STEMI Networks and Stents in STEMI-patients

Transkript

1 STEMI Networks and Stents in STEMI-patients Austrian view Bernhard Metzler University Hospital of Internal Medicine III / Cardiology bernhard.metzler@uki.at

2 STEMI Guidelines 2012 What is new? Ø Prehospital Management & Logistic prehospital Diagnosis, Triage, Networks Ø Reperfusionsstrategy Maximal tolerable Delays Ø Adjuvant Pharmacotherapy by PPCI P2Y12 Inhibitors, GpIIb/IIIa Inhibitors, Bivalirudin Ø Cardiac arrest therapeutic Hypothermia, early invasive angio

3 Prehospital Logistic by STEMI G Steg et al. EHJ ,

4 Steg G. et al, EHJ 2012

5 Time to treatment in ppci Nallamothu B et al, NEJM 2007

6 Menees D. et al, NEJM 2013

7 * Network-Time 60 * 90 * adapted from: Bates E. et al, NEJM 2013

8 Viennese STEMI Network Implementation of guidelines reduces Mortality Type of Reperfusion 20 Mortality & Delay 20 percent percent Primary PCI No reperfusion Thrombolysis Primary PCI Thrombolysis No reperfusion Total mortality Kalla et al. Circulation 2006

9 Prehospitale Diagnosis and direct transfer for ppci Sorensen JT et al. EHJ 2011

10 Urban and rural implementation of prehospital diagnosis and direct referral for ppci Sorensen JT et al. EHJ 2011

11 Urban and rural implementation of prehospital diagnosis and direct referral for ppci Sorensen JT et al. EHJ 2011

12 System delay and mortality n= 6209 STEMIs treated with PPCI Mortality estimates and system delay Co-variates of long-term mortality Terkelsen et al, JAMA 2010

13 Reperfusionsstrategie Tiroler STEMI Netzwerk HKHandy NAW 144 FMC frühe Diagnose Nicht-PCI KH field triage Sekund ärtransfer Primärtrans fer Ziel: 90 Minuten Schmer z 60 Min bei kurzem Delay Cath lab

14 Tirol Kufstein St Johann Reutte Zams Hall Innsbruck Inhabitants Distance: 200 km

15

16 Delays in Primary PCI / FL EHS-ACS III vs. Austria Variable Period 1 Period 2 Period 3 Period 4 Ptrend 60 (27-119) 53 (25-110) 50 (27-95) 45 (26-84) <0.001 FL <30min 61.7% 65.0% 67.4% 71.1% 0.01 ppci <90min 72.3% 72.3% 76.2% 80.4% <0.001 Timely reperfused 68.8% 70.4% 74.1% 78.1% <0.001 Door to artery d2b FMC to balloon ischemic time 60 (40-90) 53 (30-80) 49 (32-78) AUT 2005 AUT 2007 Ibk 2012 p= (77-171) 110 (80-176) 109 (83-160) 230 (155405) 210 (145367) 208 (148322) p=0.41 p=0.44 Delay (Min, IQ) Schiele et al. EHJ 2010; Österr. Akut PCI

17 STEMI-Mortality by ppci 6 Mortality 5,3% 5 5,0% 4 (%) 3,8% 3,6% SE CH 3 3,1% BRD AUT I Widimsky P et al. Eur Heart J Apr;31(8):943-57

18 Benchmark 2011 STEMI-Mortality by ppci - Subgroups 40 yes no Mortalit y 30 33, 3 23, , 7 10, ,2 3,3 4,0 3,5 7,0 8,4 3,8 3,7 0 Shock CPR Ang. succe ss 75 Innsbruck - Stand März DM St.post MI

19 22 trials 12,453 randomized patients Palmerini T. et al. JACC

20 Palmerini T. et al. JACC

21 Palmerini T. et al. JACC

22 Palmerini T. et al. JACC

23 Everolimus-eluting stent versus BMS in STEMI EXAMINATION Trial Sabate M et al, Lancet 2012

24 Conclusion MI-networks are very important and save lives class I recommendation) hospital delays have to be minimized!! place for BMS in STEMI-patients in the year 2013

