- Primary angioplasty, thrombolysis, and pharmaco-invasive therapy are strategies for reperfusion in STEMI patients.
- The optimal strategy depends on factors like time since symptom onset, mortality risk from STEMI, availability of a skilled PCI laboratory, and time required for transport.
- Minimizing total ischemic time is critical as myocardial necrosis increases significantly past 40 minutes from occlusion. Every 30 minute delay in reperfusion increases 1-year mortality by 8%.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
Cardiogenicshock by Dr.Afroza Prioty -140123092109-phpapp02Afroza Prioty
A small overview on cardiogenic shock which sometimes becomes a burning issue for the medical personnels and to combat the situation, the measures should be taken immediately and urgently.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Couples presenting to the infertility clinic- Do they really have infertility...
Pci or throm or pi in stemi best strategy(apicon 09022019)-final
1. Primary Angioplasty,Primary Angioplasty,
Thrombolysis orThrombolysis or
Pharmaco-Invasive Therapy in Acute STEMI –Pharmaco-Invasive Therapy in Acute STEMI –
What is the best strategy in Indian Scenario?What is the best strategy in Indian Scenario?
Dr. Vinod SharmaDr. Vinod Sharma
M.D; DM; FACC, FRCPM.D; DM; FACC, FRCP
11
National Heart InstituteNational Heart Institute
New DelhiNew Delhi
2. CAD in IndiaCAD in India
Rising prevalence with rapid EpidemiologicalRising prevalence with rapid Epidemiological
transition.transition.
Projected (1990 – 2020)Projected (1990 – 2020)
-- 117% & 105% rise in mortality from CAD117% & 105% rise in mortality from CAD
in men & women.in men & women.
Nearly 3 million STEMI are estimated to occurNearly 3 million STEMI are estimated to occur
in India per year.in India per year.
22
3. STEMISTEMI represents the critical phase ofrepresents the critical phase of
Acute Coronary SyndromeAcute Coronary Syndrome
ST Elevation MI
33
4. Correct focus of attention for optimal STEMI CARECorrect focus of attention for optimal STEMI CARE
Total Ischemic TimeTotal Ischemic Time
Wave front phenomenon of myocardialWave front phenomenon of myocardial
infarction propagationinfarction propagation
(Reimer et al: Circulation 1977)(Reimer et al: Circulation 1977)
Area of necrosis compared with area of risk when artery wasArea of necrosis compared with area of risk when artery was
occluded:occluded:
At 40 minutesAt 40 minutes :: 45% of myocardium irreversibly45% of myocardium irreversibly
injured.injured.
55% of myocardium at risk55% of myocardium at risk
waswas salvageable.salvageable.
At 3 hoursAt 3 hours :: 33% salvageable33% salvageable
At 6 hoursAt 6 hours :: 16% salvageable16% salvageable
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--
Benefit of reperfusion is time dependent from the first momentBenefit of reperfusion is time dependent from the first moment
of occlusionof occlusion
44
5. BB
CC
AA
Extent ofExtent of
Myocardial SalvageMyocardial Salvage
MortalityReduction(%)MortalityReduction(%)
DD
100100
8080
6060
4040
2020
00
00 44 88 1212 1616 2020 2424
Time From Symptom Onset to Reperfusion Therapy, hTime From Symptom Onset to Reperfusion Therapy, h
Critical Time-dependent PeriodCritical Time-dependent Period
Goal: Myocardial SalvageGoal: Myocardial Salvage
Time-independent PeriodTime-independent Period
Goal: Open Infarct-Related ArteryGoal: Open Infarct-Related Artery
Gersh BJ, et al. JAMA. 2005;293:979.Gersh BJ, et al. JAMA. 2005;293:979.
1. Time is Myocardium
2. Infarct Size is Outcome
55
6. Effects of Total Ischemic Time on Infarct Size &Effects of Total Ischemic Time on Infarct Size &
Clinical OutcomesClinical Outcomes
66
7. Time is essence ……Time is essence ……
Choice is reperfusion ......Choice is reperfusion ......
