STEMI – My Approach 2010

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  • STEMI – My Approach 2010

    1. 1. STEMI – My Approach<br />2010<br />Dr S A Merchant<br />Interventional Cardiologist<br />DM MD DNB FSCAI <br />Lilavati, CritiCare, BSES, Breach Candy Hospitals <br />
    2. 2. Clinical manifestations of arterial thrombosis<br />UA/NQMI:Partially-occlusive thrombus (primarily platelets)<br />ST  MI:occlusive thrombus (platelets, red blood cells, and fibrin)<br />Intra-plaque thrombus (platelet dominated)<br />Plaque core<br />Intra-plaque thrombus (platelet dominated)<br />Plaque core<br />SUDDEN DEATH<br />Adapted from Davies MJ. Circulation. 1990; 82 (supl II): 30-46.<br />Dr S A Merchant<br />
    3. 3. Initial Diagnosis of STEMI<br />Dr S A Merchant<br />
    4. 4. 68%<br />60<br />40<br />20<br />18%<br />14%<br />0<br /><50%<br />50%–70%<br />>70%<br />% Stenosis<br />Small, vulnerable plaques are responsible for causing MI<br />MI <br />Patients<br /> (%)<br />Falk et al: Circulation 1995;92:657–671<br />Dr S A Merchant<br />
    5. 5. MANAGEMENT OF Acute Myocardial Infarction<br />THE IMPACT OF MEDICAL THERAPY<br />% Mortality<br />Defibrillation,<br />Hemodynamic monitoring<br />Beta Blockade<br />Thrombolysis/adjuct therapy<br />PTCA, Stent<br />Dr S A Merchant<br />
    6. 6. Hospital fibrinolysis: <br />Door–to–needle <br />≤ 30 min<br />Not PCI<br />capable<br />Call 9-1-1<br />Call fast<br />Inter-hospital<br />transfer<br />EMS on scene<br /><ul><li>Encourage 12-lead ECGs
    7. 7. Consider prehospital fibrinolytic if capable and EMS–to–needle within 30 min</li></ul>Onset of symptoms of STEMI<br />9-1-1<br />EMS<br />dispatch<br />EMS triage plan<br />PCI<br />capable<br />GOALS<br />5 <br />min<br />8 <br />min<br />EMS transport<br />Patient<br />EMS<br />Prehospital fibrinolysis<br />EMS–to–needle<br />≤ 30 min<br />EMS transport<br />EMS–to–balloon ≤ 90 min<br />Patient self-transport <br />Hospital door–to–balloon <br />≤ 90 min<br />Dispatch<br />1 min<br />Total ischemic time: within 120 min<br />“Golden Hour” = 1st 60 min<br />Transport of Patients With STEMI and Initial Reperfusion Treatment<br />J Am CollCardiol. 2004;44:671; Circulation. 2004;110:588.<br />
    8. 8. Thrombolysis Versus Primary PCI - Time Dependancy<br />Absolute 35 day mortality reduction v treatment delay<br />N=50246<br />Primary PCI<br />Boersma et al, Lancet 1996 348:771<br />Dr S A Merchant<br />
    9. 9. Primary PCI<br />angioplasty vsthrombolysis<br />Dr S A Merchant<br />
    10. 10. PerCutaneous Interventions following AMI : A variety !!<br />Dr S A Merchant<br />
    11. 11. Primary PCI<br />POBA vs Stent<br />Dr S A Merchant<br />
    12. 12. primary PTCA vs stent<br />6-month outcomes<br />stent<br />PTCA<br />OR (95% CI)<br />3.3%<br />1.7%<br />4.9%<br />8.3%<br />13.7%<br />3.8%<br />3.0%<br />6.8%<br />18%<br />25.9%<br />death<br />reMI<br />death/ reMI<br />TVR<br />death/reMI/TVR<br />0.85 (0.57-1.27)<br />0.58 (0.35-0.96)<br />0.72 (0.52-0.98)<br />0.41 (0.32-0.52)<br />0.45 (0.37-0.55)<br />0<br />0.5<br />1.5<br />1<br />2<br />stentbetter<br />PTCA better<br />Dr S A Merchant<br />
    13. 13. Real world situation: Door to balloon times in USA<br />N=365<br />N Engl J Med 2006;355<br />Dr S A Merchant<br />
    14. 14. Conclusion : Every minute delay in P’PCI affects 1 year mortality.<br /> Therefore, all efforts should be made to shorten <br /> Ischemia time not only for thrombolysis but also <br /> for P’PCI.<br />
    15. 15. Door to Balloon minus Door to Needle time<br /><ul><li> Anticipated delay between door to balloon minus door to needle time if more than one hour , then thrombolysis is a better strategy.
