Warong Lapanun MD.Bhumibol Adulyadej Hospital                6/2/2011
Mr PM: 54-y-o presenting at a non-PCI hospital• 12.00 Myalgia and fatigueEpigastric fullness for 2 hrs• 12.30 : Rx Diclofi...
   Transfer for primary PCI   Lysis on Site   Lysis with immediate transfer to cath lab   Which type of Lytic Rx will ...
%            20                        n = 29,222            15Mortality                        p < 0.01            10    ...
192, 509 pts at 645 NRMI hospitals               Pinto et al. Circulation. 2006;114:2019-2025
• 43801 pts STEMI PPCI    •D2B  Mortality( P<0.001)• ACC registry 2005-2006   • 30 min = 3.0%• In hospital Mortality    ...
Rathor SS,et al. BMJ2009:338;1807
Mortality Reduction(%)10                                             Potential outcomes        E8                         ...
Infarct size                       Myocardial Edema       Myocardial Salvage        Microvascular                         ...
Fribrinolytic Characteristic                      SK      r-tPA                        TNKTIMI flow gr 3      ~30%     ~50...
Risk Factors     Risk Score   ICH(%)   Age > 75 yr          0-1        0.69   Black race            2         1.02      ...
CAPTIM: 5 Year SurvivalPrehospital Thrombolysis vs Primary PCI                            Prehosp lysis                   ...
%Historical             Points                                                                    40   Age > 75           ...
ST ResolutionBenjamin M. Scirica JACC 2010;55;1403-1415
   Primary PCI   Rescue PCI   Facilitated PCI   Pharmaco-invasive
I IIa IIb III                with PCI capability should be Rx with p-A               PCI within 90 min of FMC .    Modifie...
    STEMI within 12 h after onset of symptoms    At centre without PCI facilities with>1 high risk features:1.   Cumulat...
Carlo Di Mario, Lancet 371 February 16, 2008
   Pts with STEMI within 12 hrs after onset of symptoms   At centers : No PCI capability   Rx with Tenecteplase (TNK) ...
TRANSFER AMI                                          High Risk STEMI  12 hrs, 1059 Pts                                  ...
Kaplan-Meier CurvesPrimary Endpoint* at 30 Days             Re-infarction at 6 Months                   Std Rx            ...
Verheugt, NEJM 2009; 360, 26: 2779-2781
PharmacoinvasiveFacilitated PCI                     No Class III
   ER physician activate the Cath Lab   One call activate the cath lab   Cath lab team ready in 20-30 min   Prompt dat...
PCI-Centerผู้ป่วยเจ็บหน้ำอก รอบัตร รอแพทย์ตรวจ   ทำ EKG ใน 10 นำที      แพทย์เวร ER      แพทย์เวร Med    Fellow cardioปรึก...
Fast Track MIEKG ด่วนแพทย์ดูใน 10 นำที elevation ตำม staff cardio ทันที ST ST elevation ………………. MD. No
ESC GUIDELINESEuropean Heart Journal (2008) 29, 2909–2945
ESC PCIGuidelines 2O10
Mr PM: 54-y-o presenting at a non-PCI hospital• 12.00 Myalgia and fatigueEpigastric fullness for 2 hrs• 12.30 : Rx Diclofi...
   Transfer for PPCI   14.30 Lab   100% Prox. RCA   Clot aspiration   14.50 Balloon   Stent 4.0x20 mm   Final TIMI ...
   Oxygen,NTG, Morphine   ASA / Clopidrogrel /Prasugrel/Ticangrelor   Heparin/ LMWH/ Fonda   GP IIb IIIa antagonist  ...
Benjamin M. Scirica JACC 2010;55;1403-1415
Universal Definition of MI                               Spontaneous AMI                                 Secondary AMI    ...
Thygesen et al,Circulation November 27, 2007
Benjamin M. Scirica JACC 2010;55;1403-1415
EquallyEffective            Goncalves PA, et al. Eu Heart J 2005;26:865
   Prevalence increased  RFs:     ▪   Older age,     ▪   Predominance of females     ▪   high rate of DM     ▪   Smoking...
NSTE-ACS  63%
   Plaque rupture: 80%   Plaque erosion/spasm   CASPAR study : 448 ACS    pts     ~ 25% of ACS: no culprit lesion    ...
   OCT  Thin-Capped fibroatheromatous ( TCFA)            Positive remodeling      Plaque rupture : Rest-onset, Exertio...
   Everyone should be on anti-plt and anti-coag   Choose Rx  Consevative vs Invasive   Choose antithrombotic regimen ...
Antman. Circulation 2001;103:2310-4
57
Inf.epigastric  artery
89-y-o lady with severe Lt. RAS and TVD
   Assess/document bleeding risk in every pt.   Avoid crossover : UFH and LMWH   Proper dose Wt. and renal function  ...
