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A H Gershlick University Hospital of Leicester UK

Who should we rescue ?. A H Gershlick University Hospital of Leicester UK. AA 2008 . Tissue Plasminogen activator. Thrombolysis . Thrombolysis studied in 45 000 pt 20-30 lives saved / 1000. 150 000 patients 53% early reperfusion 52% thrombolysis. Is P-PCI deliverable everywhere .

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A H Gershlick University Hospital of Leicester UK

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  1. Who should we rescue ? A H Gershlick University Hospital of Leicester UK AA 2008

  2. Tissue Plasminogen activator Thrombolysis

  3. Thrombolysis studied in 45 000 pt 20-30 lives saved / 1000 150 000 patients 53% early reperfusion 52% thrombolysis

  4. Is P-PCI deliverable everywhere Acute MI Catchments Tertiary PCI Catchments

  5. Failure ? : “TIMI 3” In the real world ?ST segment resolution @ 60/ 90 min X Normal Flow 60% 40% While there is still lysis, there will be lytic failure

  6. Who should we Rescue ? • D - ? markers of lytic failure • Pain - insensitive • - MERLIN 43% R-PCI (ECG) pain free • - TAMI -5 – clinical variables not predictive • Biomarkers –sensitivity 92% • specificity 56% • Stewart JACC 1998 31 1499

  7. Schroder R et al. JACC 1995;26:1657-1664

  8. Peak CK values in relation to the sum of ST-segment resolution (100%, 70% or 30% cut-offs) 3 hours following start of thrombolytic therapy Schroder R et al. JACC 1995;26:1657-1664

  9. The Data :

  10. 2004

  11. REACT MERLIN Cumulative Event-free Survival following R-PCI versus Conservative Therapy Gershlick AH et al NEJM 2005;353:2758-2768 Sutton AGC et al JACC 2004;44:287-296

  12. Centres 35 5 ST Resolution 50% at 90mins 50% at 60 mins 10% had TIMI III at angios 40% TIMI III at angio SK 58% 96% Stents 69% 50% GP IIb-IIIa use 43% 3% PCI arm- PCI mandatednot mandated completed in 96.5% completed in 66% PCI within 30 days 2% of conservative group 20% conservative group Recruitment 3.3 patients /centre/ year 30.7 patients/centre/year Heart failure “NYHA III or IV” Diuretics Differing Methodology: REACT versusMERLIN

  13. Outcome MERLIN versus REACT @ 1 year

  14. REACT Trial 12 month & Long term

  15. Mortality– to a median 4 ½ years

  16. death death/reAMI

  17. RESCUE PCI – HOW DO THE OUTCOMES FROM ‘REAL-WORLD’ PATIENTS COMPARE TO THE PUBLISHED TRIALS ? • 185 Consecutive Rescue PCI patients April 2005-August 2007 @ glenfield • Clinical follow-up via PCI database, case-note review and ONS, at a mean of 4.5months • Mean (SD) delay from symptom onset to PCI =501 (229) minutes [8.35 hours], range 145-2240 min Kelly DJ, Siddiqui N, Holt M, Gershlick AH-Submitted to BCS

  18. 15.3 16 14 12 10.3 Death 10 Re-AMI 7 % 8 CVA 6.2 Heart Failure 6 4.9 MACE 4 2.2 2.1 2 0.5 0 2007 Registry* REACT Trial** 2007 R-PCI Registry vs REACT Trial * Mean 4.5month Follow-up **6/12 Follow-up

  19. Local vs Transfer Patients p=0.322 p=0.42 11.5 12 9.3 10 8.4 8 % 6 Mortality 3.7 MACE 4 2 0 Local PCI Transferred Centre Patients Patients Mean Delay 438min Mean Delay 525min Mean Delay S-B 7.3 hrs 8.75 hrs

  20. When ? : Timing issues

  21. GRACE REGISTRY- Relationship between door-to-needle time and 6-month mortality among1786 patients undergoing fibrinolytic therapy for AMI Nallamothu B et al Heart 2007;93:1552-5

  22. REACT delay after symptom onset 1

  23. 13.1 14 12 10 All-cause 8 Mortality 4.8 6 (%) 3.2 4 2 0 Shortest 290 Mid tertile Longest 694 min* 485 min min Registry Mortality versus Tertile of Delay (Symptom onset to R-PCI) p=0.09 *Mean Delay from Symptom Onset to R-PCI (all patients)

  24. Rescue PCI : • All failed lytic (25%-30%) • failure to resolve max St D to > 50% at 90 mins • As soon as possible (Sympt - balloon < 3hrs) Who not to “rescue”

  25. 1082 PCI 1084 OMT 3–28 days post AMI

  26. 22/27 (82%) sheath MAJOR ( > 3g/dl) % OVERT Bld No OVERT Bld 18.7 20 3 HPericard 1 Death 15 1 H thorax 1 Death 10 8.4 8.5 5 4.9 3.5 2.1 LysisCRPCI Lysis C RPCI REACT – Bleeding Outcomes “Mm… shall I give repeat thrombolysis ?”

  27. What can Rescue –PCI do for you ?

  28. Pre-Hospital Lysis @ 4.30 am ECG @ 6 am Angio @ 6.45

  29. RESCUE–PCI should be mandated & be part of AMI protocols Repeat lytic may be dangerous

  30. R-PCI trials

  31. *1st anterior ‘failed reperfusion’ **1st anterior ‘occluded LAD’ Adapted from Kunadian B, et al. J Invasive Cardiol 2007 Sep;19(9):359-68

  32. MERLIN: 30-day Mortality according to ST-segment resolution 6 hours after initiation of fibrinolytic therapy Sutton et al JACC 2004;44:287-96

  33. Timing of AMI Rx

  34. Absolute Reduction in 35-day Mortality versus Delay from Symptom Onset to Randomization Among 45000 Patients with ST-segment elevation or LBBB Fibrinolytic Therapy Trialists’ Collaborative Group. Lanct 1994;343:311-322

  35. Use of reperfusion therapy in 376,753 patients from NRMI-4 with STEMI or LBBB within 12 hours of symptom onset Curtis JP et al JACC 2006;47:1544-52

  36. GRACE REGISTRY- Relationship between door-to-needle time and 6-month mortality among 2173 patients undergoing Primary PCI for AMI Nallamothu B et al Heart 2007;93:1552-5

  37. Mortality versus NRMI-4 Risk Index following AMI Wiviott SD et al JACC 2004;44:783-9)

  38. Curtis JP et al JACC 2006;47:1544-52

  39. Thrombolysis Primary PCI

  40. Denmark Czech Republic

  41. REACT (REscue Angioplasty v Conservative treatment or repeat Thrombolysis ) ECG90 minpost (any incl SK) thrombolytic ST < 50 % resolution (with or without pain) CONSENT & RANDOMISE Conservative2 nd thrombolyticCoronary Angio24 iv heparinAccelerated tPA or +/- PCI Reteplase primary end point: 6/12 ~death/re-infarction/severe HF/CVA 2000

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