25 STEMI-networks

26 Thank you

27

28

29 Palmerini T. et al. JACC

30 Palmerini T. et al. JACC

31 Palmerini T. et al. JACC

32 Adjuvante Plättchenhemmung bei PPCI ESC STEMI Guidelines 2012 AHA/ACC Guidelines 2013

33 TRITON-TIMI 38 Prasugrel vs. Clopidogrel n=3534 STEMI's Montalescot G, et al. Lancet 2009

34 PLATO - STEMI Ticagrelor vs. Clopidogrel n=7544 STEMI's Steg G et al. Circ. 2010

35 Anticoagulation for ppci ESC STEMI Guidelines 2012 AHA/ACC Guidelines 2013

36 Antikoagulation bei ppci ESC STEMI Guidelines 2012 AHA/ACC Guidelines 2013

37 Antiplatelet-therapy for ACS Clopidogrel ACS Increased bleeding risc, KI or warning for Brilique / Efient ye s STEMI Primary PCI Efient koservativ no NSTEMI DM PCI Brilique Increased bleeding risk: oak or recent Lysis, anamnesis for bleeding ( z.b. Ulcus), St.p. cerebral Event, Age (biolog.) >75-80 Jahre, weight <60kg

38 Cardiac Arrest Steg G et al. EHJ 2012

39 Cardiac Arrest G Steg et al. EHJ ,

40 Kloner et al, Circ 2001

41 Schwierig zu interpretierende EKGs Atypische EKG-Veränderungen bei STEMI Linksschenkelblock Schrittmacher EKG Patienten ohne diagnostische ST-Streckenhebung, aber mit Symptomen anhaltender Ischämie ST-Streckenhebung in avr Fehlende diagnostische ST-Streckenhebung? - R-Progression? V7-V9? - isolierte ST-Senkung 0,05mV in V1 bis V3. ST-Hebung 0,05mV V7-V9 (bei <40Jahren 0,1mV) infero-basaler MI - ST-Streckensenkung >0,1mV in 8 oder mehr Standardableitungen und ST-Hebung in avr oder V1 KHK-MG / LM G Steg et al. EHJ , Sgarabossa EB et al., N Engl J Med 1996 Apr

42 HORIZONS-AMI Bivalirudin vs. UFH & GPIIb/IIIa in ppci Net Clinical Events MACE 18.3% 15.6% HR 0.83 (95% CI ) 11.9% 11.9% HR 1.0 (95% CI ) R Mehran et al. Lancet Oct 3;374(9696)

43 FINESSE & On-TIME-2 Upstream GpIIb/IIIa Inhibitor in ppci STEMI Guidelines 2008 Adjunctive Therapy in ppci: GPI, fibrinolytics or the combination III B STEMI Guidelines 2012 Upstream GPI may be considered in high risk pts. undergoing tranfer for PCI IIb B Tirofiban HDB Place bo P=0.0 4 S Ellis et al. ESC 2007 ten Berg JM et al. J Am Coll Cardiol Jun 1;55(22):

44 Periinterventionelle antithrombotische Therapie ESC STEMI Guidelines 2012 AHA/ACC Guidelines 2013

45 Cardiac Arrest G Steg et al. EHJ ,

46 Reperfusion bei STEMI Wo stehen wir?

47 Reperfusion in STEMI current situation in Europe Widimsky P et al. Eur Heart J Apr;31(8):943-57

48 Reperfusion in STEMI current situation in Europe Widimsky P et al. Eur Heart J Apr;31(8):943-57

49 Reperfusion therapy in STEMI SWEDEHEART Annual Report 2008 Jernberg T et al. Heart 2010;96:

50 Variable Delays in Primary PCI / FL EHS-ACS III vs. Austria Period 1 Period 2 Period 3 Period 4 Ptrend 60 (27-119) 53 (25-110) 50 (27-95) 45 (26-84) <0.001 FL <30min 61.7% 65.0% 67.4% 71.1% 0.01 ppci <90min 72.3% 72.3% 76.2% 80.4% <0.001 Timely reperfused 68.8% 70.4% 74.1% 78.1% <0.001 Door to artery d2b FMC to balloon ischemic time 60 (40-90) 53 (30-80) 53 (32-78) AUT 2005 AUT 2007 Ibk 2011 p= (77-171) 110 (80-176) 120 (83-170) 230 (155405) 210 (145367) 216 (148382) p=0. 41 p=0. 44Delay (Min, IQ) Schiele et al. EHJ 2010; Österr. Akut PC

