Lo mejor del Congreso ACC Chicago 2016 06/04/16 14:00 - 15:30h Casa del Corazón, Madrid http://acc16.secardiologia.es Lo mejor en cardiopatía isquémica e intervencionismo Dr. Marcelo Sanmartín Fernández, Hospital Universitario Ramón y Cajal, Madrid @ImMSanFer

1. Lo mejor en cardiopatía
isquémica e intervencionismo
#postACC16
Dr. Marcelo Sanmartín Fernández
Hospital Universitario Ramón y Cajal (Madrid)
@ImMSanFer

2. The Third DANish Study of Optimal Acute Treatment of Patients with
ST-segment Elevation Myocardial Infarction: DEFERred stent
implantation in connection with primary PCI:
DANAMI 3-DEFER

3. TIMI 0-I TIMI 2-3
Postcon
TIMI 0-I
PCI
TIMI 2-3
DeferConv
STEMI
Angiography
Excluded
Flow Chart DANAMI-3
PCI
Randomization

4. Methods
DEFER:
• Minimal acute manipulation to restore stable flow in IRA
• Stent implantation 48 hours later
Conventional PCI:
• Immediate stent implantation
Aim of DANAMI-3-DEFER study
To evaluate whether the prognosis of STEMI patients treated
with pPCI can be improved by deferred stent implantation

5. Median stent diameter (mm) 3∙5 3∙5
Median stent length (mm) 22 18 *
No stenting 3% 15%*
Use of GP-inhibitor or Bivalirudin 92% 93%
Thrombus aspiration 58% 63%
TIMI flow before PCI**
0 - 1
2 - 3
38%
62%
38%
62%
TIMI flow after PCI**
0 - 1
2 - 3
1∙0%
99%
1.0%
99%
Procedural data
* P < 0.001 ** self-reported
Conventional
(n = 612)
DEFER
(n = 603)

6. 0.000.050.100.150.200.25
Eventrate
603 543 526 359 156 0Deferred
612 568 533 360 159 0Conventional
Number at risk
0 1 2 3 4 5
Time (years)
Conventional
Deferred
HR: 0.99 [0.75-1.29]; P=0.92
Primary endpointPrimary endpoint

7. 0.000.050.100.150.200.25
Eventrate
603 584 575 409 180 0Deferred
612 594 575 403 173 0Conventional
Number at risk
0 1 2 3 4 5
Time (years)
Conventional
Deferred
A
HR: 0.83 [0.56 - 1.24]; P=0.37
All cause mortality
0.000.050.100.150.200.25
Cumulativeincidence
603 576 563 395 172 0Deferred
612 580 560 391 167 0Conventional
Number at risk
0 1 2 3 4 5
Time (years)
Conventional
Deferred
C
HR: 0.82 [0.47 - 1.43]; P=0.49
Hospitalisation for heart failure
0.000.050.100.150.200.25
Cumulativeincidence
603 564 550 383 167 0Deferred
612 586 554 379 165 0Conventional
Number at risk
0 1 2 3 4 5
Time (years)
Conventional
Deferred
B
HR: 1.1 [0.69 - 1.64]; P=0.77
Recurrent myocardial reinfarction
0.000.050.100.150.200.25
Cumulativeincidence
603 559 549 382 167 0Deferred
612 587 561 387 170 0Conventional
Number at risk
0 1 2 3 4 5
Time (years)
Conventional
Deferred
D
HR: 1.7 [1.04 - 2.92]; P=0.03
Unplanned target vessel revascularisation
Components of the primary endpoint

8. Left ventricular ejection fraction (LVEF)
at 18 months
Conventio
nal
DEFER P
Median LVEF 57% 60% 0∙04
No of patients with
LVEF ≤45%
18% 13% 0∙05
Secondary endpoint

9. Conclusion I
Deferred stent implantation in patients with STEMI
did not reduce the risk of death, heart failure, or
reinfarction compared with standard immediate
stent implantation

10. Conventional
treatment
coronary artery
ReperfusionOccluded
Reperfusion
injury
Reperfusion
injuryIschemic
postconditioning
30 30 30 sec3030 30 30 30
Balloon inflations – deflations
Ischemic postconditioning
DANAMI3-iPOST

