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Optimal Timing of PCI in ACS

Optimal Timing of PCI in ACS. Patrick Hildbrand. Trends and Prognosis in ACS. Hospital 1 year. Furman MI, JACC 2001, 37:1571-1580. Optimal Timing of PCI in ACS. ACC/AHA 2007 STEMI GUIDELINES Focused Update 2004 12/2007 ACC/AHA

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Optimal Timing of PCI in ACS

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  1. Optimal Timing of PCI in ACS Patrick Hildbrand

  2. Trends and Prognosis in ACS Hospital 1 year Furman MI, JACC 2001, 37:1571-1580

  3. Optimal Timing of PCI in ACS ACC/AHA 2007 STEMI GUIDELINES Focused Update 200412/2007 ACC/AHA PCI GUIDELINES Focused Update 200512/2007 ESC GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF NON-ST-SEGMENT ELEVATIONAUTE CORONARY SYNDROMS 06/2007

  4. Applying Classification of Recommendations and Level of Evidence

  5. Applying Classification of Recommendations and Level of Evidence

  6. ACS Therapeutic Options Anti-ischemic agents • Anti-platelet agents • ASA • Clopidrogel • GP IIb/IIIa Inhibitors • Anti-coagulants • UFH or LMWH • Factor-Xa inhibitors (Fondaparinux) • Direct Thrombin inhibitors (Bivalirudin) Revascularization

  7. Optimal Timing of PCI in ACS Trends and Prognosis in ACS Diagnosis andRiskassessment of ACS Therapeutic Options > Timing Revascularization Summary Management Strategy

  8. Chest Pain

  9. ECG Kaul P, JACC 2001, 38:64-71

  10. Biochemistry

  11. RiskStratification

  12. SummaryDiagnosis and Riskassessment • Diagnosis and short-term risk stratification should be based on a combination of • Clinical history • Symptoms • ECG and (10 minutes, 6h, 24h and before hospital discharge) • Biomarkers (admission and after 6-12 h) • Risk score results • Echocardiography is recommended to rule out differential diagnosis • Patient without recurrence of pain, normal ECG findings and negative troponins tests > non invasive stress testing

  13. Optimal Timing of PCI in ACS Trends and Prognosis in ACS Diagnosis andRiskassessment of ACS Therapeutic Options Summary Management Strategy

  14. Coronary revascularization • Revascularization for ACS is performed to • RELIEVE ANGINA • RELIEVE ONGOING MYOCARDIAL ISCHEMIA • PREVENT PROGRESSION TO MI OR DEATH

  15. Optimal Timing of PCI in ACS Acute Coronary Syndromes STEMI Primary PCI Rescue PCI Facilitated PCI Delayed PCI UA/NSTEMI

  16. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III A Primary PCI STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 min of first medical contact as a systems goal.

  17. Primary PCI versus Fibrinolysis

  18. Primary PCI versus fibrinolysis for MIMeta analysis of 23 trials P<0.0001 Keeley EC. Lancet 2003;361:13-20

  19. Defeated

  20. CAPTIM: Mortality at different time points *26% of patients had rescue PCI Steg PG. Circulation 2003;108:2828-2830

  21. Time to randomisation and one-year mortality in CAPTIM < 2h  2h p = 0.05 p = 0.34 Lysis pPCI Lysis pPCI Steg PG. Circulation 2003;108:2828-2830

  22. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B Fibrinolytic Therapie STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and undergo PCI within 90 min of first medical contact, should be treated with fibrinolytic therapy within 30 min of hospital presentation as a systems goal, unless fibrinolytic therapy is contraindicated.

  23. Facilitated PCI

  24. Meta-analysis: Facilitated PCI vs Primary PCI Mortality Reinfarction Major Bleeding 1.81 (1.19-2.77) 1.43 (1.01-2.02) 1.03 (0.49-2.17) 1.40 (0.49-3.98) 3.07 (0.18-52.0) 1.03 (0.15-7.13) 1.38 (1.01-1.87) 1.71 (1.16 - 2.51) 1.51 (1.10 - 2.08 ) 0.1 1 10 0.1 1 10 0.1 1 10 Fac. PCIBetter PPCIBetter Fac. PCIBetter PPCIBetter Fac. PCIBetter PPCIBetter Keeley E, et al. Lancet 2006;367:579.

