Kardiologie-Kreis KH Barmherzige Schwestern Linz, 2.10.2012 ESC 2012: Klinisch relevante Neuigkeiten beim ACS 30 Minuten Priv.- Doz. Dr. Hannes Alber REHA ZENTRUM MÜNSTER UNIV.- KLINIK f. INNERE MED. III (KARDIOLOGIE) Klinikum für RehabilitaKon in Tirol Medizinische Universität Innsbruck
ESC 2012 Klinisch relevant Neues beim ACS STEMI Guidelines 2012 IABP- SHOCK II TRILOGY ACS
STEMI Guidelines
STEMI Guidelines 2012 Steg PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215. presented at the ESC annual meekng in Munich, 26- Aug- 2012.
STEMI Guidelines 2012 ASA - recommendakons Steg G. and James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
STEMI Guidelines 2012 Aspirin 2012: 2008: Van de Werf et al. EHJ 2008; 29: 2909-45. Steg G. and James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
STEMI Guidelines 2012 ADP receptor antagonists - recommendakons Steg G. and James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
TRITON Prasugrel vs. Clopidogrel in Subgroups Prior Stroke / TIA Yes No Post- hoc analysis P int = 0.006 Risk (%) + 37-16 Age >=75 < 75 P int = 0.18-1 - 16 Wgt < 60 kg >=60 kg P int = 0.36 +3-14 OVERALL 0.5 1 2 Prasugrel Befer Clopidogrel Befer HR - 13
STEMI Guidelines 2012 ADP receptor antagonists - recommendakons Steg G. and James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
TRITON- TIMI 38 STEMI (n=3434, ppci=2438, spci=1094) CV death, MI, stroke CV death, MI, urgent TVR CV death at 30 days: Clopidogrel: 2.4% vs. Prasugrel: 1.4%; p= 0.0469 NNT: 109 (68-24758) Montalescot G et al. Lancet 2009;373:723
CV death, MI, stroke PLATO Subgroup of STEMI (n=7544) CV death HR 0.87 (0.75 to 1.01); p= 0.07 HR 0.83 (0.67 to 1.02); p= 0.07 Steg GP et al. CirculaKon. 2010;122:2131-41.
STEMI - ppci STEMI Guidelines 2012 AnKcoagulants STEMI guidelines 2008: Bivalirudin IIa B (Van de Werf F et al. EHJ 2008; 29:2909 2945.) Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
HORIZONS- AMI net adv. events @ 30d Harmonizing Outcomes w. RevascularizaKon a. Stents in AMI Heparin + GPIIb/IIIa inhibitor (N=1802) Bivalirudin monotherapy (N=1800) 20 30 day event rates (%) 15 10 5 HR = 0.75 (0.62-0.92)] p=0.006 12,1 9,2 8,3 5,5 4,9 5,4 0 Net adverse clinical events Major bleeding* MACE** *Not related to CABG **MACE = All cause death, reinfarckon, ischemic TVR or stroke Stone GW presented at AHA Nov- 2007, Orlando, FL.
AusKan Acute- PCI Registry Benchmark Report 2011 GP IIb/IIIa: 43.0% Bivalirudin: 5.0% ThrombusaspiraKon: 30.0%
STEMI Guidelines 2012 Doses of AnKcoagulants Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
AnKcoagulaKon in STEMI What s NOT wrong for the emergency doc in 2012 UnfracKoned Heparin (UFH): 60IU/kg, max. 4000IE iv ArgumentaKon: Bivalirudin (with its highest recommendakon IB) remains possible in ppci (Enoxaparin pre- treatment was exclusion criterion in HORIZONS- AMI) Dose seleckon allows......the use of GP IIb/IIIa- inhibitor use in ppci....thrombolysis. UFH effect is measurable in cath- lab using ACT UFH is skll a class I recommenda;on (LoE: C) Alber, 09-2012
STEMI Guidelines 2012 Timing 2008: 2012: Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
STEMI Guidelines 2012 pre- /in- hospital management large anterior MI, delay <2h adopted from Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
STEMI Guidelines 2012 pre- /in- hospital management large anterior MI, delay <2h adopted from Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
Reperfusion Therapy in STEMI RRR with ppci, delays + pakent risk n = 192.509 STEMI; NRMI 2-4 (06/ 94-08/ 03) n = 126.909 thrombolysis (92% fibrin- specific) n = 65.600 ppci Pinto DS et al. CirculaKon 2006; 114: 2019-25.
ppci vs. Thrombolysis Time Delays in RCTs Study Time to PCI Time to LyKc (from rand., min.) (from rand., min.) PRAGUE- 1 80 70 10 PRAGUE- 2 97 80 17 MAASTRICHT 85 75 10 Air- PAMI 122 103 19 CAPTIM 82 59 23 DANAMI- 2 90 70 20 PCI 71 Lysis Dalby M et al. CirculaKon 2003; 108: 1809-14.
Reperfusion Therapy in STEMI RRR with ppci, delays + pakent risk PCI- related delay (min) where PCI- and thrombolysis- mortality are equal 180 120 60 0 168 non- ant. MI; >65yrs 179 107 ant. MI; >65yrs 148 58 non- ant. MI; 65yrs 103 40 ant. MI; 65yrs MulKvariate Model includes: Treatment type PaKent variables: age, DM, gender, race, RR, pulse, AP, Killip class, previous MI, symptom durakon, discharge year, infarct locakon, payer Hospital variables: STEMI vol., ppci vol., rural locakon, teaching status, transfer- in rate 43 > 2 h delay 2 h delay Pinto DS et al. CirculaKon 2006; 114: 2019-25.
