KONGRES 2.pptx - STEMI in Norway changing paradigmas
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KONGRES 2.pptx - STEMI in Norway changing paradigmas KONGRES 2.pptx - STEMI in Norway changing paradigmas Presentation Transcript

  • Treatmant patients with acute myocardial infarcton in Bosnia and Herzegovina
    BH Heart Centre Tuzla
    Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.
  • Implementation of the STEMIESC Guidelines
  • ESC STEMI – guidelines
    ACC/AHA & ESC guidelines
  • Myokardnekrose
    • Starts 30-45min after occlusion
    • After 90min is 40-50% necrotised
    • After 6h the necrosis is often complete
    • Collaterals modify
    • Occlusion is often sub-total or fluctuating
    AHA Textbook of Advanced Cardiac Life Support, 1999
  • PCI
    Prehospitalt EKG
    Trombolyse
  • Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk.
    Risk of Fibrinolysis
    Time Since Symptom Onset
    Risk of STEMI
    Time Required for Transport to a Skilled PCI Lab
  • Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment.
    If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
    Fibrinolysis generally preferred
    • Early presentation ( ≤ 3 hours from symptom
    onset and delay to invasive strategy)
    • Invasive strategy not an option
     Cath lab occupied or not available
     Vascular access difficulties No access to skilled PCI lab
    • Delay to invasive strategy
     Prolonged transport Door-to-balloon more than 90 minutes
     > 1 hour vs fibrinolysis (fibrin-specific agent) now
  • Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment.
    If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.
    Invasive strategy generally preferred
    • Skilled PCI lab available with surgical backup Door-to-balloon < 90 minutes
    • High Risk from STEMI Cardiogenic shock, Killip class ≥ 3
    • Contraindications to fibrinolysis, including
    increased risk of bleeding and ICH
    • Late presentation > 3 hours from symptom onset
    • Diagnosis of STEMI is in doubt
  • Evolution of PCI for STEMI
    AngioJet
    ASA
    Clopidogrel
    Platelet
    GP IIb/IIIa inhibitor
    Embolization Protection Device
    Thrombus Removal and Distal Embolization Protection Devices
    Balloon
    Antiplatelet Rx
    Stent
    DES
    Antman. Circulation 2001;103:2310.
  • The essence in todays PCI -”Guidelines” (2005).
    • STEMI should be evaluated with respect to reperfusion therapy immediately
    • Establish good networks
    • Preshospital services
    • Local hospitals
    • PCI-centra
    • Implement details in guidelines at all levels in the treatment chain
  • Reperfusion strategyRecommendation IA….
    • PrimaryPCI
    • All when < 90 –120 (?) min. to balloon
    • All with contraindicasion to thrombolysis
    • Probably most patients with long chest pain history (> 3 – 6 - 12 t??)
    • Thrombolyse to the others;
    • preferably prehospital and within 3 h from onset of symptoms
  • Prognostic PCIRecommendation IA
    • PCI within 24 hrs after sucessful thrombolysis
    • Randomised trials; effect on combined endpoints
    • No effect on mortality
    • Discussed…..
  • Rescue PCIRecommendation IB-IIC
    • Cardiac shock <75 y & <18 h after development of shock (IB)
    • Unsuccessful thrombolysis after 45-60 min (ECG & clinical eval) (IIC)
  • Combined strategy, recomm IIB
    • Pretreatment with thrombolysis or Gp-IIb-IIIa-inhibitor before PCI in high-risk?
    • Insufficient documentation (Garcia, SIAM..)
    • ASSENT IV; higher mortality with combined treatment (6%)versus primaryPCI(3,8%), but positiv for some groups and some weekness in the study
    • STREAM??
  • ”Facilitated PCI” (thrombolysis before PCI)
    PCI: 3,8%
    Tenecteplase + PCI: 6,0%
    30d mort.
    But, pts with prehospital thrombolysis; ~2%
    ASSENT-4 trial, Lancet 2006; 367:569-78.
  • Pretreatment before primary PCI
    • MONA (morphine, Oxyg, Nitro, ASA 300)
    • Heparin bolus;5-10.000 iv.(70IE/kg iv. )
    • Clopidogrel 600mg pr. os
    • Evt. Thrombolyse befor transportation (facilitated PCI) when high risk??
  • TREATMENT MI IN EUROPE
    Anual incidence of hospital admissions 900-3120 on mil.
    STEMI amdissions 440-1420 on mil.
    P-PCI 20-920 on mil.
    P-PCI 5-92%
    TL – thrombolysis 0-55%
    Single p-PCI centre 0.3-7.4 mil
    In hospital mortality 4,2-13,5%
    P-PCI mortality 2,7-8 %
    TL mortality 3,5-14%
  • Bosnia and Herzegovina
    3.9 mill
    88/km2
    GNP 2300 US$/year (2005)
  • Interventional cardiology in BiH
    PCI centres 5
    PCI-mil. 770.000
    Independent interv.cardiologists 11
    Anual MI admissions 7200
    Anual STEMIs 3100
  • Invasive procedures in Bosnia and Herzegovina
    Coronography PCI
    3676 616
    3167 784
    3569 1018
  • Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
    2009.
    • 8interventional cardiologists,
    • 4 PCI centres
    • PCI totaly 1018
    • PCI – per centre 254
    • PCI – per operator 127
    • Primary PCI –NA les then 10%
    • Radial – brachial access (%) 1
    • Abciximab (%) 4
    • IABP (%) 1
    • Respirator (%) 1
  • Challenges:
    Geography
    Distances
    Number of invasive centers
    24 hours on call – costs
    Transportation
    Revascularisation mode; PCI? Thrombolysis?
    Prehospital ECG-systems
    Responsibility for patients
    Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
  • Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina
    STEMI – Do we need more PCI-centers?
  • New PCI – centers
    ”Proposal”
    • Centervolume > 600 PCI (1500-2000 angiograms)
    • Cheaf > 500 PCI (historical experience)
    • On-call operator >300 PCI (historical experience)
    • Yearly operatorvolum >100 PCI
    • 24 hours service
    • On duty – how often? 4 – 5 – 6 ??
    • On call clinical cardiology service
    • Defined geographical regions
  • M.R.38 y.m.STEMI inf.
  • B.M.44 mSTEMI ant.