77
8. Reperfusion is the key to saveReperfusion is the key to save
myocardium and life….myocardium and life….
Aim is to open the blocked I.R.A.Aim is to open the blocked I.R.A.
and Re -establish the coronary blood flowand Re -establish the coronary blood flow
-- RapidRapid
-- EarlyEarly
-- CompleteComplete
-- SustainedSustained
88
9. Every 30-minute delayEvery 30-minute delay
from onset of symptoms tofrom onset of symptoms to
reperfusion. 1 yearreperfusion. 1 year
mortality is increased bymortality is increased by
8%8%
De Luca et al, Circulation 2004
Reduction in Long Term Mortality
99
10. Myocardial perfusion, not theMyocardial perfusion, not the
epicardial perfusion is the finalepicardial perfusion is the final
determinants……determinants……
1010
12. Illustration of the traditional concept of microcirculatory impairment in the setting of no flow
in the proximal LAD compared with preserved flow in the left circumflex coronary artery, as
typically seen in acute anterior ST-segment elevation myocardial infarction (upper left panel).
Lerman A et al. Eur Heart J 2007;28:788-797 1212
13. ““Despite the proven success of restorationDespite the proven success of restoration
of epicardial coronary blood flow in aof epicardial coronary blood flow in a
reasonably timely fashion, reperfusion onreasonably timely fashion, reperfusion on
the myocardial level is not accomplished inthe myocardial level is not accomplished in
~50% of patients with STEMI and is of~50% of patients with STEMI and is of
negative prognostic implication”negative prognostic implication”
Lerman et al; European Heart Journal 2007 1313
14. ECG suggestive of failure ofECG suggestive of failure of
myocardial perfusionmyocardial perfusion
1414
15. ThrombolysisThrombolysis
Primary AngioplastyPrimary Angioplasty
Pharmaco-invasive strategyPharmaco-invasive strategy
1515
Reperfusion strategy in STEMIReperfusion strategy in STEMI
Where are we at 2019?Where are we at 2019?
16. Reperfusion strategies in the infarct relatedReperfusion strategies in the infarct related
artery according to time from symptoms onsetartery according to time from symptoms onset
1616
ESC Guidelines 2017ESC Guidelines 2017
17. Selection of Reperfusion Strategy inSelection of Reperfusion Strategy in
STEMISTEMI
Time since the onset of symptomsTime since the onset of symptoms
Risk of Mortality from STEMIRisk of Mortality from STEMI
Availability of skilled PCI LaboratoryAvailability of skilled PCI Laboratory
Time required for TransportTime required for Transport
Any contraindication to thrombolysis including bleeding,Any contraindication to thrombolysis including bleeding,
ICHICH
Patient preferencePatient preference
ACC/AHA STEMI Guidelines 2004ACC/AHA STEMI Guidelines 2004
1717
18. Lytic Vs. PCI in Acute MI Patients
Fibrinolysis Primary Angioplasty
0%
50%
100%
>95% TIMI 3
0.1% Stroke
2% Reocclusion
5% availability
100%
50%
0%
60% TIMI 3
<50% Treated
1% Stroke
5% Reocclusion
Availability
25% Late
occlusion
1818
19. 7
4.5
2.2
6
1 0
7 89
7 7
21
2 1
5
13
0
5
10
15
20
25
30
35
PTCA vs. Fibrinolysis:
Short Term Clinical Outcomes (23 RCTs)
PTCA
Frequency(%)
Keeley E. et al., Lancet 2003; 361:13-20.
P=0.0002
P=0.0003 P<0.0001
P<0.0001
P<0.0001
P=0.0004
P=0.032
P<0.0001
Death Death,
no
SHOCK
data
ReMI Rec.
Isch
Stroke
Hem.