    16. 16. Assessment of time is the key point in the choice of reperfusion strategy</li></ul>Dr S A Merchant<br />
    17. 17. USIC 2000, French Registry Data <br />Hospital administered ‘lysis as good as PCI<br />Pre hospital lysis<br />EURO-PCR Paris 2003<br />Dr S A Merchant<br />
    18. 18. French USIC 2000 survey: real world<br />USIC. Circulation 2004;110:1909-1915<br />Dr S A Merchant<br />
    19. 19. Fibrinolysis vs Transfer for PCI<br />Pre HospPrimaryIn HospLysisPCILysisCAPTIM CAPTIM DANAMI 2 DANAMI 2<br />Death (%) 3.8 4.8 6.6 7.6<br />1yr 5.4 7.3<br />Reinfarction (%) 3.7 1.7 1.6 6.3<br />Disabling CVA (%) 1.0 0.0 1.1 2.0<br />Any of Above (%) 8.2 6.2 8.0 13.7*(* P < 0.003)<br />VahanianESC, 2002<br />Dr S A Merchant<br />
    20. 20. Pre Hospital thrombolysisCAPTIM 1 Year Results (TNK)<br />Sx < 2 hours<br />Death<br />P=0.057<br />Pre Hospital<br />Lysis<br />Primary<br />PCI<br />GW Symposium, AHA 2002<br />Dr S A Merchant<br />
    21. 21. Blush Score : 30 D, M in AMI receiving fibrinolysis regardless of TIMI Grade flow in Epicardial Artery, Myocardial perfusion by blush score predicts mortality <br />Failed flows<br />Gibson : <br />Circulation 2000;<br />101-125<br />Improved flows<br />
    22. 22. PTCA vsFibrinolysis:Short Term Clinical Outcomes (23 RCTs)<br />PTCA <br />P<0.0001<br />Fibrinolysis <br />P<0.0001<br />Frequency (%)<br />P=0.0002<br />P=0.0003<br />P<0.0001<br />P=0.032<br />P=0.0004<br />P<0.0001<br />Death<br />Death, no SHOCKdata<br />ReMI<br />Rec. Isch<br />Total Stroke<br />Hem. Stroke<br />Major Bleed<br />DeathMICVA<br />N = 7739<br />Keeley E. et al., Lancet 2003; 361:13-20.<br />
    23. 23. Is timing an issue even for Primary PCI?<br />Dr S A Merchant<br />
    24. 24. Survival Benefit by Time to Treatment with Lytics<br />Dr S A Merchant<br />
    25. 25. Dr S A Merchant<br />
    26. 26. NRMI-2 : 27080 consecutive patients<br />24%<br />% of patients<br /> 21%<br />20%<br />20<br />17%<br />15<br />10%<br />10<br />8%<br />5<br />0<br />min<br /><60<br />60-90<br />120-150<br />90-120<br />150-180<br />>180<br />C.P. CANNON. JAMA 2000;283:2941-7<br />door-to-balloon times in primary PCI<br />Dr S A Merchant<br />
    27. 27. Mortality by time to reperfusion with Primary PCINRMI-2 Registry (27,080)<br />C.P. CANNON. JAMA 2000;283:2941-7<br />Dr S A Merchant<br />
    28. 28.
    29. 29.
