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U.O. Cardiologia – UTIC Emodinamica e Cardiologia Interventistica Presidio Ospedaliero “A. Pugliese” Catanzaro Dir. Dr. V.A.Ciconte. La PTCA dopo fibrinolisi: precoce o “rescue”?. Roberto CERAVOLO Responsabile U.S. Emodinamica e Cardiologia Interventistica. Ho un conflitto di interessi.

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U.O. Cardiologia – UTIC Emodinamica e Cardiologia Interventistica

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U o cardiologia utic emodinamica e cardiologia interventistica

U.O. Cardiologia – UTIC

Emodinamica e Cardiologia Interventistica

Presidio Ospedaliero “A. Pugliese” Catanzaro

Dir. Dr. V.A.Ciconte

La PTCA dopo fibrinolisi: precoce o “rescue”?

Roberto CERAVOLO

Responsabile U.S. Emodinamica e Cardiologia Interventistica


U o cardiologia utic emodinamica e cardiologia interventistica

Ho un conflitto di interessi


U o cardiologia utic emodinamica e cardiologia interventistica

12 maggio 2008

Angioplastica Primaria

421 PCI Primarie

al 15 marzo 2010

6 Emodinamisti

7 infermieri

3 perfusionisti

6 tecnici di radiologia

h 24


U o cardiologia utic emodinamica e cardiologia interventistica

Riperfusione


U o cardiologia utic emodinamica e cardiologia interventistica

Emodinamista


U o cardiologia utic emodinamica e cardiologia interventistica

Calabria


U o cardiologia utic emodinamica e cardiologia interventistica

Affollamento delle sale di emodinamica


U o cardiologia utic emodinamica e cardiologia interventistica

Infarct-related Racanalization

chest pain relief

complete resolution of ST elevation

reperfusion arrhythmias


U o cardiologia utic emodinamica e cardiologia interventistica

ST-segment levels from continuously recorded 12-lead ECGs

Circulation. 2004;110:e533-e539

U.O. Cardiologia – UTIC Presidio Ospedaliero “A. Pugliese” Catanzaro


Angiografia a 90 dalla fibrinolisi timi 4 10a 10b 14 trials

Angiografia a 90’ dalla fibrinolisiTIMI 4, 10A, 10B, 14 trials

2119 pz

Flusso TIMI <3 = 42%

Stenosi residua all’angio quantitativa

Llevadot, Am J Cardiol, 2000


U o cardiologia utic emodinamica e cardiologia interventistica

Consapevolezza della complessità del problema


U o cardiologia utic emodinamica e cardiologia interventistica

Controlla

opinione

MONDO REALE MONDO IDEALE

evidenza

Condiziona


U o cardiologia utic emodinamica e cardiologia interventistica

METTIAMO UN PO' DI ORDINE


U o cardiologia utic emodinamica e cardiologia interventistica

2007; 49; 422-30

Efficacy End Points for Rescue PCI Versus Conservative Therapy


U o cardiologia utic emodinamica e cardiologia interventistica

2005;353:2758-68.


U o cardiologia utic emodinamica e cardiologia interventistica

2005;353:2758-68.


U o cardiologia utic emodinamica e cardiologia interventistica

Il messaggio non è

“non trasferire”

ma

“chi e quanto tempo comporta

trasferire?”


U o cardiologia utic emodinamica e cardiologia interventistica

Fattore Tempo

Fattore Campo


U o cardiologia utic emodinamica e cardiologia interventistica

Results from 7 published randomized trials in patients treated with fibrinolytic therapy comparing the strategy of routine immediate or early catheterization

G. Stone et al. Circulation 2008;118;552-566


Caress in ami primary outcome

CARESS-IN-AMI: Primary Outcome

primary outcome (composite of all cause mortality, reinfarction, & refractory MI within 30 days)

occurred significantly less often in the immediate PCI group vs. standard care/rescue PCI group

10.7%

4.4%

HR=0.40 (0.21-0.76)

Di Mario et al. Lancet 2008;371.

26


U o cardiologia utic emodinamica e cardiologia interventistica

Kaplan-Meier Curves for the Primary End Point at 30 Days


U o cardiologia utic emodinamica e cardiologia interventistica

Kaplan-Meier Curves for Death or

Reinfarction and Reinfarcion Only at 6 Months


U o cardiologia utic emodinamica e cardiologia interventistica

Time from Randomization to Cardiac Catheterization in the two Treatment Group


U o cardiologia utic emodinamica e cardiologia interventistica

Rate of Ischemic Events at the Available Follow-up

Freek W.A. Verheugt N Engl J Med 360; june 25, 2009


U o cardiologia utic emodinamica e cardiologia interventistica

Invasive Procedures in the 2 Randomization Groups

A total of 266 patients with acute STEMI living in rural areas with more than 90-min transfer delays to PCI

J Am Coll Cardiol 2010;55:102–10


U o cardiologia utic emodinamica e cardiologia interventistica

Kaplan-Meier curves for the primary and the composite outcome


Pathway triage and transfer for pci in stemi

Pathway: Triage and Transfer for PCI (in STEMI)