Stroke
Major BleedDeath
MI
CVA
Fibrinolysis
N = 7739
1919
21. Time Delay to Treatment and Mortality inTime Delay to Treatment and Mortality in
Primary Angioplasty for Acute MyocardialPrimary Angioplasty for Acute Myocardial
InfarctionInfarction
Every Minute of Delay CountsEvery Minute of Delay Counts
• Every minute of delay in primary angioplasty for STEMIEvery minute of delay in primary angioplasty for STEMI
affects 1-year mortality, even after adjustment for baselineaffects 1-year mortality, even after adjustment for baseline
characteristics. Therefore, all efforts should be made tocharacteristics. Therefore, all efforts should be made to
shorten the total ischemic time, not only for thrombolyticshorten the total ischemic time, not only for thrombolytic
therapy but also for primary angioplasty.therapy but also for primary angioplasty.
Circulation 2004Circulation 20042121
23. Superiority of 1° PCI Over Lysis Lost After a
DB − DN Delay of 114 Minutes
Pinto DS, et al. Circulation. 2006;114:2019-25Pinto DS, et al. Circulation. 2006;114:2019-25..
PCI Related Delay (DB − DN) (min)PCI Related Delay (DB − DN) (min)
PCI BetterPCI Better
OddsofDeathOddsofDeath
0.8
1.25
1.5
0.5
1.0
2.0
12060 75 90 105 135 150 165 180114
Fibrino-lysisFibrino-lysis
BetterBetter
2323
24. 95.8% of patients treated after 9095.8% of patients treated after 90
minutesminutes
95.8% of patients treated after 9095.8% of patients treated after 90
minutesminutes
Door to balloonDoor to balloon Door to doorDoor to door
2424
25. • Experience & volume of primary PCI cases atExperience & volume of primary PCI cases at
PCI Lab play role in choice of therapy.PCI Lab play role in choice of therapy.
• Mortality benefit with PCI only in high volumeMortality benefit with PCI only in high volume
centre, whereas no difference in low volumecentre, whereas no difference in low volume
centres.centres.
Availability of PCI facilityAvailability of PCI facility
2525
26. Availability of PCI facilityAvailability of PCI facility
Availability of a skilled PCI Lab with the capacityAvailability of a skilled PCI Lab with the capacity
to provide expert, prompt, 24 x 7 interventionto provide expert, prompt, 24 x 7 intervention
> 50% of patients with STEMI present to a> 50% of patients with STEMI present to a
Non PCI capable centreNon PCI capable centre
Less than optimal outcome expected in a lowLess than optimal outcome expected in a low
volume centre with less experiencedvolume centre with less experienced
operators.operators.
(Water RE: JACC 2004)(Water RE: JACC 2004)
2626
27. Outcome of primary angioplasty for acuteOutcome of primary angioplasty for acute
myocardial infarction during routine duty hoursmyocardial infarction during routine duty hours
versus during off-hoursversus during off-hours
(n=1702)(n=1702)
J Am Coll Cardiol 2003; 41: 2138-2142J Am Coll Cardiol 2003; 41: 2138-2142
• Patients (47%) who presented during off hours (1800Patients (47%) who presented during off hours (1800
to 0800 hrs) had a higher rate of PCI failure & 30to 0800 hrs) had a higher rate of PCI failure & 30
days mortality compared to these who presenteddays mortality compared to these who presented
during normal duty hours.during normal duty hours.
Availability of PCI facilityAvailability of PCI facility
2727
28. High failure rate with out-of-hours PCI even
in high volume centre
In 1702 cases
– referral centre for 11 hospitals
– 48% presented between 1800hrs and 0800hrs
– PCI failure rate 6.9% vs. 3.8% p<0.01
– 30d mortality 4.2% vs. 1.9% p< 0.01
Zwolle Group JACC 2003;41:2138
Availability of PCI facilityAvailability of PCI facility
2828
29. Majority of the hospitals are not PCI enabled.
most of PCI enabled hospitals do not have inhouse
interventional Cardiologists & paramedics to carry
out interventional procedures round the clock.
