Primary Percutaneus coronary intervention


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STEMI only
Urgent angioplasty(with/out stenting)- Preferably in ≤90min
No TLT before or parallel
Open the infarct—related

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Primary Percutaneus coronary intervention

  1. 1. Primary PCI Prof A N Patnaik Dr RAMACHANDRA BARIK Dr Lalita Nemani
  2. 2. Define  STEMI only  Urgent angioplasty(with/out stenting)- Preferably in ≤90min  No TLT before or parallel  Open the infarct—related
  3. 3.  Delayed PCI PCI After TLT 1.Rescue(REACT/MERLIN/RESCU E) 2.Facilitated(BRAVE/HERO/CAPI TAL/WASTE/ASCEND) Of its kinds
  4. 4. STEMI Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Circulation 2007;116:2634-53.
  5. 5. Today’s evening • Abbreviating time is everything 1.Best transfer Protocol 2. Reverse Paradox • PPCI vs. TLT • Who need it? • PPCI in Octagenerian • Set up 1.Your Lab 2.Surgical Back up
  6. 6. Contd...... • Operator skill • Initial therapy in ICCU • Radial vs. Femoral • Optimal anticoagulation • POBA/ BMS/DES • Hardware • IABP/ECMO-When and its role
  7. 7. Contd.... • In cath lab • After cathlab=ICCU • Predischarge triage • Finance • Take home message
  8. 8. Politician also knows.....time is life
  9. 9. Time is muscle Every minute counts Gersh BJ, Stone GW, White HD, et al. Pharmacological facilitation of primary percutaneous coronary intervention foracute myocardial infarction: is the slope of the curve the shape of the future? JAMA 2005;293:979-86
  10. 10. Terkelsen CJ, Sorensen JT, Maeng M, et al. Systemdelay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA2010;304:763-71.
  11. 11. Primary PCI vs. TLT Choice (TIMI)-3 Flow in 95% vs 54%(TLT) Gersh BJ et al. Pharmacological facilitation of PPCI for STEMI: is the slope of the curve the shape of the future? JAMA 2005;293:979-86 Stone GW et al. Comparison of angioplasty with stenting,with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-66
  13. 13. PAMI Trial-1997 POBA provides a small-to-moderate, short-term clinical advantage over TLT with t-PA. PPCI when it can be accomplished promptly at experienced centers, should be considered an excellent alternative method for myocardial reperfusion. The investigators and centers participating in the GUSTO IIb Angioplasty Substudy ,Cleveland Clinic,USA
  14. 14. A 2003 meta-analysis 23 randomized trials 7739 patients  Reductions in short-term death (7% vs 9%, P 0.0002),  fatal reinfarction (3% vs 7%, P 0.0001),  stroke (1% vs 2%, P 0.0004) Keeley EC et al. Primary angioplasty versus intravenous thrombolytic therapy foracute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361:13-20
  15. 15. But TLT is the invaluable in certain conditions because delay in opening artery causes • CHF/ readmissions/OPD visits increases  independently with mortality(HR/OR=1.1)  detrimental in age<65, presenting within 2 hours Death+ reinfarction+disabling stroke at 30 days was significantly < PCI in 2 of the studies, with a trend toward significance in the underpowered third study
  16. 16. “DIDO=Door-in-door-out=30” Pretransfer TLT CAPTIM WEST
  17. 17. “Number Paradox” Golden’s Hour:2-3Hrs.
  18. 18. Evidence
  19. 19. Evidence....
  20. 20. Evidence.. • MITRA STUDY(Maximal therapy in AMI) • SWISS STUDY • DANAMI II • SHOCK(Shock) • NRMI-II(CHF)
  21. 21. Then what to choose?Then what to choose? “Reperfusion paradox” vs Best transfer protocol
  22. 22. reduce
  23. 23. Initial management =MONA Oxygen  Aspirin Nitroglycerin Opioids(Morphine)
  24. 24. Cath lab standard
  25. 25. Adjunctive Antithrombotic Therapy • Antiplatlets • Anticoagulation
  26. 26. Antiplatlets
  27. 27. Antiplatlets
  28. 28. GROUP IIB-IIIA Inhibitors
  29. 29. Anticoagulants ‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s. §The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).
  30. 30. Access No but you better understandNo but you better understand
  31. 31. Shock • Killip IV • Ionotrope optimum • Control IV fluid • CPR • IABP/ECMO • LVAD • CABG
  32. 32. IABP but use it!!!!!!!! • No Δ in infarct size at 3-5 days • No Δ in all cause death at 6 months Ohman EM, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during AMI.RCT. The Randomized IABP Study Group. Circulation 1994. Stone GW et al, (PAMI-II) Trial Investigators. J Am Coll Cardiol 1997; 29:1459. Brodie BR et al,IABP, before PPCI reduces catheterization laboratory events in high-risk patients with AMI . Am J Cardiol 1999 Patel MR,et al. CRISP AMI Trial. JAMA 2011; 306:1329.
