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Reperfusion Strategies for ST elevation MI.

Reperfusion Strategies for ST elevation MI. Tom P Stys, FACC, MD Medical Director Sanford Cardiology. 4897 community hospitals in the United States 1 2900 are located in urban areas 1 1997 are located in rural areas 1

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Reperfusion Strategies for ST elevation MI.

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  1. Reperfusion Strategies for ST elevation MI. • Tom P Stys, FACC, MD • Medical Director • Sanford Cardiology

  2. 4897 community hospitals in the United States1 • 2900 are located in urban areas1 • 1997 are located in rural areas1 • Although primary PCI is often the preferred strategy for STEMI, only about 25% of US hospitals are capable of performing PCI2 • Non–PCI-capable institutions are often located in rural areas and face challenges related to their distance from PCI centers • Almost 60% of US adults live in an area where a non–PCI-capable institution is their closest hospital2 • Guideline-based multidisciplinary care and coordinated transfer protocols are important for best outcomes ACS and Rural Hospitals • American Hospital Association Statistics. Available at: www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html. Accessed May 23, 2010. • Nallamothu BK, et al. Circulation. 2006;113(9):1189-1195.

  3. STEMI Chain of Survival

  4. Time to Treatment Is Critical in STEMI 0.4 million discharges per year for STEMI in US Call 9-1-1 Call fast Not PCI capable • EMS on-scene • Encourage 12-lead ECGs • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min Onset of symptoms of STEMI 9-1-1 EMS dispatch PCI capable GOALS 5 min 8 min EMS Transport Prehospital fibrinolysis EMS-to-needle within 30 min Patient EMS transport EMS-to-balloon within 90 min Patient self-transport Hospital door-to-balloon within 90 min Dispatch 1 min Total ischemic time: within 120 min Golden hr = 1st 60 min • Time to reperfusion is a critical determinant of the extent of myocardial damage and clinical outcomes in patients with STEMI • Key factors in STEMI care are rapid, accurate diagnosis and keeping the encounter time to reperfusion as short as possible

  5. The Thrombus in STEMI STEMI is generally caused by a completely occlusive fibrin-rich thrombus in a coronary artery Results from stabilization by fibrin mesh of a platelet aggregate at site of plaque rupture *RBC = red blood cell. GP IIb-IIIa inhibitors are not indicated for STEMI. Van de Werf F. ThrombHaemost. 1997;78(1):210-213; White HD. Am J Cardiol. 1997;80(4A):2B-10B; Davies MJ. Heart. 2000;83(3):361-366.

  6. Achieve Coronary Patency • Initial Reperfusion Therapy - Defined as the initial strategy employed to restore blood flow to the occluded coronary artery • 3 Major Options: • Pharmacological Reperfusion • PCI • Acute Surgical Reperfusion Class I All patients should undergo rapid evaluation for reperfusion therapy & have a reperfusion strategy implemented promptly after contact with the medical system Antman et al. JACC 2004;44:680.

  7. Goals When Considering a Reperfusion Strategy • Decrease amount of myocardial necrosis • Preserve LV function • Prevent major adverse cardiac events • Treat life threatening complications

  8. Importance of EarlyReperfusion Therapy in STEMI Outcomes Dependent Upon: Time to treatment-TIME IS STILL MUSCLE Early and full restoration in coronary blood flow Sustained restoration of flow

  9. Reperfusion Recommendations - STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact. I I IIa IIa IIb IIb III III A • STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI center for intervention within 90 minutes of first medical contact should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless contraindicated. B ACC/AHA 2007 STEMI Focused Update Circulation 2007; on line, December 10.

  10. Based on initial Evaluation, ECG, and Cardiac markers STEMI Patient? Risk Stratification YES NO - Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy UA or NSTEMI - Evaluate for Invasive vs. conservative treatment - Directed medical therapy

  11. Choices:Reperfusion Strategies for STEMI Plan A: percutaneous coronary intervention (primary PCI) -Mechanical means of restoring blood flow • Balloon angioplasty • Stents - More effective - Lower bleeding risk - Available at only 25% of U.S. hospitals • Treatment delays Plan B: thrombolytics (fibrinolytics) - Pharmacologic means of restoring blood flow • “Clot-busting” drugs - Less effective - Greater bleeding risk - Widely available at U.S. hospitals