Availability of transport, long transportation time,
traffic congestion & weather condition affects
access to the PCI enabled centre.
Selection of Reperfusion Strategy inSelection of Reperfusion Strategy in
STEMISTEMI
2929
30. Accounts / Billing
section
Your patient needs PPCI.
Deposit Rs.2.0 lacs
immediately for PCI
From where,
I get 2.0 lacs
at this time
in night !!!
3030
32. Indian scenario
Pain to door time:
South India: 10.8
hours (Indian Heart
J 2004;56: 210–4)
North India: 5.2
hours (Indian Heart
J 2003;55: 349–53)
Door to drug time:
1 hour
Low rate of in-
hospital
thrombolysis
mainly due to late
arrival.
Reasons for not receiving in-hospital thrombolysis
30days mortality among 1320 pts 16.9%
3232
33. Challenges in STEMI Care inChallenges in STEMI Care in
Developed CountriesDeveloped Countries
3333
36. Benefit of Thrombolytic Therapy is Greatest
in Patients Treated Within Few Hours of Symptom Onset
50,246 AMI patients randomized to lytic vs control
Boersma E et al. Lancet 1996;348:771Boersma E et al. Lancet 1996;348:771
3636
38. CAPTIM trial: Pre-hospital thrombolysis within 2 hoursCAPTIM trial: Pre-hospital thrombolysis within 2 hours
is superior to Primary PCIis superior to Primary PCI
Similar mortality for primary percutaneous coronary intervention and a policy of
pre-hospital lysis followed by transfer to an interventional center. In addition, for
patients treated within 2 h of symptom onset, 5-year mortality was lower with pre-
hospital lysis.
European Heart Journal (2009) 30, 1598–1606 3838
39. USIC 2000, French Registry Data
Hospital administered ‘lysis as good as PCI
EURO-PCR Paris 2003
Pre hospital lysis
3939
40. French USIC 2000 survey: real world
No
reperfusion
Pre-
hosp TT
Hosp
TT
Primary
PCI
Patients 386
(30%)
155
(12%)
322
(25%)
425
(33%)
Age (year) 71 60 61 61
Time to
admission
(h)
2.8 2.4 2.2 2.1
1 year
death
14.7% 3.2% 9.0% 7.9%
USIC. Circulation 2004;110:1909-1915 4040
43. Mehta, Textbook of
STEMI Interventions
Ease of Use;
Favorable
Pharmacokinetics;
briHighest Reperfusion
rates;
Agent most used in
Clinical Trials
4343
44. ““In the golden hour, when symptom duration is within 1In the golden hour, when symptom duration is within 1
to 2 hours, prompt FT may provide clinical benefitto 2 hours, prompt FT may provide clinical benefit
compared with primary PCI & should be considered as acompared with primary PCI & should be considered as a
potentially preferable option”.potentially preferable option”.
““Beyond this critical time window, the available dataBeyond this critical time window, the available data
suggest that symptoms duration need not guide thesuggest that symptoms duration need not guide the
choice of reperfusion therapy, provided that thechoice of reperfusion therapy, provided that the
Fibrinolytic drug considered for use is fibrin specific”.Fibrinolytic drug considered for use is fibrin specific”.
Peter Bogaty: Circulation 2009Peter Bogaty: Circulation 2009
4444
45. Emerging Modalities
Pharmacoinvasive Management
(PCI following TNK)
is a better , safer option than PAMI as proved
recently .
JACC Sept 2007
It widens the time window for PCIIt widens the time window for PCI
This seems to combine the benefits ofThis seems to combine the benefits of
Mechanical and pharmacologicalMechanical and pharmacological
strategies in reperfusionstrategies in reperfusion
4545
49. Definition:
Early PCI within 3 – 24 hours of successful
fibrinolysis as well as
Broad use of rescue PCI after failed fibrinolysis.