    30. 30. Why is Primary PCI less time dependent than Lysis?<br />Lysis is less effective at restoring infarct artery patency as the clot ages <br />Myocardial salvage and infarct size after lytics are very sensitive to time to reperfusion<br />Cardiac rupture is more likely to occur as the time to lysis increases<br />Dr S A Merchant<br />
    31. 31. Recommendations<br /><ul><li>When performed by experienced* operators/centers, PCI is the reperfusion strategy of choice for patients with AMI
    32. 32. PCI for AMI: door-to-balloon time < 2hrs (time window up to 12 hours accepted)</li></ul>* operator: 75 PCI (any type) / year; center: 36 Primary PCI / year<br />Dr S A Merchant<br />
    33. 33. After 12 hours???<br />BRAVE-2<br />Rationale: While thrombolysis has been shown to produce no benefit after 12 hours, no similar studies have looked at primary PCI in this group. <br />Study: 365 patients randomized to in an invasive arm or a conservative arm. The invasive group underwent angiography and then PCI if necessary, while the conservative group was treated with conventional medical therapy. The primary end point was infarct size determined by SPECT at five to 10 days. <br />Results: Infarct size (%LV) was significantly reduced in the invasive arm (8.0 vs 13%; p=0.002). No clinical differences.<br />Kastrati ACC 2005<br />Dr S A Merchant<br />
    34. 34. Role of PCI in the management of STEMI<br />agenda<br /><ul><li> primary PCI
    35. 35. primary PCI </li></ul>- angioplasty vsthrombolysis<br />- added benefit of stent placement<br /><ul><li>timing</li></ul>- culprit vessel vs all vessel intervention<br /><ul><li>role of 2b/3a inhibitors
    36. 36. transfer, rescue and facilitated PCI
    37. 37. the challenges</li></ul>how to achieve optimal reperfusion<br />what to do with the occluded IRA<br />replacing the function of death cells<br />Dr S A Merchant<br />
    38. 38. Dr S A Merchant<br />
    39. 39. culprit vessel vs all vessel intervention<br /><ul><li>The ACC/AHA guidelines on PCI give elective PCI of a non-infarct related artery at the time of AMI a class III recommendation with a C level of evidence.
    40. 40. Exception: in case of cardiogenic shock, systematic intervention in multiple vessels may be required to optimize reperfusion of the heart. </li></ul>Dr S A Merchant<br />
    41. 41. Role of GP 2b/3a inhibitors<br />Dr S A Merchant<br />
    42. 42.
    43. 43. GP IIb/IIIa Inhibitors For Primary PCI—30-Day Death, (re)MI or Urgent Revascularization<br />30%<br />Placebo<br />GP IIb/IIIa<br />26.1%<br />20%<br />14.6%<br />11.2%<br />9.7%<br />10%<br />6.8%<br />6.0%<br />5.8%<br />4.5%<br />4.5%<br />2.0%<br />p = 0.06<br />p = 0.01<br />p = 0.03<br />p = 0.03<br />p = 0.02<br />0%<br />CADILLAC<br />EPIC<br />RAPPORT<br />Neumann<br />ADMIRAL<br /> N: 64 483 200 300 2082<br />
    44. 44.
    45. 45.
    46. 46. Types of Thrombolytics<br />A. Clot Selective / Clot-Binding / fibrin Specific<br />B. Non clot Selective/ Non–Clot-Binding / Non Fibrin Specific<br />Dr S A Merchant<br />
    47. 47. Clinical Relevance of Fibrin Affinity<br />Action of Non–Clot-Binding Agents<br />Action of Clot-Binding Agents<br />(Urokinase, Streptokinase)<br />(Alteplase, Tenecteplase)<br />Clot-BindingPlasminogenActivators<br />Clot<br />Blood Vessel<br />Non–Clot-BindingPlasminogenActivators<br />Clot<br />Blood Vessel<br />Dr S A Merchant<br />
    48. 48. Thrombolytic Agents<br /><ul><li>Non-Fibrin-Specific
    49. 49. Streptokinase
    50. 50. AnisoylatedPlasminogen Streptokinase Activator Complex
    51. 51. Fibrin-Specific
    52. 52. Recombinant tissue plasminogen activator (rt-PA)
    53. 53. Mutants and Variants of Tissue-type Plasminogen Activator
    54. 54. TNK-rt-PA
    55. 55. Reteplase