  12. Determine preferred reperfusion strategy Fibrinolysis preferred if: • <3 hours from onset • PCI not available/delayed • door to balloon > 90min • door to balloon minus door to needle > 1hr • Door to needle goal <30min • No contraindications PCI preferred if: • PCI available • Door to balloon < 90min • Door to balloon minus door to needle < 1hr • Fibrinolysis contraindications • Late Presentation > 3 hr • High risk STEMI • Killup 3 or higher • STEMI dx in doubt STEMI cardiac care

  13. STEMI cardiac care • Assessment - Time since onset of symptoms 90 min for PCI / 12 hours for fibrinolysis - Is this high risk STEMI? - KILLIP classification - If higher risk may manage with more invasive rx - Determine if fibrinolysis candidate - Meets criteria with no contraindications - Determine if PCI candidate - Based on availability and time to balloon rx

  14. Acute Phase Risk Stratification:Importance of LV dysfunction Continuing Medical Implementation …...bridging the care gap

  15. Fibrinolysis indications • ST segment elevation >1mm in two contiguous leads • New LBBB • Symptoms consistent with ischemia • Symptom onset less than 12 hrs prior to presentation

  16. Absolute contraindications for fibrinolysis therapy in patients with acute STEMI • Any prior ICH • Known structural cerebral vascular lesion (e.g., AVM) • Known malignant intracranial neoplasm (primary or metastatic) • Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours • Suspected aortic dissection • Active bleeding or bleeding diathesis (excluding menses) • Significant closed-head or facial trauma within 3 months

  17. CONTRAINDICATIONS It is estimated that 20-30% of patients ineligible for thrombolytic therapy…

  18. Which Lytic Agent?EFFICACY • Benefit first demonstrated w/ streptokinase (GISSI-2 and ISIS-2 trials). ISIS-2 showed combination of ASA and streptokinase reduced mortality from 10.2% (placebo) to 7.2%. • GUSTO-I: alteplase superior to streptokinase (although more expensive) • ASSENT-2 and GUSTO-III: newer agents like tenecteplase, reteplase, lanoteplase as effective as alteplase but have significantly lower incidence of noncerebral bleeding complications and need for transfusion.

  19. Streptokinase AlteplaseReteplaseTenecteplase • Dose 1.5 MU over Up to 100mg in 10U x 2 30-50mg • 30-60 min 90 min (wt-based) each over 2 min based on weight • Bolus Admin.NoNo Yes Yes • Antigenic YesNoNoNo • Allergic ReactYes NoNoNo • SystemicMarked Mild Moderate Minimal • Fibrinogen Depletion • ~90-min patency 50 75 75? 75 • rates (%) • TIMI grade 3 flow, % 32 54 6063 Comparison of Approved Fibrinolytic Agents Adapted from Table 15, pg 53.Accessed on August 6, 2004 http://www.acc.org/clinical/guidelines/stemi/index.pdf.

  20. Relief of symptoms • Maintenance or restoration of hemodynamic and/or electrical stability • Reduction of at least 50% of initial ST segment injury pattern on a follow-up EKG 60-90 min after initiation of therapy • Serial measurements of cardiac biomarkers Assessment of response …

  21. Long-term survival… Long-term benefit primarily seen in patients who achieved TIMI 3 flow w/ lytic administration. Vessel opening (TIMI 2 or 3) reported in 60-87% of patients receiving lytics, but normalization (TIMI 3) in only 50-60% of arteries. Only TIMI 3 flow associated with improved LV function and survival. ***Note: TIMI 3 flow is achieved in ~90% of patients treated with primary PCI.

  22. Time from Symptom Onset to TreatmentPredicts 1-year Mortality after Primary PCI The relative risk of 1-year mortality increases by 7.5% for each 30-minute delay De Luca et al, Circulation 2004;109:1223-1225

  23. 2009 ACC/AHA STEMI/PCI Guidelines Focused Updates Triage and Transfer for PCI (for STEMI) New Recommendation B • It is reasonable to transfer high- risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non– PCI-capable facility to a PCI- capable facility as soon as possible where PCI can be performed either when needed or as a pharmacoinvasive strategy

  24. EFFECT OF DOOR-TO-BALLOON TIME ON MORTALITY IN PATIENTS WITH STEMI 8 7 6 5 4 3 2 1 0 In-hospital Mortality, % ≤90 >90 - 120 >120 - 150 >150 ≤90 >90 - 120 >120 - 150 >150 Door-to-Balloon Time (min) In-hospital mortality and door-to-balloon time; P for trend <.001. Reproduced with permission from McNamara RL, et al. J Am CollCardiol. 2006;47(11):2180-2186.