Pharmaco-Invasive
4949
50. Pharmacoinvasive Therapy
Why unified approach ?
• Logistic & economic difficulties of PPCI
• Benefits of prehospital thrombolysis.
• Over reaching importance of time to
reperfusion regardless of strategy.
• Thrombolysis alone has serious limitations.
5050
51. 1) Prompt induction of reperfusion (within the “golden” 2 hours after
onset of chest pain indicative of ischemia)
2) Subsequent induction of complete reperfusion
3) Sustained reperfusion and
4) Avoidance of reinfarction or bleeding.
Optimal Pharmaco-invasive therapy should achieve the
following:
The specific regimens and timing for use of the
two components entailed will require further study
in randomized clinical trials.
PHARMACO-INVASIVE THERAPYPHARMACO-INVASIVE THERAPY
5151
52. Studies (year) &
Total randomized,
n
Major Inclusion Criteria Time from
Lysis to
routine early
PCI (h)
30 day composite of
mortality / re-infarction /
ischaemia, N (%)
Lysis +
routine
early PCI
Lysis +
ischaemia-
guided
PCI
NORDI-STEMI19
(2005-2008) & 266
Symptoms of MI present for < 6 h, ST-
elevation, expected time delay to
PCI > 90 min, tenecteplase use
2.7 (median) 13(10) 26 (20)
TRANSFER-AMI18
(2004-2007) & 1059
Symptoms of MI present for < 12 h
and ST-elevation.
Only tenecteplase-treated patients
used
< 6 (3.9
median)
39 (7) 58 (11)
WEST17
(2005) &
204
Age > 18 years, not pregnant
Symptoms presumed secondary to
STEMI lasting at least 20 min and
ST-elevation / new LBBB
< 24 (4.9
median)
10 (10) 13 (13)
CARESS-AMI 15
(2002 – 2007) & 600
Symptoms of MI present for < 12 h
and ST-elevation / new LBBB/Killip
class > 2/LV ejection fraction < 30%
< 3 (2.2
median)
13 (4) 32 (11)
CAPITAL – AMI14
(2001-2004) & 170
Presentation < 6 h of onset of chest
discomfort of > 30 min duration and ST-
elevation / LBBB
< 3 (1.6
median)
12 (14) 29 (35)
SUMMARY OF STUDIES
53. Studies (year) &
Total randomized,
n
Major Inclusion Criteria Time from
Lysis to
routine early
PCI (h)
30 day composite of
mortality / re-infarction /
ischaemia, N (%)
Lysis +
routine
early PCI
Lysis +
ischaemia-
guided
PCI
GRACIA-I13
(2000-
2001) & 500
Chest pain lasting 30 min to 12 h and
ST-elevation / LBBB
< 24 [16.7
mean (SD
5.6)]
12 (5) 16 (6)
SIAMI III 11
(1998 –
2001) & 197
Symptoms of MI present for < 12 h +
ST – elevation
Eligible for thrombolysis
No secondary / iatrogenic MI
< 6 (3.5 + 2.3) 7 (8) 25 (31)
PRAGUE – I10
(1997 – 1999) & 199
Within 6 h of symptom and ST-
elevation / LBBB
Present to community hospital sans
PCI facility
< 1.1 (n/a) N/A N/A
Pooled (1997-2007)
& 3195
< 24 106 (7.3) 199 (13.5)
SUMMARY OF STUDIES
55. STREAM SUBSTUDY –STREAM SUBSTUDY – ABORTED STEMIABORTED STEMI
MORE COMMON WITH STRATEGY OFMORE COMMON WITH STRATEGY OF
EARLY FIBRINOLYSISEARLY FIBRINOLYSIS
ABORTED MI Time Since
Symptoms to
Start of
Reperfusion
Pharmaco-
Invasive group
N = 99 (11.1%) 100 minutes
Primary PCI
Group
N = 59 (6.9%)
P < 0.01
178 minutes
5555
56. ABORTED MYOCARDIAL INFARCTIONABORTED MYOCARDIAL INFARCTION
ST Segment ResolutionST Segment Resolution >> 50% (9050% (90
minutes post TNK & 30 minutes post PCI)minutes post TNK & 30 minutes post PCI)
Minimal Biomarker Rise (CK-MBMinimal Biomarker Rise (CK-MB << 2 times2 times
the ULN, T/Ithe ULN, T/I << 5 times the UNL)5 times the UNL)
Those who develops new pathological QThose who develops new pathological Q
waves are excluded.waves are excluded.
