KONGRES 2.pptx - STEMI in Norway changing paradigmasPresentation 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
Starts 30-45min after occlusion
After 90min is 40-50% necrotised
After 6h the necrosis is often complete
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
Implement details in guidelines at all levels in the treatment chain
Reperfusion strategyRecommendation IA….
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
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
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.
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?