Presentation on theme: "Reperfusion Strategies for ST elevation MI. Tom P Stys, FACC, MD Medical Director Sanford Cardiology."— Presentation transcript:
Reperfusion Strategies for ST elevation MI. Tom P Stys, FACC, MD Medical Director Sanford Cardiology
ACS and Rural Hospitals 4897 community hospitals in the United States 1 – 2900 are located in urban areas 1 – 1997 are located in rural areas 1 Although primary PCI is often the preferred strategy for STEMI, only about 25% of US hospitals are capable of performing PCI 2 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 hospital 2 – Guideline-based multidisciplinary care and coordinated transfer protocols are important for best outcomes 1.American Hospital Association Statistics. Available at: facts.html. Accessed May 23, facts.html 2.Nallamothu BK, et al. Circulation. 2006;113(9):
STEMI Chain of Survival
Time to Treatment Is Critical in STEMI Onset of symptoms of STEMI EMS dispatch EMS on-scene Encourage 12-lead ECGs Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min Total ischemic time: within 120 min EMS Transport GOALS PCI capable Not PCI capable Golden hr = 1st 60 min Patient Prehospital fibrinolysis EMS-to-needle within 30 min EMS transport EMS-to-balloon within 90 min Patient self-transport Hospital door-to-balloon within 90 min Dispatch 1 min 5 min 8 min 0.4 million discharges per year for STEMI in US 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
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. Thromb Haemost. 1997;78(1): ; White HD. Am J Cardiol. 1997;80(4A):2B-10B; Davies MJ. Heart. 2000;83(3):
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.
Goals When Considering a Reperfusion Strategy Decrease amount of myocardial necrosis Preserve LV function Prevent major adverse cardiac events Treat life threatening complications
Importance of Early Reperfusion 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
Reperfusion Recommendations - STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact. IIIIIIaIIb 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. IIIIIIaIIb ACC/AHA 2007 STEMI Focused Update Circulation 2007; on line, December 10.
Risk Stratification Based on initial Evaluation, ECG, and Cardiac markers STEMI Patient?YESNO - Assess for reperfusion - Select & implement reperfusion therapy - Directed medical therapy UA or NSTEMI - Evaluate for Invasive vs. conservative treatment - Directed medical therapy
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
STEMI cardiac care Determine preferred reperfusion strategy Fibrinolysis preferred if: Fibrinolysis preferred if: <3 hours from onset <3 hours from onset PCI not available/delayed PCI not available/delayed door to balloon > 90min door to balloon > 90min door to balloon minus door to needle > 1hr door to balloon minus door to needle > 1hr Door to needle goal <30min Door to needle goal <30min No contraindications No contraindications PCI preferred if: PCI preferred if: PCI available PCI available Door to balloon < 90min Door to balloon < 90min Door to balloon minus door to needle < 1hr Door to balloon minus door to needle < 1hr Fibrinolysis contraindications Fibrinolysis contraindications Late Presentation > 3 hr Late Presentation > 3 hr High risk STEMI High risk STEMI Killup 3 or higher Killup 3 or higher STEMI dx in doubt STEMI dx in doubt
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
Acute Phase Risk Stratification: Importance of LV dysfunction Continuing Medical Implementation …...bridging the care gap
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
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
CONTRAINDICATIONS It is estimated that 20-30% of patients ineligible for thrombolytic therapy…
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.
Comparison of Approved Fibrinolytic Agents Streptokinase Alteplase Reteplase Tenecteplase Dose 1.5 MU over Up to 100mg in 10U x mg min 90 min (wt-based) each over 2 min based on weight Bolus Admin. No No Yes Yes Antigenic Yes No No No Allergic React Yes No No No Systemic Marked Mild Moderate Minimal Fibrinogen Depletion ~90-min patency ? 75 rates (%) TIMI grade 3 flow, % Adapted from Table 15, pg 53.Accessed on August 6, 2004
Assessment of response … 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 min after initiation of therapy Serial measurements of cardiac biomarkers
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.
Time from Symptom Onset to Treatment Predicts 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:
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
EFFECT OF DOOR-TO-BALLOON TIME ON MORTALITY IN PATIENTS WITH STEMI > > >150 In-hospital Mortality, % 90> > >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 Coll Cardiol. 2006;47(11):
Estimated in-hospital mortality by door-to-balloon times Time (min)Adjusted mortality* (2.8–3.1) (2.9–3.2) (3.4–3.6) (4.2-–4.4) (5.4–5.7) (8.2–8.7) (10.0–10.7) *Adjusted for age, sex, race, findings on presentation, medical history, procedural characteristics, angiographic findings, and hospital factors 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
D2B: PCI Engineering 1.ED physician activates cath lab a.Via Field Interpretation b.Via Referral Interpretation c.Via ED Interpretation 2.One call activates the cath lab 3.Cath lab team ready in minutes 4.Prompt data feedback 5.Senior management commitment 6.Team-based approach
PCI after thrombolytics??? This issue remains unresolved… 3 possible scenarios… *Facilitated PCIlytic drug given prior to planned PCI in attempt to achieve an open infarct-related artery before arrival of cath lab *Adjunctive PCIPCI performed within hours after thrombolysis *Early elective PCIPCI performed within a few days after thrombolysis
Comparing outcomes: PCI vs Lytics
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 Recognition leads to a concrete action occurring downstream Recognition allows early Reperfusion… but does not guarantee it!
STEMI – Door-to-Balloon and Door- to-Needle Times Cumulative 12-Month Data from ACTION Registry ACTION DATA: January 1, 2007 – December (n=19,523) DTB = 1st door to balloon for primary PCI DTN = Door to needle for lytics
ACTION Median Door-to-Balloon Times For Transfer In & Non-Transfer In Patients Transfer in DTB TimesNon-Transfer in DTB Times
Today: The 5 Essential Elements of STEMI System Optimization R1Relationships R2Recognition R3Reperfusion R4Real-time data collection R5Reassessment & refinement
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-vessel revascularisation
Motor Blood outlet Blood Inlet Cardiogenic Shock: Impella Axial flow pump Much simpler to use Increases cardiac output & unloads LV LP F percutaneous approach; Maximum 2.5 L flow LP F surgical cut down; Maximum 5L flow Cost: 3-5K Pressure Lumen
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 a STEMI Receiving Facility (PCI Center)!
CARESS-in-AMI: Primary Outcome
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