5656
57. Comparison of 30-Day Outcomes byComparison of 30-Day Outcomes by
Treatment Strategy in STREAM SubstudyTreatment Strategy in STREAM Substudy
ABORTED MI
(n = 158)
No ABORTED
MI (n = 1,596)
P Value
Primary Composite
Endpoint
Pharmacoinvasive
Primary PCI
5.1%
10.2%
12.0%
12.9%
0.38
0.545
Cardiogenic shock
Pharmacoinvasive
Primary PCI
0
3.4%
4.4%
4.6%
0.26
1.00
CHF
Pharmacoinvasive
Primary PCI
1.0%
3.4%
6.6%
7.3%
0.23
0.423
Overall 7% 12.5% 0.042
5757
58. STREAM SUBSTUDY: ABORTION OFSTREAM SUBSTUDY: ABORTION OF
STEMISTEMI
ONE YEAR FOLLOW UPONE YEAR FOLLOW UP
All Cause MortalityAll Cause Mortality
Aborted MI Vs Non-aborted MIAborted MI Vs Non-aborted MI
3.1% Vs 4.5%3.1% Vs 4.5%
(P = .818)(P = .818)
5858
59. STREAM TRIALSTREAM TRIAL
Coronary Flow DataCoronary Flow Data
> 70% of patients receiving early fibrinolysis had> 70% of patients receiving early fibrinolysis had
TIMI flow grade 2 or 3, compared with 20% ofTIMI flow grade 2 or 3, compared with 20% of
those arriving for primary PCI.those arriving for primary PCI.
Larger clinical benefit at longer term follow up.Larger clinical benefit at longer term follow up.
5959
60. From: Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with
ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial
Eur Heart J. 2007;28(8):949-960. doi:10.1093/eurheartj/ehl461
6060
Myocardial ReperfusionMyocardial Reperfusion
61. STEMI Care in India & the Real World:STEMI Care in India & the Real World:
Challenges AheadChallenges Ahead
In a registry involving 50 cities, only 58.5% ofIn a registry involving 50 cities, only 58.5% of
patients with STEMI were thrombolysedpatients with STEMI were thrombolysed mostlymostly
with Streptokinasewith Streptokinase and a minority receivedand a minority received
percutaneous coronary intervention (PCI).percutaneous coronary intervention (PCI).
6161
62. Victor SM etal, IHJ 2016;68:169-73Victor SM etal, IHJ 2016;68:169-73
6262
63. The primary end points of 30 days incidenceThe primary end points of 30 days incidence
of death, cardiogenic shock, reinfarction,of death, cardiogenic shock, reinfarction,
CHF and repeat revascularization was similarCHF and repeat revascularization was similar
in both groups, although there was trendin both groups, although there was trend
towards benefit in PPCI group.towards benefit in PPCI group.
At the end of two years follow up, initialAt the end of two years follow up, initial
benefit from PPCI seemed to be narrowed.benefit from PPCI seemed to be narrowed.
PI approach resulted in similar outcomesPI approach resulted in similar outcomes
when compared with PPCI in patients withwhen compared with PPCI in patients with
STEMI at 2 years follow up.STEMI at 2 years follow up.