    56. 56. Lanetoplase
    57. 57. Single-chain Urokinase-type Plasminogen Activator
    58. 58. Recombinant pro-urokinase (saruplase)
    59. 59. Staphylokinase</li></ul>Dr S A Merchant<br />
    60. 60. Overview of Thrombolytics<br />
    61. 61. Overview of Thrombolytics<br />
    62. 62. Comparison with Streptokinase<br />Dr S A Merchant<br />
    63. 63. Dr S A Merchant<br />
    64. 64. Dr S A Merchant<br />
    65. 65. Dr S A Merchant<br />
    66. 66. total<br />528<br />6.7%<br />11.5%<br />0.55 (0.30-1.01)<br />p=0.052<br />rescue PCI<br />short termoutcome: death<br />odds ratio (95% CI)<br />n PCI cons.<br />0.13 (0.01-1.40)<br />Belenkie<br />RESCUE<br />PRAGUE<br />Vermeer<br />28<br />151<br />200<br />149<br />6.3%<br />5.1%<br />7%<br />8.7%<br />33.3%<br />9.6%<br />14.0%<br />6.7%<br />0.51 (0.12-2.06)<br />0.46 (0.16-1.30)<br />1.24 (0.31-4.49)<br />0<br />0.5<br />1.5<br />1<br />2.0<br />Dr S A Merchant<br />
    67. 67. Incidence of Shock<br />P=0.09<br />Pre Hospital<br />Lysis<br />Primary<br />PCI<br />CAPTIM – PrehospitaltPAvs 1°PCI1 Year Results<br />Death at 1 Year<br />P=0.27<br />Primary<br />PCI<br />Pre Hospital<br />Lysis<br />Bonnefoy Lancet 2002<br />Dr S A Merchant<br />
    68. 68. Tenecteplase is the lytic of choice<br /><ul><li>Cantor also emphasized that previous trials have used different lytics and no clopidogrel preloading.
    69. 69. "Streptokinase is not very cath-lab friendly, so patients were more prone to getting bleeding complications when they went to the cath lab.
    70. 70. Those previous trials were also done before we knew the benefits of preloading patients with clopidogrel and using antithrombotic therapies like GP IIb/IIIa inhibitors during the angioplasty."</li></ul>Dr S A Merchant<br />
    71. 71. Dr S A Merchant<br />
    72. 72.
    73. 73.
    74. 74.
    75. 75.
    76. 76. ExTRACT TIMI 25Net Clinical Benefit at 30 Days<br />UFH (%)<br />Enox (%)<br />RRR (%)<br />Death / Nonfatal MI / Nonfatal Disabling Stroke<br /> 10.1<br />18<br />12.3<br />Death / Nonfatal MI / Nonfatal Major Bleed<br /> 11.0<br />14<br />12.8<br />Death / Nonfatal MI / Nonfatal ICH<br /> 10.1<br />17<br />12.2<br />Enox Better<br />UFH Better<br />RR<br />Dr S A Merchant<br />
    77. 77.
    78. 78.
    79. 79.
    80. 80.
    81. 81.
    82. 82. CLARITY–TIMI 281° Endpoint:Occluded Artery (or D/MI Thru Angio/HD)<br />36% <br />odds reduction<br />Odds ratio 0.64<br />(95% CI, 0.53 – 0.76)<br />P < 0.001<br />Occluded artery or death/MI (%)<br /> n = 1,752 n = 1,739<br /> | | | | | |<br /> 0.4 0.6 0.8 1.0 1.2 1.6<br />Clopidogrel Placebo<br /> LD 300 mg MD 75 mg<br />Clopidogrel Placebo<br /> better better<br />Sabatine MS, N Engl J Med. 2005;352:1179-1189.<br />Dr S A Merchant<br />
    83. 83. 10<br />9<br />8<br />7<br />6<br />5<br />4<br />3<br />2<br />1<br />0<br />0 7 14 21 28<br />COMMIT: Effect of Clopidogrel on Death Inhospital<br />Placebo + ASA: <br />1,845 deaths (8.1%)<br />Clopidogrel + ASA:<br />1,726 deaths (7.5%)<br />Proportion dead before first discharge (%)<br />0.6% ARD7% RRR <br />P = 0.03<br /> N = 45,852 No age limit; 26% age ≥ 70 years<br /> Lytic Rx 50%<br /> No LD given<br />Time since randomization (days)<br />Chen ZM, et al. Lancet. 2005;366:1607-1621.<br />Dr S A Merchant<br />
    84. 84. Summary<br /><ul><li>Acute therapy in STEMI focuses on reperfusion & antithrombotic therapy
    85. 85. Reasonable options for hospitals without onsite PCI capability
    86. 86. Fibrinolytic Therapy (goal : door to needle time ≤ 30 minutes)
    87. 87. Transfer for Primary PCI (goal: door to balloon time ≤ 90 minutes)
    88. 88. Transfer for Rescue PCI if reperfusion with lytic fails
    89. 89. Facilitated PCI : no clinical benefit seen to date