STEMI patient who is a

candidate for reperfusion

Initially seen at a non-PCI

capable facility

Initially seen at a PCI

capable facility

Initial Treatment

with fibrinolytic

therapy

(Class 1, LOE:A)

Send to Cath Lab for primary PCI

(Class I, LOE:A)

Transfer for primary PCI

(Class I, LOE:A)

HIGH RISK

Transfer to a PCI facility is reasonable for early diagnostic angio & possible PCI or CABG (Class IIa, LOE:B),

High-risk patients as defined by 2007 STEMI Focused Update should undergo cath (Class 1: LOE B)

NOT HIGH RISK

Transfer to a PCI facility may be considered (Class IIb, LOE:C), especially if ischemic symptoms persist and failure to reperfuse is suspected

At PCI facility, evaluate for timing

of diagnostic angio

Prep antithrombotic (anticoagulant

plus antiplatelet) regimen

Diagnostic angio

Medical

therapy only

PCI

CABG

2009 STEMI Focused Update. Appendix 5

35


Triage and transfer for pci stemi patients who are candidates for reperfusion

Triage and Transfer for PCI: STEMI Patients Who Are Candidates for Reperfusion

Terms “facilitated PCI” and “rescue PCI” no longer used for the recommendations in this update

Contemporary therapeutic choices leading to reperfusion for pts with STEMI can be described without these potentially misleading labels

36


Recommendations for triage and transfer for pci high risk definition

Recommendations for Triage and Transfer for PCI: *High Risk Definition

Defined in CARESS-in-AMI as STEMI patients with one or more high-risk features:

extensive ST-segment elevation

new-onset left bundle branch block

previous MI

Killip class >2, or

left ventricular ejection fraction <35% for inferior MIs;

Anterior MI alone with 2 mm or more

ST-elevation in 2 or more leads qualifies

Di Mario et al. Lancet 2008;371.

37


Recommendations for triage and transfer for pci high risk definition1

Recommendations for Triage and Transfer for PCI: *High Risk Definition

Defined in TRANSFER-AMI as >2 mm ST-segment elevation in 2 anterior leads or ST elevation at least 1 mm in inferior leads with at least one of the following:

systolic blood pressure <100 mm Hg

heart rate >100 beats per minute

Killip Class II-III

>2 mm of ST-segment depression in the anterior leads

>1mm of ST elevation in right-sided lead V4 indicative of right ventricular involvement

Cantor et al. N Eng J Med 2009;360:26.

38


U o cardiologia utic emodinamica e cardiologia interventistica

Thirty-day mortality in patients treated with thrombolysis, according to use and timing of subsequent PCI

Duchin et al Circulation 2008;118;268-276


U o cardiologia utic emodinamica e cardiologia interventistica

SU QUALE CAMPO SI GIOCA?

I campi non sono tutti eguali …S.Siro, S. Paolo, Olimpico, … Marassi, Cibali, Favorita … … di quartiere … di periferia …


U o cardiologia utic emodinamica e cardiologia interventistica

Cath Lab 1

Cath Lab 2

Cath Lab 3


U o cardiologia utic emodinamica e cardiologia interventistica

Abilità degli operatori


U o cardiologia utic emodinamica e cardiologia interventistica

<75 PTCA/anno

<75 PTCA/anno

>75 PTCA/anno

<200 PTCA

>400 PTCA

>400 PTCA

Classe I

Classe II

Classe III

STANDARD in EMODINAMICA

PTCA primaria in Ospedali dotati o collegati alla Cardiochirurgia

AHA/ACC, Circulation, 2001 June 19


U o cardiologia utic emodinamica e cardiologia interventistica

TECHNICAL COMPETENCE

JACC, Vol. 46, No. 4, 2005

Adjusted odds ratios for major adverse cardiovascular events….


U o cardiologia utic emodinamica e cardiologia interventistica

18.3%

2.4%

Angioplastiche Coronariche

Dati Gise 2008


U o cardiologia utic emodinamica e cardiologia interventistica

Angioplastiche Coronariche

Dati Gise 2008 - 242 centri

pPCI < 5

PCI rescue < 5

10%

56%

46%

90%

pPCI > 5

pPCI > 5


U o cardiologia utic emodinamica e cardiologia interventistica

Angioplastiche Coronariche

Dati Gise 2008 - 242 centri

pPCI < 5

PCI rescue < 5

10%

56%

46%

90%

pPCI > 5

PCI rescue > 5


U o cardiologia utic emodinamica e cardiologia interventistica

eleggibili ineleggibili

“I sommersi e i salvati”

Koeth O. (MITRA Plus) Am J Cardiol 2009;104:1074


U o cardiologia utic emodinamica e cardiologia interventistica

PCI

Trombolisi


U o cardiologia utic emodinamica e cardiologia interventistica

Non bisogna essere frenetici


U o cardiologia utic emodinamica e cardiologia interventistica

Eagle K,A. et al. Eur Heart J 2008; 29

GRACE


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