  33. 33. Anticoagulation-ACT Anticoagulation ACT HEPARIN ONLY 250 to 350 seconds  +GIIB-IIIA 200-250 POST Procedural No heparin Sheath removal ≤150-180sec Heparin reversal 100 Unit=1mg of Protamin Sulphate IV bolus
  34. 34. Manual aspiration thrombectomy • 1.Microvascular function improves • 2.Decrease death • 3.MCE I IIa IIb III  Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008;371:1915–20 Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307: 1817–26 No reduction infarction size in large AWMI
  35. 35. Culprit vs. Bystanders
  36. 36. Culprit vs. Bystanders PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable(2013 STEMI guideline). I IIa IIb III Preventive Angioplasty in Myocardial Infarction=PRAMI 2008 through 2013, at five centers in UK 465(234/234) Subsequent PCI for inducible ischemia/refractory angina  composite of death/nonfatal MI/refractory angina  significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery
  37. 37. STENTS BMS/DES is useful I IIa IIb III BMS:High bleeding risk/noncomply with 1 year of DAPT/ anticipated invasive or surgical procedures in the coming year I IIa IIb III DES should not be used if unable to tolerate/comply with a prolonged course of DAPT. I IIa IIb III Harm
  38. 38. POBA vs. BMS  tenting further reduced subsequent TLR but not shown a survival advantage 1. Stone GW et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-66 2. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent primary angioplasty in myocardial infarction study group. N Engl J Med 1999;341:1949-56.
  39. 39. BMS vs. DES DES greater reduction in TLR BUT not associated with improved survival because added late ST Stone GW et al. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009;360:1946-59. Brar SS et al. Use of drug-eluting stents in acute myocardial infarction: a systematic review and meta-analysis. J Am Coll Cardiol 2009;53:1677-89. TYPHOON, PASSION, SESAMI, DEDICATION, and HORIZONS AMI
  40. 40. DES for STEMI • TVR reduction >>BMS • No extra stent thrombosis with DAP • PCI with DES is not mandatory in STEM • BMS may be preferable in cases in which comorbid conditions, compliance, or financial means may interfere with the required duration of dual- antiplatelet therapy after DES placement
  41. 41. POBA vs.BMS vs. DES(G1/G2) Keeping to right is right
  42. 42. BMS Vs DES( G1) • no significant difference in mortality, (8.5 versus 10.2 percent; HR 0.85,(95% CI 0.70-1.04). • TLR was lower with DES (12.7 versus 20.1 percent; HR 0.57, 95% CI 0.50-0.66). • No Δ in the cumulative rate of ST (5.8 versus 4.3 percent; HR 1.13, 95% CI 0.86-1.47). VLS (events after two years) was higher for DES (HR 2.81, 95% CI 1.28-6.19). • No Δ in the cumulative rate of reinfarction (9.4 versus 5.9 percent; HR 1.12, 95% CI 0.88-1.41). 2Y- the rate significantly increased for DES (HR 2.06, 95% CI 1.22-3.49). De Luca G, et al. DES vs BMS in primary angioplasty: a pooled patient-level meta-a
  43. 43. BMS vs DES -G2 Cobalt-chromium everolimus-eluting stents (CoCr-EES) • one-year risk of cardiac death/ MI was reduced with the former but not the latter (odds ratio [OR] 0.63, 95% CI 0.42-0.92 and 0.86, 95% CI 0.50- 1.49). • one-year risk TVR was reduced with the former but not the latter (OR 0.45, 95% CI 0.29-0.66 and 0.60, 95% CI 0.34-1.05). • the one-year risk of definite stent thrombosis was reduced with the former but not the latter (OR 0.32, 95% CI 0.11-0.78 and 0.44, 95% CI 0.12- 1.79). • lower one-year rates of cardiac death or MI, definite stent thrombosis, and target vessel revascularization
  44. 44. The COMFORTABLE AMI trial • WITH Biolums as polymer the MCE FURTHER REDUCED
  45. 45. Drug-eluting balloon plus BMS • First human trial • not significantly different between the DEB-BMS and BMS groups • Drug is paclitaxel Belkacemi A, J Am Coll Cardiol. 2012 Jun;59(25):2327-37. Epub 2012 Apr 11.
  46. 46. Direct Stenting • significantly lower rate of all-cause death • Lesser no flow/slow flow • Better myocardial preservation HORIZON AMI  Loubeyre C et al. A RCT of direct stenting with conventional stent implantation in selected patients with AMI . J Am Coll Cardiol 2002; 39:15. Ly HQ et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol 2005; 95:383. Antoniucci D, et al. Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction. Am Heart J 2001; 142:684.