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
Acute coronary syndrome
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Acute coronary syndrome

  1. 1. Warong Lapanun MD.Bhumibol Adulyadej Hospital 6/2/2011
  2. 2. Mr PM: 54-y-o presenting at a non-PCI hospital• 12.00 Myalgia and fatigueEpigastric fullness for 2 hrs• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferiorwall+ RVMI BP 90/40 mmHg•Nearest cath lab 40 min away
  3. 3.  Transfer for primary PCI Lysis on Site Lysis with immediate transfer to cath lab Which type of Lytic Rx will be selected?
  4. 4. % 20 n = 29,222 15Mortality p < 0.01 10 7.4 5.7 5 4.2 3.0 0 < 90 91-120 121-150 > 150 Door-to-Balloon Time (minutes) McNamara et al. JACC. 2006;47:2180-6.
  5. 5. 192, 509 pts at 645 NRMI hospitals Pinto et al. Circulation. 2006;114:2019-2025
  6. 6. • 43801 pts STEMI PPCI •D2B  Mortality( P<0.001)• ACC registry 2005-2006 • 30 min = 3.0%• In hospital Mortality • 60 min = 3.5%• Median D2B 83 min. • 90 min = 4.3%• Overall MR 4.6% • 120 min = 5.6% • 180 min = 8.4% Rathor SS,et al. BMJ2009:338;1807
  7. 7. Rathor SS,et al. BMJ2009:338;1807
  8. 8. Mortality Reduction(%)10 Potential outcomes E8 A-B : No benefit A-C : Benefit6 D C B-C : Benefit E-D : Harm42 B A0 Hr 1 3 6 12 24 Time to Rx is Critical Opening the artery is 1o Goal ( PCI>lysis) Gersh BJ et al. JAMA 2005;293:979-986
  9. 9. Infarct size Myocardial Edema Myocardial Salvage Microvascular obstruction Francone M, et al.JACC2009;23:2145
  10. 10. Fribrinolytic Characteristic SK r-tPA TNKTIMI flow gr 3 ~30% ~50% ~60% Boden et al. JACC 2007,50;10. 923
  11. 11. Risk Factors Risk Score ICH(%) Age > 75 yr 0-1 0.69 Black race 2 1.02 3 1.63 Female 4 2.49 Hx of stroke >5 4.11 SBP > 160 mmHg Wt <65(w),<80(m) INR>4 Use of rt-PA
  12. 12. CAPTIM: 5 Year SurvivalPrehospital Thrombolysis vs Primary PCI Prehosp lysis <2 hrs Survival of Proability PPCI PPCI >2 hrs Prehosp lysis Bonnefoy, E. et al. Eur Heart J 2009 30:1598-1606
  13. 13. %Historical Points 40 Age > 75 3 35.9 65-74 2 35 DM or HT or 1 30 Angina 26.8Exam. 23.4 25 SBP<100 3 20 HR >100 2 16.1 Killip II-IV 2 15 12.4 Wt < 67kg 1 10 7.3Presentation 4.4 5 Ant. STE or LBBB 1 1.6 2.2 0.8 Time to Rx > 4 hr 1 0 0 1 2 3 4 5 6 7 8 >8 Points Antman et al Circulation 2000;102:2031-7
  14. 14. ST ResolutionBenjamin M. Scirica JACC 2010;55;1403-1415
  15. 15.  Primary PCI Rescue PCI Facilitated PCI Pharmaco-invasive
  16. 16. I IIa IIb III with PCI capability should be Rx with p-A PCI within 90 min of FMC . Modified without PCI capability who cannot beB transferred and PCI within 90 min of FMC Modified should be Rx with Lytic Rx within 30 min, unless Lytic Rx is contraindicated. FMC: First Medical Contact
  17. 17.  STEMI within 12 h after onset of symptoms At centre without PCI facilities with>1 high risk features:1. Cumulative ST-segment elevation of > 15 mm2. New onset LBBB3. Previous MI4. Killip class of 2 or more or5. LV ejection fraction of 35% or less. Carlo Di Mario, Lancet 371 February 16, 2008
  18. 18. Carlo Di Mario, Lancet 371 February 16, 2008
  19. 19.  Pts with STEMI within 12 hrs after onset of symptoms At centers : No PCI capability Rx with Tenecteplase (TNK) ST-segment elevation of ≥ 2 mm in two anterior leads or ST-segment elevation of ≥ 1 mm in two inferior leads andOne high-risk characteristics: 1. Systolic BP < 100 mm Hg, 2. HR > 100 bpm, 3. Killip class II or III, 4. ST- depression of ≥ 2 mm in the anterior leads, or 5. ST- elevation of ≥ 1 mm in V4R indicative of RV involvement. Cantor WJ et al. N Engl J Med 2009;360:2705-2718
