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U.O. Cardiologia – UTIC Emodinamica e Cardiologia Interventistica

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

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  1. 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

  2. Ho un conflitto di interessi

  3. 12 maggio 2008 Angioplastica Primaria 421 PCI Primarie al 15 marzo 2010 6 Emodinamisti 7 infermieri 3 perfusionisti 6 tecnici di radiologia h 24

  4. Riperfusione

  5. Emodinamista

  6. Calabria

  7. Affollamento delle sale di emodinamica

  8. Infarct-related Racanalization chest pain relief complete resolution of ST elevation reperfusion arrhythmias

  9. ST-segment levels from continuously recorded 12-lead ECGs Circulation. 2004;110:e533-e539 U.O. Cardiologia – UTIC Presidio Ospedaliero “A. Pugliese” Catanzaro

  10. 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

  11. Consapevolezza della complessità del problema

  12. Controlla opinione MONDO REALE MONDO IDEALE evidenza Condiziona

  13. METTIAMO UN PO' DI ORDINE

  14. 2007; 49; 422-30 Efficacy End Points for Rescue PCI Versus Conservative Therapy

  15. 2005;353:2758-68.

  16. 2005;353:2758-68.

  17. Il messaggio non è “non trasferire” ma “chi e quanto tempo comporta trasferire?”

  18. Fattore Tempo Fattore Campo

  19. 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

  20. 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

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

  22. Kaplan-Meier Curves for Death or Reinfarction and Reinfarcion Only at 6 Months

  23. Time from Randomization to Cardiac Catheterization in the two Treatment Group

  24. Rate of Ischemic Events at the Available Follow-up Freek W.A. Verheugt N Engl J Med 360; june 25, 2009

  25. 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

  26. Kaplan-Meier curves for the primary and the composite outcome

  27. 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

  28. 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

  29. 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

  30. 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

  31. Thirty-day mortality in patients treated with thrombolysis, according to use and timing of subsequent PCI Duchin et al Circulation 2008;118;268-276

  32. SU QUALE CAMPO SI GIOCA? I campi non sono tutti eguali …S.Siro, S. Paolo, Olimpico, … Marassi, Cibali, Favorita … … di quartiere … di periferia …

  33. Cath Lab 1 Cath Lab 2 Cath Lab 3

  34. Abilità degli operatori

  35. <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

  36. TECHNICAL COMPETENCE JACC, Vol. 46, No. 4, 2005 Adjusted odds ratios for major adverse cardiovascular events….

  37. 18.3% 2.4% Angioplastiche Coronariche Dati Gise 2008

  38. Angioplastiche Coronariche Dati Gise 2008 - 242 centri pPCI < 5 PCI rescue < 5 10% 56% 46% 90% pPCI > 5 pPCI > 5

  39. Angioplastiche Coronariche Dati Gise 2008 - 242 centri pPCI < 5 PCI rescue < 5 10% 56% 46% 90% pPCI > 5 PCI rescue > 5

  40. eleggibili ineleggibili “I sommersi e i salvati” Koeth O. (MITRA Plus) Am J Cardiol 2009;104:1074

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