The document discusses different strategies for reperfusion in ST-elevation myocardial infarction (STEMI) patients, including primary percutaneous coronary intervention (PPCI), fibrinolysis, and PCI following fibrinolysis. It summarizes the TRANSFER-AMI trial which compared a "pharmacoinvasive" strategy of early PCI within 6 hours of fibrinolysis to standard treatment of PCI only for failed reperfusion in high-risk STEMI patients initially treated with fibrinolysis. The trial found the pharmacoinvasive strategy reduced the primary composite endpoint of death, reinfarction, or ischemia at 30 days with no increase in bleeding risks compared to standard treatment.
1. PCI after MI, When ? Ahmed Magdy, MD, FACC, FSCAI National Heart Institute, Cairo
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6. Gersh, B. J. et al. JAMA 2005;293:979-986. 1)Time is myocardium 2)Infarct size is outcome Relationship Between Duration of Symptoms of MI Before Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial Salvage Modified by collaterals,ischemic preconditioning,myocardial oxygen uptake, other vessels
7. Gersh, B. J. et al. JAMA 2005;293:979-986. 1)Time is myocardium 2)Infarct size is outcome Relationship Between Duration of Symptoms of MI Before Reperfusion Therapy, Mortality Reduction, and Extent of Myocardial Salvage Modified by collaterals,ischemic preconditioning,myocardial oxygen uptake, other vessels Symptom onset to hosp Arrival 2 hr Thrombolysis given, 2 ½ hr Symptom onset to balloon 3 ½ hr Thrombolysis induced reperfusion 3 ½ hr
8. Importance of Rapid Time to Treatment With Fibrinolysis in STEMI Time from onset of symptoms to treatment (hours) Absolute % difference in mortality at 35 days 3.5% 2.5% 1.8% 1.6% 0.5% 0.0 1.0 3.0 2.0 4.0 0 – 1 2 – 3 4 – 6 7 – 12 12 – 24 The Fibrinolytics Therapy Trialists’ collaborative group. Lancet . 1994; 343:311.
9. PCI In-hospital Mortality vs Door to Balloon Time Door to Balloon Time (hours) In-hosp Death Rate 0-1.4 1.5-1.9 2.0-2.9 >3.0 N= 2,322 Brodie BR, JACC 47, 2006 N=384 N=493 N=750 N=673
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14. Mortality rates with primary PCI as a function of PCI-related time delay Circle sizes = sample size of the individual study. Solid line = weighted meta-regression . 62 min Benefit Favors PCI Harm Favors Lysis For Every 10 min delay to PCI: 1% reduction in mortality difference towards lytics P = 0.006 0 20 40 60 80 100 PCI-Related Time Delay (door-to-balloon - door to needle) Absolute Risk Difference in Death (%) -5 0 5 10 15 Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-6
51. Post-Lysis PCI studies GRACIA-1 SIAM III CAPITAL MI CARESS P=0.001 P=0.0008 P=0.04 P=0.001 N=1436
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53. T rial of R outine AN gioplasty and S tenting after F ibrinolysis to E nhance R eperfusion in A cute M yocardial I nfarction The TRANSFER-AMI trial Warren J. Cantor, David Fitchett, Bjug Borgundvaag, Michael Heffernan, Eric A. Cohen, Laurie J. Morrison, John Ducas, Anatoly Langer, Shamir Mehta, Charles Lazzam, Brian Schwartz, Vladimir Dzavik, Amparo Casanova, Paramjit Singh, Shaun G. Goodman on behalf of the TRANSFER-AMI Investigators
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56. PCI Centre Cath Lab Community Hospital Emergency Department Cath / PCI within 6 hrs regardless of reperfusion status Cath and Rescue PCI GP IIb/IIIa Inhibitor TNK + ASA + Heparin / Enoxaparin + Clopidogrel “ Pharmacoinvasive Strategy” Urgent Transfer to PCI Centre Assess chest pain, ST resolution at 60-90 minutes after randomization ‘ High Risk’ ST Elevation MI within 12 hours of symptom onset Failed Reperfusion* Successful Reperfusion Elective Cath PCI > 24 hrs later “ Standard Treatment” * ST segment resolution < 50% & persistent chest pain, or hemodynamic instability Repatriation of stable patients within 24 hrs of PCI Randomization stratified by age (≤75 vs. > 75) and by enrolling site