    90. 90. Clopidogrel in combination with aspirin results in significant further improvements in outcomes of patients with STEMI (CLARITY-TIMI 28/COMMIT)</li></ul>Dr S A Merchant<br />
    91. 91. Summary (cont.)<br /><ul><li>Current ACC/AHA STEMI guidelines recommend IV UFH as ancillary therapy to reperfusion therapy
    92. 92. Enoxaparin is superior to current standard of UFH as the antithrombin to support fibrinolysis (ExTARCT TIMI 25)
    93. 93. Enoxaparin has a beneficial effect in patients undergoing elective PCI,with no increase in bleeding (PCI - ExTARCT TIMI 25)
    94. 94. Fondaparinux is beneficial in STEMI without increasing the risk of bleeding or stroke (OASIS 6), but some subsets do not benefit (eg primary PCI)
    95. 95. Fondaparinux was not superior to UFH is Stratum 2 of OASIS 6 for STEMI
    96. 96. Long term treatment involves aggressive multifactorial lifestyle modification & both antithrombotic & anti ischemic therapies</li></ul>Dr S A Merchant<br />
    97. 97. PCI p lytic<br />Pharmacoinvasive approach<br />Partial flow<br />Complete obstruction<br />Partial success with<br />pharmacologic<br />reperfusion<br />Rethrombosis:<br />Prevented by antiplatelet and anticoagulant Rx<br />Full flow<br />Ideal goal of<br />pharmacologic<br />reperfusion<br />Dr S A Merchant<br />
    98. 98. ACC/AHA Guidelines for Management of Patients With STEMI, 2004 Reperfusion Options for STEMI Patients<br />If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy.<br />Fibrinolysis generally preferred <br /><ul><li>Early presentation ( ≤ 3 hours from symptom </li></ul> onset and delay to invasive strategy)<br /><ul><li>Invasive strategy not an option</li></ul> Cath lab occupied or not available <br /> Vascular access difficulties No access to skilled PCI lab<br /><ul><li>Delay to invasive strategy</li></ul> Prolonged transport Door-to-balloon more than 90 minutes<br /> > 1 hour vsfibrinolysis (fibrin-specific agent) now<br />ACC/AHA Guidelines for Management of Patients With STEMI,<br />Journal of the American College of Cardiology 2004<br />Dr S A Merchant<br />
    99. 99. Emerging Modalities<br /><ul><li>Pharmacoinvasive Management </li></ul> (PCI following TNK) <br /> is a better , safer option than PAMI as proved recently . <br />It widens the time window for PCI<br />This seems to combine the benefits of Mechanical and pharmacological strategies in reperfusion<br />JACC Sept 2007<br />Dr S A Merchant<br />
    100. 100. When patients present to a primary unit withoutinterventional capabilities:Therapeutic options a) lytics b) “transfer” to a facility with acardiaccath lab (with or without adjunctive therapy – “facilitated PCI”). Any such “transfer” needs to be effected rapidly to take advantage of the early benefits of revascularization.<br />Dr S A Merchant<br />
    101. 101. ‘Best of both worlds’ :<br /> Local rapidThrombolysisto majority <br />& <br />PCI Routinely<br />Dr S A Merchant<br />
    102. 102. TRANSFER-AMI:<br /><ul><li>high-risk STEMI
    103. 103. Standard treatment after fibrinolysis</li></ul> (rescue PCI for failed reperfusion, with elective PCI encouraged for successfully reperfused patients after 24 hours)<br /><ul><li>Pharmacoinvasive strategy</li></ul> (transfer for PCI within six hours of fibrinolysis).<br />Both groups received Tenecteplase<br />Dr S A Merchant<br />
    104. 104. TRANSFER-AMI:30-Day Primary End Point and Components<br />Dr S A Merchant<br />
    105. 105. TRANSFER-AMI:<br /><ul><li>STEMI to centers without timely access to a catheterization labpharmacoinvasiveapproach consisting of full-dose thrombolytics, followed by emergent transfer for cardiac catheterization within 6 hours, is safe and efficacious compared to treatment with thrombolytics and transfer for rescue PCI only.
