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STEMI

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STEMI

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  1. ACS and Thrombosis in the Emergency Setting STEMI

  2. Q1: Which reperfusion strategy would you select as optimal for this patient if the nearest cardiac center were 3 hours drive away? a) Immediate transfer to cardiac cath lab for primary PCI b) Immediate fibrinolysis and then transfer to cardiac centre c) Immediate fibrinolysis with transfer only if no reperfusion

  3. Choosing the Optimal Reperfusion Strategy • Goal is rapid reperfusion • Time targets from first medical contact to treatment • Fibrinolysis 30 minutes • Primary angioplasty (PPCI) 90-120 minutes • Delayed reperfusion associated with increased mortality • When time to PPCI will exceed 90-120 minutes fibrinolysis should be given immediately • Time delay for PPCI to achieve greater benefit than fibrinolysis may be less than 90 minutes when • Anterior MI • Patient age <65 yrs • Time from symptom onset <120 minutes

  4. Impact of Delay to Primary PCI 90 DAY MORTALITY RELATED TO DOOR-TO-BALLOON TIME <60 min 60-90 min 90-120 min ≥120 min (n=1071) (n=1354) (n=1186) (n=1762) SURVIVAL(%) 100% 99% 90-day mortality 98% 3.2% 97% 4.0% 96% 4.6% 95% 5.3% 94% P<0.0001 93% 92% DAYS 0 10 20 30 40 50 60 70 80 90 Hudson MP et al. Circ Cardiovasc Qual Outcomes 2011;4:183-92

  5. Which Patients Cannot Afford a PPCI Delay? 0-120 Prehospital Delay (min) 121+ 179 PCI RELATED DELAY (DB-DN) WHERE PCI AND FIBRINOLYTIC MORTALITY ARE EQUAL (MIN) 180 168 10,614 148 20,424 3,739 120 107 103 9,812 16,119 58 60 43 40 41,774 5,296 19,517 0 NonAnt MI65+ YRS Ant MI65+ YRS NonAnt MI < 65 YRS Ant MI < 65 YRS Pinto DS et al. Circulation 2006; 114: 2019-2025

  6. Prehospital and In-Hospital Management and Reperfusion Strategies Primary-PCI capable center STEMI diagnosisa EMS or non primary-PCI capable center PCI possible ˂120 min? Preferably ˂60 min Immediate transfer to PCI center Primary-PCI YES NO Preferably ≤90 min (≤60 min in early presenters) Rescue PCI Preferably ≤30 min Immediately Immediate transfer to PCI center NO Immediate fibrinolysis Successful fibrinolysis? YES Preferably 3-24 h aThe time point the diagnosis is confirmed with patient history and ECG ideally within 10 min from the first medical contact (FMC). All delays are related to FMC (first medical contact). Coronary angiography Cath = catheterization laboratory; EMS = emergency medical system; FMC = first medical contact; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction ESC STEMI Guidelines 2012

  7. Q2: In the event that the patient receives fibrinolysis, which anticoagulant is preferred? a) UHF b) Enoxaparin c) Fondaparinux Q3: Which would be the optimal antiplatelet agent to add to the anticoagulant? a) clopidogrel b) ticagrelor c) prasugrel

  8. Anticoagulation and Antiplatelet Therapy with Fibrinolysis • Anticoagulation • Initiate UFH, enoxaparin or fondaparinux immediately after administration of fibrinolytic agent • UFH 70u/kg iv • Enoxaparin • <75yrs old 30mg iv bolus followed by s/c 1mg/kg • >75yrs old no iv bolus, s/c 1mg/kg • Fondaparinux 2.5mg s/c • Antiplatelet Therapy • ASA 81-160mg po • Clopidogrel • <75 yrs old 300mg load followed by 75mg daily • > 75 yrs old no load, 75mg po daily NB Ticagrelor and Prasugrel should not be used with fibrinolysis as they have not been tested in this situation 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

  9. Need for PCI after Fibrinolysis • Rescue PCI • Failed fibrinolysis • Persistence of chest pain • Failure of ST elevation to decrease more than 50% at 1 hr after fibrinolysis • Pharmaco-Invasive strategy • Consider routine transfer patients to cardiac centre for PCI within 2-24 hrs of fibrinolysis 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

  10. Impact of Routine Early Transfer for PCI after Fibrinolysis DEATH, REINFARCTION, WORSENING HEART FAILURE, OR CARDIOGENIC SHOCK 0.20 Standard treatment 0.15 HR 0.64; 95% CI, 0.47 - 0.87 Routine early PCI 0.10 Death, reinfarction, or recurrent ischemia HR 0.65 (95% CI 0.44–0.96) 0.05 Early PCI 2.8 hrs Standard treatment PCI 32.5 hrs 0.00 0 5 10 15 20 25 30 DAYS Cantor et al N Eng J Med 2009;360:2705