  25. Estimated in-hospital mortality by door-to-balloon times No “floor” to the mortality reduction that can be achieved by reducing time to treatment Any delay in D2B time associated with increased in-hospital mortality Rathore SS, et al. BMJ 2009; 339:b1807. Yale University School of Medicine; ACC-NCDR

  26. D2B: PCI Engineering • ED physician activates cath lab • Via Field Interpretation • Via Referral Interpretation • Via ED Interpretation 2. One call activates the cath lab 3. Cath lab team ready in 20-30 minutes 4. Prompt data feedback 5. Senior management commitment 6. Team-based approach

  27. PCI after thrombolytics??? This issue remains unresolved… 3 possible scenarios… *Facilitated PCI—lytic drug given prior to planned PCI in attempt to achieve an open infarct-related artery before arrival of cath lab *Adjunctive PCI—PCI performed within hours after thrombolysis *Early elective PCI—PCI performed within a few days after thrombolysis

  28. Comparing outcomes: PCI vs Lytics

  29. The Golden Rule: Once a STEMI is Identified it Must Trigger a Clear Response Downstream! Rapid Recognition of STEMI on ECG will only improve the process IF Recognitionleads to a concrete action occurring downstream Recognition allows early Reperfusion… but does not guarantee it!

  30. STEMI – Door-to-Balloon and Door-to-Needle TimesCumulative 12-Month Data from ACTION Registry ACTION DATA: January 1, 2007 – December 31. 2007 (n=19,523) DTB = 1st door to balloon for primary PCI DTN = Door to needle for lytics

  31. ACTION Median Door-to-Balloon TimesFor Transfer In & Non-Transfer In Patients 250 240 236 230 223 220 215 212 210 200 190 180 170 169 160 158 151 156 150 Time (min) 140 123 130 120 120 116 113 103 110 102 100 96 95 90 79 78 80 75 74 70 62 60 60 57 57 50 40 30 20 10 0 Q1 07 Q2 07 Q3 07 Q4 07 Transfer in DTB Times Non-Transfer in DTB Times

  32. Today: The 5 Essential Elements of STEMI System Optimization R1 Relationships R2 Recognition R3 Reperfusion R4 Real-time data collection R5 Reassessment & refinement

  33. What we should do about STEMI Cardiogenic Shock • Emergency angiography and revascularisation: Primary PCI preferably • -All patients <75 years - Selected patients ≥75 years • On-table echo to rule out mechanical defects • Stabilise the patient in the lab before revascularisation - IABP - Pressors if required (Norepinephrine/dopamine) - Anaesthetic support • Consider calling the surgeon for true surgical disease • PCI culprit artery. Other vessels if shock persists • Use abciximab for PCI • Consider percutaneous LVAD if shock persists with IABP + multi-vesselrevascularisation

  34. Cardiogenic Shock: Impella • Axial flow pump • Much simpler to use • Increases cardiac output & unloads LV • LP 2.5 - 12 F percutaneous approach; Maximum 2.5 L flow • LP 5.0 - 21 F surgical cut down; Maximum 5L flow • Cost: 3-5K Blood Inlet Blood outlet Motor Pressure Lumen

  35. STEMI 2012: “60 is the New 90” • <30 Minutes : First Medical Contact (Recognition) to Thrombolytic administration • <90 Minutes : First Medical Contact to on-site PCI (AHA/ACC recs) ????? • <90 Minutes : First Medical Contact followed by inter-facility transfer to a PCI-capable facility • ***BUT realistically <60 Minutes should be the goal for Contact/Recognition to Reperfusion @ a STEMI Receiving Facility (PCI Center)!

  36. CARESS-in-AMI: Primary Outcome

  37. Barriers to Timely Reperfusion • The patient - Failure to promptly recognize symptoms - Hesitation to seek medical attention • Time to transport - Mandated delivery to the closest hospital, regardless of PCI capabilities - Long transport in rural areas • Decision process on arrival - Clot-busting drugs vs. PCI - Off hours - Transfer to PCI facility • Time to implement treatment strategy - Procedural factors - Team assembly

  38. 1970  Cardiology invented EMS Emergency! Gage & DeSoto 2010  EMS transforming Cardiology

  39. Thank You!

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