  20. 20. TRANSFER AMI High Risk STEMI  12 hrs, 1059 Pts TNK + ASA + Clopidogrel + Community Heparin or Enoxaparin Hospital Randomization Emergency Department Pharmacoinvasive : Standard Strategy: Urgent  PCI Centre Assess chest pain, ST resolution at 60-90 min after randomization PCI Centre Failed Reperfusion* Successful Reperfusion Cath / PCI within 6 hrs Cath and Rescue Elective Cath regardless of reperfusion PCI  GP IIb/IIIa  PCI status Inhibitor > 24 hrs later* ST segment resolution < 50% & persistent chest pain, or hemodynamic instability Cantor WJ et al. N Engl J Med 2009;360:2705-2718
  21. 21. Kaplan-Meier CurvesPrimary Endpoint* at 30 Days Re-infarction at 6 Months Std Rx Std Rx Early PCI Early PCI *Primary endpoint was death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock at 30 days Cantor WJ et al. N Engl J Med 2009;360:2705-2718
  22. 22. Verheugt, NEJM 2009; 360, 26: 2779-2781
  23. 23. PharmacoinvasiveFacilitated PCI No Class III
  24. 24.  ER physician activate the Cath Lab One call activate the cath lab Cath lab team ready in 20-30 min Prompt data feed back Senior management commitment Team-based approach
  25. 25. PCI-Centerผู้ป่วยเจ็บหน้ำอก รอบัตร รอแพทย์ตรวจ ทำ EKG ใน 10 นำที แพทย์เวร ER แพทย์เวร Med Fellow cardioปรึกษำ staff cardio ผ่ำน singlecall operator, rtafheart@gmail.com ตำมเจ้ำหน้ำที่ Cath Lab Time to Lab ส่งทำ PCI
  26. 26. Fast Track MIEKG ด่วนแพทย์ดูใน 10 นำที elevation ตำม staff cardio ทันที ST ST elevation ………………. MD. No
  27. 27. ESC GUIDELINESEuropean Heart Journal (2008) 29, 2909–2945
  28. 28. ESC PCIGuidelines 2O10
  29. 29. Mr PM: 54-y-o presenting at a non-PCI hospital• 12.00 Myalgia and fatigueEpigastric fullness for 2 hrs• 12.30 : Rx Diclofinac IM• 12 .45 : VF arrest CPR ,DF x 5• 13.00 : ECG Ac STEMI inferiorwall+ RVMI BP 90/40 mmHg•Nearest cath lab 30 min away
  30. 30.  Transfer for PPCI 14.30 Lab 100% Prox. RCA Clot aspiration 14.50 Balloon Stent 4.0x20 mm Final TIMI III flow
  31. 31.  Oxygen,NTG, Morphine ASA / Clopidrogrel /Prasugrel/Ticangrelor Heparin/ LMWH/ Fonda GP IIb IIIa antagonist Lab Echo IABP CAG / PCI : Early or Late
  32. 32. Benjamin M. Scirica JACC 2010;55;1403-1415
  33. 33. Universal Definition of MI Spontaneous AMI Secondary AMI Sudden cardiac death Post PCI : 3x 99%URL Post CABG : 5x 99%URLURL: upper reference limit Thygesen et al,Circulation November 27, 2007
  34. 34. Thygesen et al,Circulation November 27, 2007
  35. 35. Benjamin M. Scirica JACC 2010;55;1403-1415
  36. 36. EquallyEffective Goncalves PA, et al. Eu Heart J 2005;26:865
  37. 37.  Prevalence increased  RFs: ▪ Older age, ▪ Predominance of females ▪ high rate of DM ▪ Smoking and obesity Use of preventive medications Increasing sensitive Troponin Assay Robert P, et al. Circulation 2009; 54: 1544
  38. 38. NSTE-ACS 63%
  39. 39.  Plaque rupture: 80% Plaque erosion/spasm CASPAR study : 448 ACS pts  ~ 25% of ACS: no culprit lesion  ~ 50% of no culprit IC Ach spasm  CCBs / nitrates : may benefit  Endothelial function Ong P, et al. JACC 2008; 52:523CASPAR: Coronary Artery Spasm in Patients With ACS
  40. 40.  OCT  Thin-Capped fibroatheromatous ( TCFA)  Positive remodeling  Plaque rupture : Rest-onset, Exertion-trigger Plaque shoulder Lipid core Lipid core Thin-capped Thick-cappedOCT: Optical Coherence Tomography Tanaka A. et al. Circulation 2008;118;2368
  41. 41.  Everyone should be on anti-plt and anti-coag Choose Rx  Consevative vs Invasive Choose antithrombotic regimen   The strategy selected  Bleeding risk of patients Strategy selected  Pt risk stratification Bleeding vs Ischemic risk  Equally important
  42. 42. Antman. Circulation 2001;103:2310-4
  43. 43. 57
  44. 44. Inf.epigastric artery
  45. 45. 89-y-o lady with severe Lt. RAS and TVD
  46. 46.  Assess/document bleeding risk in every pt. Avoid crossover : UFH and LMWH Proper dose Wt. and renal function Use radial access in pts at high risk of bleeding Stop anticoag after PCI/ indication? Selective “downstream” use of GPI

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