57. Procedures Cardiac Cath performed (%) Time- TNK to Cath (hrs) PCI performed (%) Stent used (% of PCI cases) Time- TNK to PCI (hrs) PCI within 6 hrs of TNK (%) PCI within 12 hrs of TNK (%) GP IIb/IIIa inhibitor use (%) Time- TNK to GP IIb/IIIa inhib. (hrs) IABP use (%) CABG performed (%) Standard Treatment (n=508) 82 27 (4, 69) 62 98 18 (4, 73) 38 47 53 11 (4, 63) 6 8 Pharmacoinvasive Strategy (n=522) 97 3 (2, 4) 84 98 4 (3, 5) 89 97 73 4 (3, 5) 7 6 PRELIMINARY
58. Selected Medications Used ASA 1 st 6 hrs Clopidogrel 1 st 6 hrs * Heparin Enoxaparin Beta Blocker 1 st 6 hrs ASA at discharge Clopidogrel at discharge Beta Blocker at discharge ACE Inhibitor at discharge Lipid Lowering at discharge Standard Treatment (n=508) 97 69 57 55 61 85 73 79 74 80 Pharmacoinvasive Strategy (n=522) 98 87 57 51 55 85 79 81 73 81 * p< 0.05 PRELIMINARY
70. 2010 4 th . Acute Cardiac Care Course EGYPT COMBAT MI 2010 Cairo Sheraton, March 24-26, 2010
Editor's Notes
Review recent influences/randomized clinical trials (RCTs) in reperfusion that have impacted the guidelines and that this will be reviewed in-depth during this session: Superiority of PPCI over fibrinolysis if Door-to-Balloon completed in a timely fashion (Keeley & Grines, European STEMI Guidelines 2003 heralded PPCI as the preferred method of reperfusion) Plain old balloon angioplasty (POBA) has become almost extinct in the states. The most commonly used PPCI in the US- Stents + GP IIb-IIIa Inhibitor Drug eluting stents (DES) in STEMI is on the horizon Finally, acknowledgement that Time Matters in PPCI. Zwolle group, CADDILAC data, Nallamathou and Bates (graph on Door- to- Balloon minus Door-to- Needle), etc. Recommendations for time to reperfusion for PPCI (time from first medical contact-to-balloon; door-to-balloon) have been lowered to within 90 minutes Phase III studies on GP IIb-IIIa + ½ dose TNK-tPA, ½ dose rPA as well as Enoxaparin + full dose TNK-tPA have been published and reviewed. Studies with other antithrombins (including, ASSENT-3 ASSENT-3+, HERO-2). Awaiting EXTRACT (ENOX vs UFH with any lytic). To date, nothing Phase III scheduled with Bivalrudin and newer fibrinolytics. Recent predominantly European STEMI trials influence the guidelines Prehospital received a Phase IIa rating-explored in TIMI 19, CAPTIM, ASSENT-3 + European Transfer Trials (PRAGUE experience, DANAMI-2) and their transferability to the US system is in question; Guidelines emphasize ‘Prehospital Destination Protocols’.
“ The mortality benefit associated with primary percutaneous coronary intervention in ST-segment elevation myocardial infarction may be lost if door-to-balloon time is delayed by > 1 hour as compared with fibrinolytic therapy door-to-needle time. Interventional cardiology laboratories endeavoring to achieve the benefits of primary percutaneous coronary intervention seen in randomized clinical trials should aim to match their short door-to-balloon times”. (pg. 824) Legend key (pg.825) Absolute risk reduction in 4- to 6-week mortality rates with primary PCI as a function of PCI-related time delay. Circle sizes reflect the sample size of the individual study. Values > 0 represent benefit and values < 0 represent harm. Solid line , weighted meta-regression . Nallamothu BK, Bates ER. Am J Cardiol. 2003;92:824-6