  11. Primary PCI for STEMI • Improved outcomes if PPCI performed in timely manner • Delayed PPCI worse than timely fibrinolysis • Goal • Patient contact to PCI < 90 minutes for most patients • Adjuvant anticoagulation / antiplatelet agents • By agreement with local interventional cardiology team

  12. Oral Antiplatelets in STEMI TRITON TIMI 38 Prasugrel vs ClopidogrelCV death / MI / Stroke PLATO TicagrelorvsClopidogrelCV death / MI / Stroke CUMULATIVE INCIDENCE (%) CUMULATIVE INCIDENCE (%) 12 Clopidogrel 15 Clopidogrel 11 10 9 8 10 Prasugrel Ticagrelor 7 6 5 4 5 HR 0.79 95% CI 0.65-0.97 p=0.0221 HR 0.87; 95% CI 0.75 - 1.01; P= 0.07 3 2 P=0.0017 P=0.0221 1 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 50 100 150 200 250 300 350 400 450 At risk MONTHS DAYS FROM RANDOMISATION 60% Primary PCI 30% Secondary delayed PCI No reduction of mortality, MI HR 0.70 p=0.01 Stent thrombosis HR 0.58 p=0.23 No increase in TIMI major or life threatening bleeding All primary PCI Mortality HR, 0.82; P=0.05 MI HR 0.80 p=0.03 Stent thrombosis HR 0.60 p=0.03 Stroke increased 1.7% vs 1.0% HR 1.63 p=0.02 No increase in major bleeding Montelescot et al Lancet 2009; 373: 723 Steg et al Circulation. 2010;122:2131

  13. Pre-Hospital Fibrinolysis + PCI vs Primary PCI for Patients Unable to Undergo Primary PCI within 1 Hour DEATH, SHOCK, CHF, OR REINFARCTION 20 % Primary PCI 15 Fibrinolysis 10 5 RR 0.86; 95% CI, 0.68 -1.09; P = 0.21 0 0 5 10 15 20 25 30 DAYS STREAM Study Armstrong et al N Eng J Med 2013;368:1379

  14. Q4: How would you have handled this patient if in addition to medical history described, he also had a recent (past 6 months) CVA? a) Administer fibrinolysisb) Transfer to regional cardiac centre for PCIc) Manage medically with UFH and ASA

  15. 2013 STEMI Management • Early identification of STEMI- pre hospital preferred • Performing 12-lead ECG by EMS personnel or at site of first medical contact • Early decision for reperfusion strategy and administration within 12 hours of symptom onset for all eligible STEMI patients • Primary PCI preferred if can be performed in timely manner (First medical contact to PCI < 90 -120 min) • Consider fibrinolysis in young anterior STEMI presenting< 120 minutes from symptom onset if PCI not available within 60 minutes O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary

  16. 2013 STEMI Management (cond’t) • Following fibrinolysis consider referral for early PCI • Choice of anticoagulant / antiplatelet agent depends upon reperfusion strategy and policy of PCI centre (P2Y12 receptor inhibitor therapy prior to PCI and maintenance for a year; ASA 160-325mg loading and 81mg maintenance; UHF, bivalirudin with or without prior UHF) O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary

  17. 2013 STEMI Management STEMI patient who is a candidate for reperfusion Initially seen ata PCI-capable hospital Initially seen at a non-PCI-capable Hospital* DIDOtime≤30 min Send to cath lab for primary PCI FMC-device time ≤90 min (Class 1, LOE: A) Transfer for primary PCI FMC-device time as soon as Possible and ≤120 min (Class 1, LOE: B) Administer fibrinolytic agent within 30 min of arrival when anticipated FMC- device >120 min (Class 1, LOE: B) Urgent transfer for PCI for patients with evidence of failed reperfusion or reocclusion (Class IIa, LOE: B) Transfer for angiography and revascularization within 3-24 h for other patients as part of an invasive strategyϮ (Class IIa, LOE: B) Diagnostic angiogram Medical therapy only PCI CABG Figure 1. Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. Performance of PCI is dictated by an anatomically appropriate culprit stenosis. *Patients with cardiogenic shock or severe heart failure initially seen at a non-PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Ϯangiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. CABG indicates coronary artery bypass graft; DiDO, door-in-door-out; FMC, first medical contact; LOE, Level of Evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary