EXPERTS WORKSHOP ON EARLY TREATMENT  STRATEGIES FOR ACUTE MYOCARDIAL INFARCTION FOR THE MIDDLE EAST COUNTRIES FEBRUARY 26 ...
Fire ! <ul><li>Your house is on fire... </li></ul>
The Fire Spreads Quickly <ul><li>Every second is crucial, the damage is getting worse </li></ul>
Transportation !? <ul><li>You are watching the firemen loading the burning stuff... </li></ul>
To  Extinguish the Fire ! <ul><li>” Time is muscle and life!” </li></ul>
“ Time is Muscle”  Cross-sections of left ventricle after experimental coronary artery occlusion (Reimer KA, et al. Circul...
Acute MI again? Why? <ul><li>   It is serious </li></ul><ul><li>   It’s desperately urgent </li></ul><ul><li>   We must...
“ Time is muscle”   MITI 4.9 11.2 14 12 10 8 6 4 2 0 Infarct Size (%) < 70 min 70-180 min
Estimated benefit (lives saved at 35 days) per 1000 patients Time  from onset (hours) Mortality Reduction Depends on the D...
Morrison’s Meta-analysis <ul><li>OBJECTIVE   </li></ul><ul><ul><li>To realize a meta-analysis  of randomized trials explor...
Delay pain – treatment French experience 1.60 1.59 2.10 2.10 2.35 3.03 3.03 2.50 3.03 2002 2001 1997 2001 2002 2001 2000 1...
Material and Drugs of   the  SMUR  <ul><li>Diagnostics: </li></ul><ul><li>ECG </li></ul><ul><li>Mini laboratory </li></ul>...
ASSENT-3  Plus (Pre-hospital Treatment) Early treatment  (ambulance-car) of AMI patients <6 hrs  ASA RANDOMIZATION  1:1 TN...
Hours to treatment  (median) 3+ 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 ENOX UFH TNK TNK Symptom - call Call - a...
Thrombolysis or PTCA still a debate ?
CAPTIM <ul><li>C omparison of </li></ul><ul><li>A ngioplasty and </li></ul><ul><li>P re-hospital </li></ul><ul><li>T hromb...
<ul><li>M I C U - SMUR  </li></ul>CAPTIM  Design ST segment     onset of pain < 6 h All received ASA + Heparin Central ra...
<ul><li>Primary </li></ul><ul><ul><li>Composite (30 day)      all-cause mortality </li></ul></ul><ul><ul><li>     recurr...
<ul><li>Primary endpoint %  </li></ul><ul><li>Death (%) </li></ul><ul><li>Reinfarction (%) </li></ul><ul><li>Disabling str...
<ul><li>Cardiovascular death (%) </li></ul><ul><li>New onset of angina (%) </li></ul><ul><li>Urgent angioplasty (%) </li><...
DANAMI-2 DENMARK 5.4 mill. inhabitants 5 PCI centers 24 referral hospitals 62% of Danish  population Transport distance up...
DANAMI II ACC 2002 <ul><li>5 PCI centers + 22  referring hospitals </li></ul><ul><li>distance average = 56 km </li></ul><u...
Comparaison CAPTIM / DANAMI II <ul><li>  Thrombolysis  PCI  p </li></ul><ul><li>CAPTIM 8.2 %   6.2 %   0.29  </li></ul><ul...
<ul><li>  CAPTIM  DANAMI II combined </li></ul><ul><li>PHT   PCI   thrombolysis  PCI </li></ul><ul><li>Death 3.8 %   4.8 %...
Preventing Reinfarction :  IIb/IIIa Inhibitors, Enoxaparin, or Primary PCI PRAGUE-2 30-day deaths 6.8 v 10.0 % , p = 0.12 ...
DANAMI-2 vs CAPTIM vs ASSENT-3 Mortality at 30 days % (TNK + ENOX) ESSAI TOTAL 6.6 4.8 7.6 3.8 5.4 5.8 0 2 4 6 8 DANAMI-2 ...
CAPTIM 1-Year Results Pre-Hospital Lysis Primary PCI Death GW Symposium, AHA 2002 Death Pre-Hospital Lysis Primary PCI Sx ...
CAPTIM 1 Year Results Pre-Hospital Lysis Primary PCI P=0.032 Shock Randomization to DC GW Symposium, AHA 2002 P=0.0007 Sho...
All presented periods are median Beginning  of pain 65 min Emergency  call at  SAMU 19 min PEC SMUR Beginning  of thrombol...
 
The Lille Experience 4h55 3h 3h 1h49 1h42 0 1 2 3 4 5 6 Thr. pre-hosp. Thr. pre-hosp. + angioplasty Thr. hosp. Thr. hosp.+...
USIC 2000 <ul><li>French nationwide survey designed as a multicenter, prospective longitudinal study over one month </li><...
One-month Mortality in Patients  with Reperfusion Therapy:  USIC 2000 n = 428   370   108   47 %   41 %   12 % 7.9 7.8 4.6...
USIC 2000: One-month Mortality  in Patients with Reperfusion Therapy n = 370   108   428   41%   12%   47% 7.1 9.6 3.0 5.8...
Combined Strategy of reperfusion
The Combined Strategies of Reperfusion   J.M. Julliard :  A matched comparison of the combination of prehospital thromboly...
Which Delays for This Technique of Combined Reperfusion <ul><li>PHT Admission = 58    20 min </li></ul><ul><li>Admission ...
<ul><li>Outcome after Combined Reperfusion Therapy for AMI, Combining Pre-hospital Thrombolysis with Immediate PTCA and St...
131 patients Angiography 95 min after TT 64 (49%) TIMI 3 54 (84%) PTCA  65 (50%) TIMI 0 - 2 PTCA  119 (91%) PTCA 114 stent...
Long-term follow-up  <ul><li>2    1 year </li></ul><ul><li>mortality rate : 6% (8 patients) </li></ul><ul><li>non-fatal r...
Early PCI versus Guided PCI  after Lytics in the Modern Era   Death Relative risk, fixed model Bilateral CI, 95% for trial...
Rescue PCI after Lytics RESCUE 0.53  [0.16;1.75] REACT 0.51  [0.24;1.10] MERLIN 1.14  [0.59;2.20] LIMI 0.84  [0.27;2.65] B...
Conclusion <ul><li>Pre-hospital thrombolysis is still the gold standard </li></ul><ul><li>Very high risk patients MUST hav...
<ul><li>Pre-hospital thrombolysis </li></ul><ul><li>+ immediate angioplasty </li></ul><ul><li>+ stent implantation </li></...
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Primary angioplasty

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  • Primary angioplasty

    1. 1. EXPERTS WORKSHOP ON EARLY TREATMENT STRATEGIES FOR ACUTE MYOCARDIAL INFARCTION FOR THE MIDDLE EAST COUNTRIES FEBRUARY 26 TH -28 TH 2005 / DUBAI, UAE SPONSORED BY BOEHRINGER INGELHEIM SUNDAY, 27 th FEBRUARY – SESSION 2 A rationale for pre-hospital thrombolytic therapy Patrick Goldstein
    2. 2. Fire ! <ul><li>Your house is on fire... </li></ul>
    3. 3. The Fire Spreads Quickly <ul><li>Every second is crucial, the damage is getting worse </li></ul>
    4. 4. Transportation !? <ul><li>You are watching the firemen loading the burning stuff... </li></ul>
    5. 5. To Extinguish the Fire ! <ul><li>” Time is muscle and life!” </li></ul>
    6. 6. “ Time is Muscle”  Cross-sections of left ventricle after experimental coronary artery occlusion (Reimer KA, et al. Circulation. 1977;56:786-794). Duration of occlusion 3 h Area supplied by occluded artery x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x XXXX Necrosis Ischemic but viable Non-ischemic 24 h 40 min
    7. 7. Acute MI again? Why? <ul><li> It is serious </li></ul><ul><li> It’s desperately urgent </li></ul><ul><li> We must act efficiently, in order to significantly reduce mortality before arrival at the hospital </li></ul><ul><li> The diagnosis is clinical </li></ul><ul><li> The strategy and the therapeutic management are in constant movement </li></ul>
    8. 8. “ Time is muscle” MITI 4.9 11.2 14 12 10 8 6 4 2 0 Infarct Size (%) < 70 min 70-180 min
    9. 9. Estimated benefit (lives saved at 35 days) per 1000 patients Time from onset (hours) Mortality Reduction Depends on the Delay “Onset of Pain - Thrombolytic Treatment” Eric Boersma’s meta-analysis (22 trials from 83 to 93 - 50 246 patients) BOERSMA, E. et al Early thrombolytic in acute myocardial treatment infarction : reappraisal of the golden hour - Lancet 1996 ; 771 - 775 0 12 18 24 6 0 20 40 60 80 11% 30 to 50 lives saved for 1000 patients 1 to 3 hours 60 to 80 lives saved for 1000 patients 30 to 60 min 1- month benefit Delay
    10. 10. Morrison’s Meta-analysis <ul><li>OBJECTIVE </li></ul><ul><ul><li>To realize a meta-analysis of randomized trials exploring mortality in pre-hospital vs in-hospital thrombolysed AMI </li></ul></ul><ul><ul><li>INCLUDED STUDIES </li></ul></ul><ul><ul><li>6 studies (n = 6 434) </li></ul></ul><ul><li>RESULTS </li></ul><ul><ul><li>Delay pain to treatment : Pre-hospital thrombolysis = 104 min In-hospital thrombolysis = 162 min (diff = 58 min) (p=0.007) </li></ul></ul><ul><ul><li>Significant reduction of the in-hospital death rate (all causes) with pre-hospital thrombolysis : (- 17%) (OR 0.83; 95% CI, 0.70-0.98). </li></ul></ul>JAMA, May 2000 - Vol 283 - N ° 20 - 2686-92
    11. 11. Delay pain – treatment French experience 1.60 1.59 2.10 2.10 2.35 3.03 3.03 2.50 3.03 2002 2001 1997 2001 2002 2001 2000 1995 1990 ESTIM Nord ESTIM IdF STIM SAMU CAPTIM A3+ A3 A2 G3 GI
    12. 12. Material and Drugs of the SMUR <ul><li>Diagnostics: </li></ul><ul><li>ECG </li></ul><ul><li>Mini laboratory </li></ul><ul><li>Therapeutics: </li></ul><ul><li>fibrinolytic </li></ul><ul><li>heparin </li></ul><ul><li>anti GP IIb/IIIa </li></ul><ul><li>aspirin </li></ul><ul><li>nitroglycerine </li></ul><ul><li>morphine </li></ul><ul><li>defibrillator </li></ul><ul><li>electric syringe </li></ul><ul><li>oxygen </li></ul><ul><li>and more </li></ul><ul><li>Monitoring : </li></ul><ul><li>Scope Sao2 </li></ul>
    13. 13. ASSENT-3 Plus (Pre-hospital Treatment) Early treatment (ambulance-car) of AMI patients <6 hrs ASA RANDOMIZATION 1:1 TNK-tPA full dose 0.53 mg/kg bolus Unfractionated heparin 60 IU/kg bolus (max. 4000 IU) 12 IU/kg/hr infusion (max 1000 IU/ hr) target aPTT 50-70 sec Patients’ outcome will be compared with matched pairs extracted from the corresponding arm of the ASSENT-3 main study. The same exploratory endpoints (single and composite) as in the ASSENT-3 main study will be evaluated; the influence of time to treatment will be analyzed. (500) TNK-tPA full dose 0.53 mg/kg bolus Enoxaparin 30 mg i.v. bolus 1 mg/kg s.c. twice a day (500)
    14. 14. Hours to treatment (median) 3+ 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 ENOX UFH TNK TNK Symptom - call Call - arrival Arrival - Rand. Rand. - first drug First drug - ER ASSENT-3 In-hospital Symptom – TNK 45 min
    15. 15. Thrombolysis or PTCA still a debate ?
    16. 16. CAPTIM <ul><li>C omparison of </li></ul><ul><li>A ngioplasty and </li></ul><ul><li>P re-hospital </li></ul><ul><li>T hrombolysis </li></ul><ul><li>I n acute </li></ul><ul><li>M yocardial infarction </li></ul>ESC 2001
    17. 17. <ul><li>M I C U - SMUR </li></ul>CAPTIM Design ST segment  onset of pain < 6 h All received ASA + Heparin Central randomisation In-hospital Pre-hospital PCI thrombolysis Diagnosis positive in 95%
    18. 18. <ul><li>Primary </li></ul><ul><ul><li>Composite (30 day)  all-cause mortality </li></ul></ul><ul><ul><li>  recurrent MI </li></ul></ul><ul><ul><li>  disabling stroke </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Cardiovascular death </li></ul></ul><ul><ul><li>New onset of angina </li></ul></ul><ul><ul><li>Urgent angioplasty </li></ul></ul><ul><ul><li>Cardiogenic shock </li></ul></ul><ul><ul><li>Hemorrhagic stoke </li></ul></ul><ul><ul><li>Severe hemorrhage </li></ul></ul>CAPTIM - Clinical Endpoints
    19. 19. <ul><li>Primary endpoint % </li></ul><ul><li>Death (%) </li></ul><ul><li>Reinfarction (%) </li></ul><ul><li>Disabling stroke (%) </li></ul>CAPTIM - Results primary endpoint Pre-hospital thrombolysis n = 419 Primary PCI n = 421 P Value 8.2 RR = 0.76 3.8 3.7 1.0 6.2 RR = 0.76 4.8 1.7 0.0 0.29 0.60 0.13 0.12
    20. 20. <ul><li>Cardiovascular death (%) </li></ul><ul><li>New onset of angina (%) </li></ul><ul><li>Urgent angioplasty (%) </li></ul><ul><li>Cardiogenic shock (%) </li></ul><ul><li>Hemorrhagic stoke (%) </li></ul><ul><li>Severe hemorrhage (%) </li></ul>CAPTIM - secondary endpoints Pre-hospital thrombolysis n = 419 Primary PCI n = 421 P Value 3.8 7.2 33.0 2.5 0.5 0.5 4.3 4.0 4.0 4.9 0.0 2.0 0.86 0.09 < 0.01 0.09 0.49 0.06
    21. 21. DANAMI-2 DENMARK 5.4 mill. inhabitants 5 PCI centers 24 referral hospitals 62% of Danish population Transport distance up to 95 US miles (mean 35 miles) 100 US miles
    22. 22. DANAMI II ACC 2002 <ul><li>5 PCI centers + 22 referring hospitals </li></ul><ul><li>distance average = 56 km </li></ul><ul><li>1129 patients 443 patients </li></ul><ul><li>referring hospitals PCI centers </li></ul><ul><li>no transfer ambulance PCI fibrinolysis </li></ul><ul><li>transfer on site </li></ul><ul><li>fibrinolysis </li></ul>Very high risk patients: ST > 4 mm
    23. 23. Comparaison CAPTIM / DANAMI II <ul><li> Thrombolysis PCI p </li></ul><ul><li>CAPTIM 8.2 % 6.2 % 0.29 </li></ul><ul><li>DANAMI II combined 13.7 % 8.0 % 0.003 </li></ul><ul><li>DANAMI II referring 14.2 % 8.5 % </li></ul><ul><li>DANAMI II invasive 12.3 % 6.7 % 0.048 </li></ul>Combined Death, ReMI and stroke
    24. 24. <ul><li> CAPTIM DANAMI II combined </li></ul><ul><li>PHT PCI thrombolysis PCI </li></ul><ul><li>Death 3.8 % 4.8 % 7.6 % 6.6 % </li></ul><ul><li>Disabling 1.0 % 0.0 % 2.0 % 1.1 % stroke </li></ul><ul><li>Reinfarction 3.7 % 1.7 % 6.3 % 1.6 % </li></ul>Look at the single endpoints: 30 days
    25. 25. Preventing Reinfarction : IIb/IIIa Inhibitors, Enoxaparin, or Primary PCI PRAGUE-2 30-day deaths 6.8 v 10.0 % , p = 0.12 * 6-month data in press, Simes AHU 2002 ** Pre-hospital administration p < 0.05 reMI, death (PCAT only) ; stroke (PCAT only) CAPTIM 840 PCI t - PA** DANAMI - 2 1.572 PCI t - PA C - PORT* 451 PCI t - PA PCAT* 2.725 PCI lytic Death 4.6% 3.7% 6.6% 7.6% 6.2% 7.1% 6.2% 8.2% ReMI 1.7% 3.7% 1.6% 6.3% 5.3% 10.6% 4.8% 9.8% Stoke 0 1.0% 1.1% 2.0% 2.2% 4.0% 0.7% 1.9%
    26. 26. DANAMI-2 vs CAPTIM vs ASSENT-3 Mortality at 30 days % (TNK + ENOX) ESSAI TOTAL 6.6 4.8 7.6 3.8 5.4 5.8 0 2 4 6 8 DANAMI-2 CAPTIM ASSENT-3 ASSENT3+ PCI TT
    27. 27. CAPTIM 1-Year Results Pre-Hospital Lysis Primary PCI Death GW Symposium, AHA 2002 Death Pre-Hospital Lysis Primary PCI Sx < 2 hours Sx > 2 hours P=0.057 P=0.47 2.2% 5.7% 0% 5% 5.9% 3.7% 0% 10%
    28. 28. CAPTIM 1 Year Results Pre-Hospital Lysis Primary PCI P=0.032 Shock Randomization to DC GW Symposium, AHA 2002 P=0.0007 Shock Randomization to Adm Pre-Hospital Lysis Primary PCI Sx < 2 hours Sx < 2 hours 1.3% 5.3% 0% 5% 0.0% 3.6% 0%
    29. 29. All presented periods are median Beginning of pain 65 min Emergency call at SAMU 19 min PEC SMUR Beginning of thrombolysis 35 min 66 min Arrival at hospital 84 min Puncture According to ATLS: 32 min 120 min 185 min E-MUST Comparable periods
    30. 31. The Lille Experience 4h55 3h 3h 1h49 1h42 0 1 2 3 4 5 6 Thr. pre-hosp. Thr. pre-hosp. + angioplasty Thr. hosp. Thr. hosp.+ angioplasty Angioplasty
    31. 32. USIC 2000 <ul><li>French nationwide survey designed as a multicenter, prospective longitudinal study over one month </li></ul><ul><li>Aim: to assess current practices and clinical outcome in patients admitted to an ICU for AMI in France </li></ul><ul><li>Organisation : </li></ul><ul><ul><li>in-hospital outcome </li></ul></ul><ul><ul><li>one-year follow-up </li></ul></ul>
    32. 33. One-month Mortality in Patients with Reperfusion Therapy: USIC 2000 n = 428 370 108 47 % 41 % 12 % 7.9 7.8 4.6 0 1 2 3 4 5 6 7 8 9 Primary PTCA IV lysis Lysis + PTCA
    33. 34. USIC 2000: One-month Mortality in Patients with Reperfusion Therapy n = 370 108 428 41% 12% 47% 7.1 9.6 3.0 5.8 3.6 7.9 0 2 4 6 8 10 12 Hosp. lysis no PCI Pre-hosp. lysis no PCI Hosp. lysis + PCI Pre-hosp. lysis + PCI Primary PCI
    34. 35. Combined Strategy of reperfusion