  25. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III C IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Facilitated PCI A planned reperfusion strategy using full-dose fibrinolytic therapy followed by immediate PCI is not recommended and may be harmful. Facilitated PCI using regimens other than full-dose fibrinolytic therapy might be considered as a reperfusion strategy when all of the following are present: a. Patients are at high risk, b. PCI is not immediately available within 90 minutes, and c. Bleeding risk is low (younger age, absence of poorly controlled hypertension, normal body weight).

  26. Facilitated PCI Defeated • Further Studies Ongoing • Prehospital fibrinolytic therapy • Better anticoagulant and antiplatelet therapy • Use in circumstances of longer delays to PCI • However, based on available data, facilitated PCI offered no clinical benefit, and was associated with harm when full dose fibrinolytics were used.

  27. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment ECG Triage Call Call fast Inter-Hospital Transfer Onset of symptoms of STEMI SZO • EMS on-scene • Encourage 12-lead ECGs. EMS Dispatch Sion GOALS 5 min. EMS Transport Patient EMS EMS transport EMS-to-balloon within 90 min. Patient self-transport Hospital door-to-balloon within 90 min. Dispatch 1 min. Golden Hour = first 60 min. Total ischemic time: within 120 min.

  28. Late PCI

  29. Occluded Artery Trial (OAT) • Exclusion criteria: • Significant left main or 3 vessel CAD • Hemodynamic or electrical instability • Rest or low-threshold angina • NYHA Class III-IV HF or shock Eligibility: • Total IRA occlusion • 3-28 days (>24 hours) RESULTS 2166 randomized 1082 PCI + optimal medical therapy 1084 Optimal medical therapy (MED) Death, MI, CHF Class IV Fatal and Non fatal MI 4 year event rate: n.s. Hochman JS, et al. Am Heart J 2005;150:627-42; Hochman JS, et al. N Engl J Med 2006;355:2395-407.

  30. I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III B IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B Late PCI after Fibrinolysis or for Patients Not Undergoing Primary Reperfusion PCI of a hemodynamically significant stenosis in a patent infarct artery > 24 hours after STEMI may be considered as part of a invasive strategy. PCI of a totally occluded infarct artery > 24 hours after STEMI is not recommended in asymptomatic patients with 1- or 2-vessel disease if they are hemodynamically and electrically stable and do not have evidence of severe ischemia.

  31. Optimal Timing of PCI in ACS Acute Coronary Syndromes STEMI UA/NSTEMI Routine Invasive (Timing) Selective Invasive

  32. Coronary revascularization

  33. Randomized trials comparing early invasive (dark bars) vs. conservative strategy (open bars)

  34. Invasive vs. Conservative Strategies New data coming from long-term follow up of RITA-3 and FRISC-2 and Mehta meta-analysis show significant risk reduction for death and „death & MI“ at long-term follow up Early hazard shown in ICTUS Trial Early hazard shown in Mehta meta-analysis ICTUS, Lancet 2007 FRISC 2, Lancet 2000 RITA 3 Lancet 2005 Metha JAMA 2005

  35. Timing of Intervention NSTEMI • Few studies have shown superiority of very early intervention vs. deferred intervention • ISAR-COOL (small sample size) JAMA 2003 • VINO • Many trials have shown early hazard with early intervention vs. deferred intervention • ICTUS trial NEJM 2005 • Mehta meta-analysis JAMA 2005 • Grace and Crusade registries Heart 2007, Arch Intern Med 2006 • > Timing of intervention recommended on the basis of risk stratification

  36. Clinical Outcomes for Patients Stratified by Age(Invasive Vs Conservative Strategies) from TACTICS–TIMI-18 Trial

  37. Outcomes According to Degree of Renal Function Impairment in NSTE-ACS Patients in GRACE Registry Special Conditions & Populations chronic Kidney Disease

  38. Special Conditions& PopulationsDiabetes Treatment Effect on 30-day Mortality Among Diabetic Patientswith NSTEMI from Six Randomized Clinical Trials

  39. Special Conditions& PopulationsDiabetes

  40. Risk Stratification

  41. Options for Transport of Patients With NSTEMI and Initial Reperfusion Treatment ECG Triage Call Call fast Inter-Hospital Transfer Onset of symptoms of STEMI • EMS on-scene • Encourage 12-lead ECGs. EMS Dispatch SZO Sion GOALS 5 min. EMS Transport Urgent Patient EMS Diagnosis before treatment Risk stratification Early Dispatch 1 min. No Transfer

  42. Summary Management Strategy

  43. www.herzpraxis-brig.ch

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