  47. 47.  Bioresorbable vascular Scaffolds • Safe • Feasible • Available Size, short expiry is limitation • Not approved/not guide lined • Long term result awaited PRAGUE-19 Study,87 pts/3 yrs//started in 2012/Abbott vascular
  48. 48. Intra coronary IIB-IIIA inhibitor(abciximab)  Death+ reinfarction, p=0.03  Death ,p=0.04)  TVR ,p=0.045)  Reinfarction; p=0.13 Raffaele Piccolo et al,Italy,Meta analysis,2012, Heart doi:10.1136/heartjnl- 2011-301101
  49. 49. Intracoronary Adenosine • A bolus injection of intracoronary adenosine (900 micrograms in 5 mL of 0.9% sodium chloride solution). Control patients received an intravenous bolus injection of adenosine (900 micrograms in 20  mL sodium chloride) during the procedure • Elective intracoronary administration of high-dose adenosine as adjunctive therapy to primary PCI reduces MVO
  50. 50. INTRA CORONARY TLT • 2.5 lakhs unit STK • Improves no reflow • Improves TFC • EPICARDIAL coronary looks beautiful • At 6 months ,no gain add to viable myocardium Murat Sezer et al, Turkey, N Engl J Med 2007; 356:1823-1834,
  51. 51. Date of download: 9/28/2013 Copyright © The American College of Cardiology. All rights reserved. From: Effect of Intracoronary Streptokinase Administered Immediately After Primary Percutaneous Coronary Intervention on Long-Term Left Ventricular Infarct Size, Volumes, and Function J Am Coll Cardiol. 2009;54(12):1065-1071. doi:10.1016/j.jacc.2009.04.083
  52. 52. Intracoronary hyperoxemic reperfusion therapy • Safe and well tolerated Dixon SR et al,Pilot study, J Am Coll Cardiol. 2002;39(3):387
  53. 53. Ischemic conditioning • Ischemic preconditioning • Ischemic post conditioning confer benefit • Remote Ischemic conditioning 30sec-1min-30sec-1min-30sec Kloner RA, Jennings RB.
  54. 54. Suboptimal reperfusion after PPCI/Complication  Persistent stenosis or thrombosis  Coronary dissection  Intramural hematoma  Side branch occlusion  Coronary spasm  Distal macroembolism  Acute stent thrombosis  No-reflow phenomenon  Reperfusion injury  Capillary blistering and edema of endothelial cells  Edema and swelling of myocytes PAMI: Age ≥70 years Diabetes Longer time to reperfusion Initial TIMI flow grade ≤1 Left ventricular ejection fraction <50 percent
  55. 55. Ventricular Arrhythmias • Immediate defibrillation or cardioversion for VF or pulseless sustained VT, • Early (within 24 hours of presentation) administration of beta blockers. • The prophylactic use of lidocaine is not recommended. • VPC, NSVT not associated with hemodynamic compromise, and AIVR are not indicative of increased SCD risk needs less attention.
  56. 56. No reflow phenomenon • 10 – 30 % • Influences the long term results of PCI significantly. • Minimised by NTG(25 microgram). Verapamil, diltiazem, GpIIBIIIA inhibitors, nikorandil(IONA), thrombectomy, intracoronary STK, ischemic post conditioning.
  57. 57. Rescue CABG < 3% Aspirin should not be withheld Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG. Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible. I IIa IIb III I IIa IIb III I IIa IIb III
  58. 58. RESCUE CABG Abciximab should be discontinued at least 12 hours before urgent CABG. Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding. Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding. I IIa IIb III I IIa IIb III I IIa IIb III
  59. 59. Role of third antiplatlet Yes you may add,but bleeding matters
  60. 60. Sheath removal timing • ACT <160 SEC • SHEATH SIZE α compression time • USE OF Group IIA-IIIB inhibitors • After 6 hrs for femoral and 2 hours for Radial
  61. 61. Beware of Bleeding
  62. 62. Very Elderly (≥85 Years)  Claessen et al. Primary percutaneous coronary intervention for ST elevation myocardial infarction in octogenarians: trends and outcomes. Heart 2010;96:843–7 Danish Registry Supports Primary PCI in Elderly STEMI Patients-2013 Senior-PAMI-2005
  63. 63. Secondary prevention • Beta Blockers: initiated in the first 24 hours unless C/I • Renin-Angiotensin-Aldosterone System Inhibitors:within 24 hrs • Lipid Management
  64. 64. Posthospitalization Plan of Care •Prevent hospital readmissions •Should be used to facilitate the transition to effective •Outpatient care I IIa IIb III •Exercise-based cardiac rehabilitation •Secondary prevention programs I IIa IIb III
  65. 65. Posthospitalization Plan of Care Medication adherence Follow-up Dietary and physical activities Compliance with interventions for secondary prevention should be provided to patients with STEMI. No smoking No secondhand smoke I IIa IIb III I IIa IIb III
  66. 66. CVD risk can begin before birth!!