heart disease Mortality from stroke relative to ischemic heart disease World Health Organization Global Burden of Disease Program, 2004 Kim AS et al. Circulation. 2011 Jul 19;124(3):314-23.