6363
64. Kaplan-Meier curves for the primary endpoint. The primaryKaplan-Meier curves for the primary endpoint. The primary
endpoint was a composite of death, cardiogenic shock,endpoint was a composite of death, cardiogenic shock,
reinfarction, repeat revascularization and CHF at 2 years (p = 0.40)reinfarction, repeat revascularization and CHF at 2 years (p = 0.40)
6464
65. Observational study comparing Pharmaco-invasive strategyObservational study comparing Pharmaco-invasive strategy
with primary PCI in patients presenting with ST elevation MIwith primary PCI in patients presenting with ST elevation MI
to a tertiary care centre in Indiato a tertiary care centre in India
6565
ResultsResults
At 1 month follow up, incidence rate for primary endpoints was 5At 1 month follow up, incidence rate for primary endpoints was 5
events per 43 patients (11.6%) in pharmaco-invasive arm & 18events per 43 patients (11.6%) in pharmaco-invasive arm & 18
events per 95 patients (18.9%) in primary PCI arm, a difference ofevents per 95 patients (18.9%) in primary PCI arm, a difference of
– 7.3% (95% confidence interval: 18.5, 7.1).– 7.3% (95% confidence interval: 18.5, 7.1).
Pharmaco-invasive strategy as compared with primary PCI in thePharmaco-invasive strategy as compared with primary PCI in the
management of STEMI was equivalent in terms of compositemanagement of STEMI was equivalent in terms of composite
primary outcome.primary outcome.
There was no significant difference between the secondaryThere was no significant difference between the secondary
outcomes between the two groups.outcomes between the two groups.
Use of thrombus aspiration device and in turn the thrombusUse of thrombus aspiration device and in turn the thrombus
burden was significantly lower in the pharmaco-invasive arm.burden was significantly lower in the pharmaco-invasive arm.
Alex et al (CMC, Vellore) Journal of PG Med 2018; 64:2; 80-85
66. Observational study comparing Pharmaco-invasive strategyObservational study comparing Pharmaco-invasive strategy
with primary PCI in patients presenting with ST elevation MIwith primary PCI in patients presenting with ST elevation MI
to a tertiary care centre in Indiato a tertiary care centre in India
6666
ConclusionConclusion
Pharmaco-invasive strategyPharmaco-invasive strategy was as good aswas as good as
primary PCIprimary PCI in STEMI, in the setting, wherein STEMI, in the setting, where
primary PCI may be delayed or not possibleprimary PCI may be delayed or not possible atat
all due to financial and logistic constraints.all due to financial and logistic constraints.
Alex et al (CMC, Vellore) Journal of PG Med 2018; 64:2; 80-85
67. The degree of reversibility and extent ofThe degree of reversibility and extent of
myocardial necrosis were both timemyocardial necrosis were both time
dependentdependent
Reimer 1979Reimer 1979
6767
68. Fibrinolytics are needed becauseFibrinolytics are needed because
primary PCI cannot be delivered to allprimary PCI cannot be delivered to all
patients with STEMI within evidencepatients with STEMI within evidence
based time frames needed for fullbased time frames needed for full
effectiveness.effectiveness.
6868
69. Timely reperfusion is the more important than the choiceTimely reperfusion is the more important than the choice
of reperfusionof reperfusion
The timeliness of treatment with either
PPCI or thrombolysis as per ACC 2007
guidelines is a strong predictor of
overall mortality .
However, no association is observed
with choice of reperfusion therapy.
Untimely PPCI has worse prognosis than timely fibrinolysis and
untimely fibrinolysis has poor prognosis than timely PPCI.
JAMA 2010, 303 (21): 2148-55 6969
70. On-site FT better than delayed PCIOn-site FT better than delayed PCI
PCI-related delays are extensivePCI-related delays are extensive
among patients transferred foramong patients transferred for
transfer for PCI (X-PCI) and aretransfer for PCI (X-PCI) and are
associated with poorer outcomes.associated with poorer outcomes.