    35. 36. The Combined Strategies of Reperfusion J.M. Julliard : A matched comparison of the combination of prehospital thrombolysis and stand bye rescue angioplasty with primary angioplasty. Am.J. Cardiol. 1999 ; 83 - 305-310. 170 patients in Paris city Pre-hospital Thrombolysis Angiography at 80 min TIMI 3 108 (64%) TIMI 2 12 (7%) TIMI 0 50 (29%) angioplasty TIMI 3 91% TIMI 2 7%
    36. 37. Which Delays for This Technique of Combined Reperfusion <ul><li>PHT Admission = 58  20 min </li></ul><ul><li>Admission Angiography = 59  19 min </li></ul><ul><li>Then </li></ul>2 h after PHT only 2% of patients are TIMI O or 1
    37. 38. <ul><li>Outcome after Combined Reperfusion Therapy for AMI, Combining Pre-hospital Thrombolysis with Immediate PTCA and Stent </li></ul>1995-1999 1010 patients with AMI (Paris Sud Cardiovascular Institute) 148 patients with pre-hospital full-dose thrombolytic therapy 131 patients included (median time = 2 h after onset of pain ) C. Loubeyre and all. Eur. Heart J. 2001 ; 22 : 1128-1135
    38. 39. 131 patients Angiography 95 min after TT 64 (49%) TIMI 3 54 (84%) PTCA 65 (50%) TIMI 0 - 2 PTCA 119 (91%) PTCA 114 stent 120/131 TIMI 3 (92%) 9/131 TIMI 2 2 TIMI 0-1 no emergency surgery From C. Loubeyre
    39. 40. Long-term follow-up <ul><li>2  1 year </li></ul><ul><li>mortality rate : 6% (8 patients) </li></ul><ul><li>non-fatal re MI : 2 patients </li></ul><ul><li>survival + no RI rate </li></ul><ul><li>= 90% </li></ul><ul><li>94 patients (70%) symptom free </li></ul><ul><li>- no re-hospitalization </li></ul><ul><li>- no revascularization </li></ul>C. Loubeyre. Eur. Heart J. 2001 ; 22 : 1128-1135
    40. 41. Early PCI versus Guided PCI after Lytics in the Modern Era Death Relative risk, fixed model Bilateral CI, 95% for trials, 95% for MA SIAM III 0.44 [0.14;1.37] GRACIA-1 0.57 [0.26;1.26] CAPITAL-AMI 0.67 [0.11;3.89] Total 0.54 [0.29;0.99] 0.047 Cochran Q het. p=0.91 Rel. Risk 0 1 2 3 4 0.538, p=0.047 RR CI p
    41. 42. Rescue PCI after Lytics RESCUE 0.53 [0.16;1.75] REACT 0.51 [0.24;1.10] MERLIN 1.14 [0.59;2.20] LIMI 0.84 [0.27;2.65] Belenkie et al 0.19 [0.02;1.47] Total 0.73 [0.48;1.11] 0.138 Cochran Q het. P=0.33 Death 6 weeks Relative risk, fixed model Bilateral CI, 95% for trials, 95% for MA Rel. Risk 0.4 1.0 1.6 2.2 RR CI p
    42. 43. Conclusion <ul><li>Pre-hospital thrombolysis is still the gold standard </li></ul><ul><li>Very high risk patients MUST have a PCI with a minimum delay </li></ul><ul><li>Transfer is not an additional risk </li></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul><ul><li>Pre-hospital thrombolysis + Angioplasty </li></ul>
    43. 44. <ul><li>Pre-hospital thrombolysis </li></ul><ul><li>+ immediate angioplasty </li></ul><ul><li>+ stent implantation </li></ul><ul><li>is safe and effective </li></ul>EP. Mc Fadden. Eur. Heart J. 2001 ; 22 : 1067-69
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