51 Tele-EKG Triage 565 Pat. ppci n=169 periph. KH n=397 sek. ad ppci n=16 STEMI n=133 (79%) STEMI n=11 (69%) periph KH n=381 STEMI keine Revask. n=4 (1%) Sejersten et al Am J Cardiol 2008;101:941 94

52 Zuweisungsmodus Österreich vs. Tirol 47, Tirol 42, 0 Österreich Prozent 30 25, , 5 9, , 0 16, 0 11, 8 7,4 6,5 1,7 2,9 0 Rettung Heli Rettung Heli Primärtransport Sekundärtransport field triage: 68,1 % selbst inhospital 67,6 % Benchmark Acute PCI-Registry 2011

53 Prasugrel in Primary PCI Austrian Acute PCI Registry (n=2454 pts.) In-hospital outcome Multivariate analysis OR p=0.01 5% 4.7% Age (years) % Sex (female) % Diabetes mellitus % 1% 0% 1.8% 0.8 % % 0% 0.2% p= % 0% maj. Mortali Bleedin ReStroke/TIA ty g infarction Clopidogr el Prasugrel 0.96 pvalue < Card. Shock Reanimation <0.0 Smoker % CI Prev. PCI 0.75 Prev. MCI 1.23 Pain to PCI 0.99 Field Triage ÖKG 2012 Best Abstracts I 1.59 Austrian Acute 2.77PCI Investigators 1

54 Falsch positive Aktivierung des Katheterlabors Larson et al. JAMA Dec 19;298(23):

55 Rates of Cath.-Lab Cancelation after Activation by EMS or Emergency Physicians Garvey JL et al. Circulation. 2012;125:3

56 Antithrombotische Vortherapie bei PPCI in Tirol 100 % 99, , 7 80,6 75 % 50 % 25 % 0 11,7 9,0 AS S He Clo p. 201 p. 0 Pr as. AS S He Clo p. 201 p. 1 Pr as.

57 Welche Reperfusionsstrategie? (Notfallort, peripheres Krankenhaus) Decision delay 120min.: = max. PCI assoziiertes Delay Ziel: 90 Min. bis zur Primär PCI 60 Min. bis zur Primär PCI bei kurzem Schmerzdelay und großem MI 30 Min. für Thrombolyse

58 Zusammenfassung Durch Tiroler STEMI Netzwerk wurde erreicht - Steigerung der PPCI (24/7) - Verkürzung der D2B-time Erhöhung des Anteils der Reperfusion in Gesamt-STEMIPopulationbleiben: geführt Hauptprobleme Verbesserung der adjuvanten Therapie - Zu späte Patientenpräsentation in ca. 20 % bei PPCI - Zeitverlust durch Sekundärtransporte (30% der Pat.) - Optimale Therapie im Einzelfall oft unklar wegen Unklarer Zeitangaben, Transportlogistik Fehldiagnosen (EKG, atyp. Symptome)

59 Dank e

60

61 Aust ria n Ac ut e PCI Re gist r y En r o l l e d p at i e n t s (St at u s : Oc t 2012) Acute PCI (n=15551) STEMI (75,6%) Primary PCI (70,1%) NSTEMI 3792 (24,4%) Rescue PCI / post Lysis 667 (4,2%) Facil. PCI 201 (1,3%) Stand Okt 2012

62 Aust ria n Ac ut e PCI Re gist r y En r o l l e d p at i e n t s (St at u s : Oc t 2012) Acute PCI (n=5957) STEMI 4351 (73,0%) Primary PCI 4176 (96,0%) NSTEMI 1606 (27,0%) Rescue PCI 98 (2,3%) post Lysis 76 (1,7%) Stand Okt 2012