    106. 106. This suggests that transfer to PCI centers should be initiated immediately after fibrinolysis without waiting to see whether reperfusion is successful or not. </li></ul>Dr S A Merchant<br />
    107. 107. TRANSFER-AMI:30-Day Bleeding End Points<br />Dr S A Merchant<br />
    108. 108. direct stenting in acute MI<br />26.9%<br />11.7%<br />angioendpoint<br />slow flow (TIMI 3  2)<br />12.5%<br />2.9%<br />direct<br />stenting<br />n 102<br />pre-<br />dilatation<br />n 104<br />p=0.01<br />p=0.02<br />26.9%<br />12.5%<br />7.6%<br />6.7%<br />3.8%<br />3.8%<br />6.7%<br />11.7%<br />2.9%<br />4.9%<br />3.9%<br />0.9%<br />2.9%<br />8.8%<br />angioendpoint<br />slowflow (TIMI 3  2)<br /> no-flow (TIMI 0-1)<br /> distal embolization<br />clinicaloutcomes (6-m F/U)<br />death<br /> re-MI<br /> TVR<br />C. LOUBEYRE et al. JACC 2002;39:15-21<br />
    109. 109. cooling n 21<br /> control n 21<br />10%<br />% LV<br />% pts<br />10<br />10<br />8%<br />5<br />5<br />2%<br />0%<br />0<br />0<br />median infarct size<br />MACE<br />endovascularcooling<br />COOL-MI n 400 pts<br />SR DIXON. JACC 2002;40:1928-34<br />
    110. 110. X-SIZER•<br />ANGIOJET<br />EXPORT CATHETER<br />PERCU-SURGE<br />FILTER-WIRE<br />thrombectomy<br />distal protection<br />device<br />mechanism<br />new cathether-based techniques<br />X-AMINE<br />AIMI<br />EMERALD<br />CRTs in AMI<br />N 200<br />N 500<br />PROMISE<br />N 200<br />Dr S A Merchant<br />
    111. 111. RECOMMENDATION<br />Task Force ESC 2005 guideline<br />Routine Coronary Angio & PCI, if applicable, <br />in successful Thrombolysis: 1 A<br />LYSE NOW, STENT LATER !!<br />Dr S A Merchant<br />
    112. 112. Despite the clinical superiority of PAMI, thrombolytic therapy is the default treatment in many countries due to the practical limitations of PAMI<br />Dr S A Merchant<br />
    113. 113. Conclusion<br /><ul><li>In Indian context – Thrombolysis is the commonly accepted method of treatment in STEMI
    114. 114. PCI is superior as per data but not practical and feasible, not only in India but also all over world</li></ul>Dr S A Merchant<br />
    115. 115. <ul><li>New TNK is an ideal , novel thrombolytic agent, IV bolus reduces door to needle time and higher TIMI III and II flow( 86%)
    116. 116. New emerging post fibrinolysis PCI has emerged as an alternative method of treatment that appears to be safer &better as compared to PAMI</li></ul>Dr S A Merchant<br />
    117. 117. API Guidelines<br />Indications for thrombolytic therapy<br /><ul><li>Early presentation (3 h or less from symptom onset and delay to invasive strategy)
    118. 118. Invasive strategy is not an option</li></ul>- Catheterization laboratory not available / occupied.<br />- Financial reasons<br />- Lack of access to a skilled PCI laboratory<br />- Vascular access difficulties<br /><ul><li>Delay to invasive strategy</li></ul>Prolonged transport (Door-to-Balloon)- (Door-to-Needle) time > 1 hour.<br />Medical contact-to-balloon or door-to-balloon time > 90 minutes<br />Dr S A Merchant<br />
    119. 119. ELAXIM INDIAN REGISTRY<br />Dr S A Merchant<br />
    120. 120. ELAXIM INDIAN REGISTRY<br />* ICH = Intracranial hemorrhage<br />Dr S A Merchant<br />
    121. 121.