11. Outcome
Convention
al
(n = 617)
iPOST
(n = 617)
Hazard ratio
[95% CI]
p
Primary composite
endpoint
69 (11∙2) 65 (10∙5) 0·93 [0∙66 – 1∙30] 0∙66
All-cause mortality 50 (8∙1) 38 (6∙2) 0∙75 [0∙49 – 1∙14] 0∙18
Heart failure
hospitalization
30 (4∙9) 30 (4∙9) 0∙99 [0∙60 – 1∙64] 0∙96
Cardiovascular mortality 30 (4∙9) 26 (4∙2) 0∙86 [0∙51 – 1∙45] 0∙56
Recurrent myocardial
infarction
29 (4∙7) 33 (5∙4) 1∙13 [0∙68 – 1∙86] 0∙64
TVR by PCI 14 (2∙3) 19 (3∙1) 1∙35 [0∙67 – 2∙68] 0∙40
TVR by CABG 2 (0∙3) 6 (1∙0)
2∙97 [0∙60 –
14∙72]
0∙28
DANAMI3-iPOST outcomes
DANAMI3-iPOST

12. Conventional
(n = 299)
iPOST
(n = 275)
P
LVEF all patients (%) 50.8 52.7 <0.05
LVEF anterior infarcts (%) 45.9 49.5 0.04
Number of patients with LVEF >45% 215 (72%) 220 (80%) 0.015
DANAMI3-iPOST
DANAMI3-iPOST outcomes

15. (Código IM Madrid)

29. Safety and Efficacy of CMX-2043 for Periprocedural Injury Protection in Subjects
Undergoing Coronary Angiography at Risk of Radio-contrast Induced Nephropathy
- CARIN
• Objetivo: demostrar seguridad y eficacia del CMX-2043 en prevenir empeoramiento
función renal tras ICP
• Diseño: Inclusión: - FGE 15 a 45 ml/min o 45-60 ml/min + uno de los siguientes: edad
>75 años, diabetes, FEVI<40%, Hipotensión, ICC. Aleatorización 1:1:1:1 a CMX-2043
2.4 mg/kg (n = 87), 3.6 mg/kg (n = 94), 4.8 mg/kg (n = 87), o placebo (n = 93).
• Endpoint primario -AKI a 4 días (> creat 0,3 mg/dl), para CMX-2043 2.4 mg/kg vs 3.6
mg/kg vs 4.8 mg/kg vs. placebo: 25.6% vs. 25.3% vs. 18.9% vs. 18.6%, p > 0.05
• Conclusiones: el fármaco no es más eficaz que el placebo, no hubo otras diferencias en
complicaciones periprocedimiento.

30. SURVIVAL TO HOSPITAL DISCHARGE
RANDOMIZE
(open study kit)
Neither
Saline Placebo
(N=1059)
Amiodarone
(n=974)
Lidocaine
(n=993)
Vascular Access
Adult nontraumatic
out-of-hospital cardiac arrest
Persistent or
recurrent VF/VT after
≥ 1 shock(s)


 Vasopressor
Hospital Admission - Monitored Care
The Amiodarone,
Lidocaine or Placebo
Study (ALPS)

31. The Amiodarone, Lidocaine or Placebo Study
(ALPS)
• Primary outcome, survival to hospital discharge, for amiodarone vs.
lidocaine vs. placebo: 24.4% vs. 23.7% vs. 21.0% (amiodarone vs.
placebo, p = 0.08; lidocaine vs. placebo, p = 0.16)
• Secondary outcomes (for amiodarone vs. lidocaine vs. placebo):
– Survival with favorable neurological status: 18.8% vs. 17.5% vs. 16.6%, p = 0.19 and 0.59,
respectively vs. placebo)
– Return of spontaneous circulation at emergency department arrival: 35.9% vs. 39.9% vs.
34.6%
– Number of EMS shocks: 5 vs. 5 vs. 6, p < 0.0001
– Clinical seizure activity within 24 hours: 3.2% vs. 5.1% vs. 3.7%, p = 0.07
– Temporary cardiac pacing within 24 hours: 4.9% vs. 3.2% vs. 2.7%, p = 0.02

32. Efficacy and safety of ticagrelor in patients
with prior MI and MVD: PEGASUS-TIMI 54

33. SWAP-3

34. DAPT score
Yeh RW, JAMA 29 marzo