STEMI Guidelines 2012 pre- /in- hospital management large anterior MI, delay <2h adopted from Steg, PG, James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215.
ESC 2012 Klinisch relevant Neues beim ACS STEMI Guidelines 2012 IABP- SHOCK II TRILOGY ACS
IABP- SHOCK II
Cardiogenic Shock RecommendaKons in STEMI guidelines 2012 SHOCK trial!! IABP- SHOCK II not included JAMA 2005; 294:1664 SOAP- II James SK et al. EHJ 2012; doi: 10.1093/eurheartj/ehs215. presented at the ESC annual meekng in Munich, 26- Aug- 2012.
Cardiogenic Shock IABP- SHOCK II trial n = 600 AMI with cardiogenic shock (RRs < 90mmHg or catecholamines + pulmonary congeskon + end- organ hypoperfusion) open- label randomizakon: IABP vs. no IABP 1 EP: all- cause mortality at 30 days Thiele H. et al. NEJM 2012; epub 27- Aug- 2012.
IABP- SHOCK II all- cause mortality 41.3% 39.7% Thiele H. et al. NEJM 2012; epub 27- Aug- 2012.
IABP- SHOCK II Efficacy / Safety outcome parameters Thiele H. et al. NEJM 2012; epub 27- Aug- 2012.
IABP- SHOCK II all- cause mortality subgroup analysis Thiele H. et al. NEJM 2012; epub 27- Aug- 2012.
ESC 2012 Klinisch relevant Neues beim ACS STEMI Guidelines 2012 IABP- SHOCK II TRILOGY ACS
TRILOGY- ACS
AnKpläfchentherapie beim ACS SOP Innsbruck 2012 Alber, Frick, Pachinger 2012
TRILOGY ACS Prasugrel in medically managed pts. TRILOGY ACS - The Targeted Platelet InhibiKon to Clarify the OpKmal Strategy to Medically Manage Acute Coronary Syndromes Roe MT et al., NEJM 2012; published 26- Aug- 2012; DOI: 10.1056/NEJMoa1205512
TRILOGY ACS Study Design Medically Managed UA/NSTEMI PaKents N 10, 300 RandomizaKon StraKfied by: Age, Country, Prior Clopidogrel Rx (Primary analysis cohort Age < 75 yrs) n=9326 < 75 yrs = 7243 75 yrs = 2083 Med Management Decision 72 hrs (No Prior Clopidogrel Given) Med Management Decision 10 days (Clopidogrel Started 72 hrs OR on Chronic Clopidogrel) Low Dose ASA + Clopidogrel 300 mg LD + 75 mg MD Prasugrel 30 mg LD + 5* or 10 mg MD Clopidogrel 75 mg MD Prasugrel 5* or 10 mg MD Minimum Rx Dura;on: 6 months; Maximum Rx Dura;on: 30 months, Median FU: 17.1 months (10.4-24.4) * For subjects < 60 kg or 75 years Primary Efficacy Endpoint: CV Death, MI, Stroke Chen et al., AHJ 2010 and Roe MT et al, NEJM 2012; DOI: 10.1056/NEJMoa1205512
TRILOGY ACS 1 Efficacy EP < 75 years 1 Efficacy EP (CV death, nf MI, nf stroke) Clopidogrel Prasugrel 0.91 (95% CI, 0.79 to 1.05); p = 0.21 TIMI non- CABG major bleeds Roe MT et al., NEJM 2012; published 26- Aug- 2012; DOI: 10.1056/NEJMoa1205512
TRILOGY ACS EPs <75 years (overall, 1y, >1y) EP 30mo 0-12mo >12mo CV death, n- f MI, 0.91 0.99 0.72* n- f stroke (0.79-1.05) (0.84-1.16) (0.54-0.97) TIMI major bleeds 1.31 (non- CABG) (0.81-2.11) CV death 0.93 1.00 0.75 (0.76-1.15) (0.78-1.28) (0.49-1.14) All MI 0.89 0.97 0.68 (0.74-1.07) (0.78-1.19) (0.48-0.99) All strokes 0.67 0.86 0.35 (0.42-1.06) (0.50-1.47) (0.14-0.88) * p (interackon): 0.07 Roe MT et al., NEJM 2012; published 26- Aug- 2012; DOI: 10.1056/NEJMoa1205512
Natural History of CAD Fate of culprit and non- culprit lesions n = 697 ACS pts. a~er successful PCI (66.1% DES) 3- vessel IVUS plus VH examinakon MACE (cardiac death, cardiac arrest, MI, rehosp. due to unstable / worsening AP) adjudicated as inikally culprit or inikally non- culprit lesion according to FU- CAG. FU MEDIAN = 3.4 yrs. Stone GW et al. NEJM 2011; 364: 226-35.
CumulaKve rate of MACE* (%) 25 20 15 10 5 0 Natural History of CAD PROSPECT indetermined events (no FU- CAG) overall events CL- related events NCL- related events 20.4% 12.9% 11.6% 2.7% 0 1 2 3 years *Cardiac death, cardiac arrest, MI, rehosp. for unstable/progressive AP modified a~er Stone GW et al. NEJM 2011; 364: 226-35.
AnKpläfchentherapie beim ACS SOP Innsbruck 2012 Alber, Frick, Pachinger 2012
ESC 2012 Klinisch relevant Neues beim ACS STEMI Guidelines 2012 IABP- SHOCK II TRILOGY ACS
AusKan Acute- PCI Registry Benchmark Report 2010 as of 17.5.11