    122. 122. CAPTIM – PrehospitaltPAvs 1°PCI1 Year Results<br />Incidence of Shock<br />P=0.09<br />Pre Hospital<br />Lysis<br />Primary<br />PCI<br />Death at 1 Year<br />P=0.27<br />Pre Hospital<br />Lysis<br />Primary<br />PCI<br />Bonnefoy Lancet 2002<br />Dr S A Merchant<br />
    123. 123. OPEN ARTERY THEORY:<br />Better flow in the infarct artery improves survival<br />Mortality at 42 Days<br />TIMI 0 Complete occlusion<br />TIMI 1 Penetration of obstruction by contrast but no distal perfusion<br />TIMI 2 Perfusion of entire artery but delayed flow<br />TIMI 3 Full perfusion, normal flow<br />P < 0.005<br />TIMI 1<br />Chesebro JH et al. Circulation 1987;76:142-54<br />
    124. 124. Full-Dose TNK 3-12h Before PCI: GRACIA-2<br />Characteristic TNK+PCI PCI<br />No. patients 103 102<br />TIMI flow grade 3 59%* 43%<br />Complete STRes (6h) 61%* 43%<br />Death, MI, RI-UR 9% 12%<br />Major bleeding 2% 3%<br />No differences in infarct size, LV function<br />*p < 0.05<br />Aviles ESC 2003<br />Dr S A Merchant<br />
    125. 125. n 3200 patients<br />occluded IRA (TIMI 0,1)<br />randomization<br />PCI (3-28 days after MI)<br /> + risk factor modification<br />no PCI<br />ASA<br />-blockers<br />ACE inhibitors<br />Occluded Artery Trial (OAT)<br />multicenter, randomized, controled<br />1º endpoint: death/reMI/rehosp. CHF (NYA class IV) over 3 years<br />
    126. 126. Apoptotic Rate in Occluedvs Open IRA <br />Abbate A et al. Circulation 2002<br />
    127. 127. open questions on infarct/necrotic tissue<br /><ul><li>hazards of stem cell manipulation
    128. 128. arrhythmogenic potential of implanted cells
    129. 129. economic issues
    130. 130. the capacity of the stem cells to find their optimal myocardial ‘niche’
    131. 131. long-term fate of transplanted cells in the recipient heart
    132. 132. optimal timing for transplantation</li></ul>Dr S A Merchant<br />
    133. 133. Take Home Message:<br />Optimum management of STEMI –<br /> A PharmacoInvasive Approach<br /><ul><li>Initial Fibrinolysiswith t-PA within 30-60 mins of chest pain in ambulance, nursing home, non-PCI hospital
    134. 134. Endovascular cooling: Aspirin, loading dose clopidogril/prasugrel, InjEnoxyparin, GpIIb/IIIa Inhibitor, nitrates, Ace-Inhibitors, beta blocker, diltiazem, high dose statins, trimatazione, sedation</li></ul>Dr S A Merchant<br />
    135. 135. Transfer patient within 6 hours to PCI centre for<br /><ul><li>Cor angiography
    136. 136. Thrombectomy: Suction by Export Cath, AngioJet
    137. 137. Direct stenting
    138. 138. Intracoro NTG/Nicorandil</li></ul>This makes sense to everyone – patient, relations, family doctor, consultant physician, interventional cardiologist. Also, both short term & long term clinical trials show excellent result with pharmacoinvasive approach in terms of reduce mortality, re-infarction & overall preservation of LV function <br />Dr S A Merchant<br />
    139. 139. Rescue PCI, Cardiogenic shock PCI, Facilitated PCI, Elective PCI are special subsets where clinician discretion is required <br />Dr S A Merchant<br />LONG DIFFUSE STENOSIS<br />
    140. 140. HOW FAST SHOULD WE GO ? <br />QUICKER IS BETTER <br />THANK YOU<br />

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