No differential excess in mortalityNo differential excess in mortality
was seen with X-PCI comparedwas seen with X-PCI compared
with on-site fibrinolysis (O-FT)with on-site fibrinolysis (O-FT)
even with long PCI-related delays,even with long PCI-related delays,
but as XDB door-to-needle timebut as XDB door-to-needle time
times increase, the mortalitytimes increase, the mortality
advantage for X-PCI over O-FTadvantage for X-PCI over O-FT
declinesdeclines
Circulation. 2011;124:2512-2521
7070
71. SummarySummary
Time is EssenceTime is Essence
-- Time isTime is “Muscle”“Muscle”
-- Valid with both PCI & ThrombolysisValid with both PCI & Thrombolysis..
Choice is ReperfusionChoice is Reperfusion
-- Timely Reperfusion is more important thanTimely Reperfusion is more important than
the choice of Reperfusion.the choice of Reperfusion.
-- Onsite Fibrinolytic Therapy is better thanOnsite Fibrinolytic Therapy is better than
Delayed PCI.Delayed PCI.
7171
72. Management of STEMI in IndiaManagement of STEMI in India
A Pharmaco-invasive strategy isA Pharmaco-invasive strategy is
more appropriate to alleviate themore appropriate to alleviate the
logistic & geographical barriers inlogistic & geographical barriers in
the timely reperfusion of STEMI,the timely reperfusion of STEMI,
more appropriate to Indianmore appropriate to Indian
scenario.scenario. 7272
We expect that this strategy will result in 15 and maybe even 20 extra lives saved per 1000 treated.
This estimate is Based on available evidence, showing that a one-hour of reduction in treatment delay
Reduces 1-yerar mortality by 14% and an observational study documenting that in our county
One-year mortality is 11% among STEMI patients treated by PCI.
Therefore, the beneficial effect of earlier reperfusion thereapy may be of the
Same magnitude as the beneficial effect obtained when we introduced aspirin instead of placebo,
Fibrinolysis instead of placebor or primary PCI instead of fibrinolysis.
Illustration of the traditional concept of microcirculatory impairment in the setting of no flow in the proximal LAD compared with preserved flow in the left circumflex coronary artery, as typically seen in acute anterior ST-segment elevation myocardial infarction (upper left panel). The sequence starts with the vulnerable atherosclerotic plaque, which, by rupture or fissure, causes thrombus formation and thereby complete coronary artery occlusion. Embolization of particulate matter, potentially aggravated by PCI, in addition to ischaemia, oxidative stress, and inflammation can lead to dysfunction of the myocardial microcirculation with impairment of myocardial perfusion that can persist or be even intensified after restoration of epicardial blood flow.
S2D time is an average of 300 minutes
In an observational study conducted in a tertiary centre in south India, the mean duration between symptom onset and hospitalization was 10.8 hours and the 30 day mortality among the 1320 evaluated patients was 16.9% (Indian Heart J 2004;56: 210–4).
In an another observational study from North India, the median pain-to-door time was 5.2 hours Time delay (&gt; 6 hours) was the commonest cause of not receiving thrombolysis (79%) while pre-tertiary centre thrombolysis was the reason only in 5% of the patients. Thus 79% of the patients missed pre-tertiary centre thrombolysis. (Indian Heart J 2003;55: 349–53)
Table 3. Properties of approved fibrinolytic agents
Pharmacoinvasive Therapy: A Tale of Two Treatments Seen as One
Thrombolytic or/vs Percutaneous Coronary Intervention (PCI)
Both Complementary –One treatment (Pharmacoinvasive therapy)
EHJ 2006;27,1530-1538
Figure 2 Prevalence of TFG 3, TIMI myocardial perfusion grade 3, complete ST-resolution, and full reperfusion after coronary intervention in the post-fibrinolysis angioplasty group compared with the primary angioplasty group. Full reperfusion denotes the prevalence of patients who achieved TFG 3, TIMI myocardial perfusion grade 3, and complete ST-resolution following percutaneous coronary intervention. *P &lt; 0.01.
