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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

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


12 maggio 2008

Angioplastica Primaria

421 PCI Primarie

al 15 marzo 2010

6 Emodinamisti

7 infermieri

3 perfusionisti

6 tecnici di radiologia

h 24


Riperfusione


Emodinamista


Calabria


Affollamento delle sale di emodinamica


Infarct-related Racanalization

chest pain relief

complete resolution of ST elevation

reperfusion arrhythmias


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 fibrinolisiTIMI 4, 10A, 10B, 14 trials

2119 pz

Flusso TIMI <3 = 42%

Stenosi residua all’angio quantitativa

Llevadot, Am J Cardiol, 2000


Consapevolezza della complessità del problema


Controlla

opinione

MONDO REALE MONDO IDEALE

evidenza

Condiziona


METTIAMO UN PO' DI ORDINE


2007; 49; 422-30

Efficacy End Points for Rescue PCI Versus Conservative Therapy


2005;353:2758-68.


2005;353:2758-68.


Il messaggio non è

“non trasferire”

ma

“chi e quanto tempo comporta

trasferire?”


Fattore Tempo

Fattore Campo


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

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


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


Kaplan-Meier Curves for Death or

Reinfarction and Reinfarcion Only at 6 Months


Time from Randomization to Cardiac Catheterization in the two Treatment Group


Rate of Ischemic Events at the Available Follow-up

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


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


Kaplan-Meier curves for the primary and the composite outcome


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

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

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 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


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

Duchin et al Circulation 2008;118;268-276


SU QUALE CAMPO SI GIOCA?

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


Cath Lab 1

Cath Lab 2

Cath Lab 3


Abilità degli operatori


<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


TECHNICAL COMPETENCE

JACC, Vol. 46, No. 4, 2005

Adjusted odds ratios for major adverse cardiovascular events….


18.3%

2.4%

Angioplastiche Coronariche

Dati Gise 2008


Angioplastiche Coronariche

Dati Gise 2008 - 242 centri

pPCI < 5

PCI rescue < 5

10%

56%

46%

90%

pPCI > 5

pPCI > 5


Angioplastiche Coronariche

Dati Gise 2008 - 242 centri

pPCI < 5

PCI rescue < 5

10%

56%

46%

90%

pPCI > 5

PCI rescue > 5


eleggibili ineleggibili

“I sommersi e i salvati”

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


PCI

Trombolisi


Non bisogna essere frenetici


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

GRACE


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