63 Akut-PCI Register ÖKG 2011 Indikationen und Vergleich zum Vorjahr Indikation 2011 n (%) 2012 n (%) Primär-PCI: Rescue PCI: PCI after NSTEMI NSTEMI urgent NSTEMI <72h Kard. Schock Z.n. Reanimation 1786 (69,4) 778 (62,8) 41 (1,6) 13 (1,1) 32 (1,2) 16 (1,3) 24 (0,9) 692 (26,9) 20 (1,6) 431 (34,8) 207 (8,0) 206 (8,0) 102 (8,2) 104 (8,4) Stand Okt 2012

64 Benchmark 2011 in-hospital Outcome bei Akut PCI gesam t PPC I Rescu e PCI Post Lyse n=1814 n=1742 n=40 n=32 Mortalität 5,5% 5,0% 30,0% 3,0% Reinfarkt 0,8% 1,0% 3,0% - Major Bleeding 0,8 % 1,0% 8,0% 3,0% 2. elekt. 11,0% 11,0% 10,0% 9,0% 0,5% - - 3,0% Revaskularisierung Schlaganfall/TIA Stand März 2012

65 Benchmark 2011 Prozent Zuweisungsmodus Rettung Helikopter Primär Rettung Helikopter Sekundär Stand März 2012 selbst inhospital

66 Benchmark 2011 Primär PCI n=1742 Variabl p-wert Patientencharakte e ristika Alter (Jahre, Range) %62 (17Männer % 95) 74,0% % Kardiogener %9,9,0 Schock % % Reanimation %8,0% Diabetiker % 16,0% Raucher % 48,0% Frühere MCI % 11,0% Frühere PCI / 13,0% CABG Stand Frühere TIA / März 20123,0%

67 Benchmark 2011 Therapie bei Primär PCI n= 1742 Med. ASSVortherapie 98,0% Heparin LMWH UFH Clopidogrel prä PCI Zentrum PCI Zentrum Prasugrel prä PCI Zentrum PCI Zentrum Ticagrelor prä PCI Zentrum PCI Zentrum Fondaparinux GPIIb/IIIa Prä PCI Zentrum Stand März ,0% 72,0% 44,0% 23,0% 9,0% 13,0% 1,0% 1,0% <0,1% <0,1% 5,0%

68 Benchmark 2011 Interventionsdaten TIMI Fluss TIMI vor Intervention 0-I 72,0% II16,0% III 12,0% BMS DES ohne Stent MV-PCI Keine PCI TIMI nach Intervention 0-I 5,0% II 6,0% III 89,0% No reflow 1,0% Intervention TIMI II + III 95,0% 30,0% GpIIb/IIIa 55,0% 43,0% 6,0% Bivalirudin 5,0% 14,0% Thrombectomie 9,0% 30,0% IABP 2,0% Stand März 2012

69 Benchmark 2011 Delays bei Primär PCI 225 Gesamtischämi ezeit Schmerz bis 1. med. Kontakt med. Kontakt bis Ballon Door to Balloon Zeit in Minuten (Median)

70 Paramedics vs. Cardiologists Sejersten et al, J Electrocardiol 2008

71 Early Diagnosis G Steg et al. EHJ ,

72 Palmerini T. et al. JACC

73 Universal definition of myocardial infarction Steg G et al. EHJ 2012

74 Atypical ECG-Changes STEMI by LBBB

75 Atypical ECG-Changes Elevation in avr

76 Early Diagnosis - Initial Management G Steg et al. EHJ ,

77 Dörler J et al. EHJ 2011

78 Subgroupanalysis according the use of GP IIb/IIIa in the Cath-Lab Variable GP IIb/IIIa yes OR 95% CI Clopidogrel pre-treatment (yes vs. no) Clopidogrel pre-treatment (yes vs. no) Cardiogenic shock Resuscitation (yes vs. no) (yes vs. no) Previous myocardial infarction (yes vs. no) Year ( vs ) Gender Age (male vs. female) (per year) ASA / heparin pre-treatment pvalue GP IIb/IIIa no OR < < % CI pvalue 0.75 < < Dörler J et al. EHJ 2011