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Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Il valore aggiunto degli anti GPIIb/IIIa nella.

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Presentation on theme: "Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Il valore aggiunto degli anti GPIIb/IIIa nella."— Presentation transcript:

1 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Il valore aggiunto degli anti GPIIb/IIIa nella terapia delle SCA Stefano Savonitto Divisione di Cardiologia IRCCS Arcispedale S. Maria Nuova Reggio Emilia

2 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto ACS with persistent ST-segment elevation

3 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Time from symptom onset to reopening of the IRA and myocardial salvage

4 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Silvain J. JACC 2011;57:1359

5 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Valgimigli M, et al Prasugrel vs Tirofiban HBD in PCI for STEMI Variability of platelet inhibitory effect 30’ after drug administration

6 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto All-Cause Mortality 1-Year open label & double-blind, n = 1398 On-TIME-2 Ten Berg J. J Am Coll Cardiol. 2010;55:2446-55.

7 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto A: all pts N= 2,452 B: TRS>3 N= 1,229 C: TRS>3 spoke site N= 502 D: TRS>3 spoke site symptom to rand. < 4h N= 397 6.6% 13.3% 16.0% Herrmann HC. JACC Intv 2009;2:917-24 Benefit of facilitated PPCI in high-risk patients presenting at non-PCI centers 1-year mortality

8 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Time from symptom onset to reopening of the IRA and myocardial salvage JACC Intv 2010; 3: 1292-4 ON TIME 2OrtolaniFINESSE “Educating the public to seek treatment at an early stage… is likely to reduce mortality to a greater degree than pharmacological facilitation before PCI, although translation of this goal to reality in a community setting is and will continue to be extremely difficult.”

9 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Heestermans AACM J Thrombosis Haemostasis 2009;7:1612 -8 Reduction of early stent thrombosis with pre- hospital high-dose tirofiban in STEMI

10 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Acute Stent Thrombosis 0.3% 1.5% HR (95%CI) = 5.93 [2.06,17.04] P = 0.0002 16111583158015781577 15911587158415831583 Number at risk Bivalirudin UFH+GPIIb/IIIa Def/Prob Stent Thrombosis (%) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Time in Hours 061218 24 hours Bivalirudin monotherapy Heparin + GPIIb/IIIa inhibitor Dangas G. ACC 2009 Scientific Sessions; March 29, 2009; Orlando, FL.

11 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto 1.6% 3.4% 1.5% 1.2% HR [95%CI] = 1.30 [0.54-3.16] P = 0.56 HR [95%CI] =2.11 [1.07,4.17] P = 0.03 1013 519 1009990969957943863 514497486480474430 Number at risk 600 mg 300 mg Def/Prob Stent Thrombosis (%) 0 1 2 3 4 5 Time in Days 013090180270365 Clopidogrel Loading in Bivalirudin pts Stent Thrombosis 1-Day Landmark Analysis 600mg Clopidogrel 300mg Clopidogrel Dangas G. ACC 2009 Scientific Sessions; March 29, 2009; Orlando, FL.

12 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Comparison of changes in platelet aggregation induced between STEMI patients (n=9) and healthy controls (n=10) after a 600 mg clopidogrel loading dose. 5  mol/l ADP 20  mol/l ADP Impaired bioavailability of clopidogrel in STEMI patients Heestermans A, et al Thrombosis Research 2008;122:776-781

13 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Abciximab for primary PCI in STEMI significant mortality reduction -29% De Luca G, et al. JAMA 2005;293:1759

14 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto HORIZONS - Outcome in Patients With Symptom Onset to Hospital ER Admission <2.2 hrs. -43% p=0.03 EMEA. Assesement Report For Angiox. Doc. Ref No.:EMEA/724835/2009. Page 10. www.emea.europa.eu MACE at 30 Days (%)

15 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Predictors of no-reflow: the ISAR database Type of intervention 0.96 Stenting 88 (81.5) 843 (81.7) Balloon angioplasty 20 (18.5) 189 (18.3) Pre-procedural abciximab therapy 84 (77.8) 800 (77.5) 0.95 Data are median [25th; 75th %] or number of patients (%) Ndrepepa J et al. Circ Cardiovasc Interv. 2010;3-27-33

16 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

17 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Troponins elevated or not ACS without persistent ST-segment elevation

18 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Patients judged to be at high risk for progression to MI or death Patients with recurrent ischemia Recurrent chest pain Dynamic ST-segment changes ( ST-segment depression or transient ST segment elevation) Early post infarction unstable angina Elevated troponin levels Diabetes Hemodynamic instability Major arrhythmias (VF, VT) Patients with recurrent ischemia Recurrent chest pain Dynamic ST-segment changes ( ST-segment depression or transient ST segment elevation) Early post infarction unstable angina Elevated troponin levels Diabetes Hemodynamic instability Major arrhythmias (VF, VT) Introduction of GpIIB/IIIA blocker and Coronary angiography ESC NSTEACS GUIDELINES YEAR 2002

19 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto GP IIb-IIIa Blockade Before and After PCI: CAPTURE, PURSUIT, PRISM-PLUS 0% 2% 4% 6% 8% 10% PCI N=2754 P=0.001 N=12,296 P=0.001 +24 h+48 h+72 h +24 h+48 h Boersma E, et al. Lancet. 2002;359:189-198. 4.3% 2.9% 8.0% 4.9% Death or MI Before PCIPost-PCI Placebo GP IIb-IIIa inhibitor 0 -33%-39%

20 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Impact of early intervention in HR pts With NSTEACS: the TIMACS study Mehta SR, NEJM 2009;360:2165-75 30% of the pts GRS >140) Risk of Death, MI or stroke

21 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto <24h>24-48h>48-72h>72h % pts undergoing angiography 100- 80- 60- 40- 20- 0- 11 15 62 60 20 10 Hub hosp (N=165) Spoke hosp (N=222) Time to angiography among NSTEACS pts In hub and spoke hospitals of the Reggio Emilia province Savonitto S et al. GIC 2012;13:157-68

22 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto CVD/MI/Stroke Time From Randomization 0.5 0.4 0% 4% 5% 24 hr48 hr72 hr0-7 Days Placebo N=6303 Clopidogrel N=6259 1% 1.1 1.4 0.9 1.2 3% 2% 2.5 2.1 RR=0.80 p=NS RR=0.81 p=NS RR=0.85 p=NS RR=0.82 p=NS CURE: Early Impact of Clopidogrel in UA/NSTEMI Yusuf S. Circulation 2003;107:968

23 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Clopidogrel Pretreatment: Events in UA/NSTEMI Before Cardiac Catheterization n = 206n = 68 PCI-CURE (Median time to Catheterization = 10 Days) n = 159n = 47 Placebo Clopidogrel RR=0.68 95% CI (0.47-0.99) p=0.04 RR=0.76 95%CI (0.62-0.93) p=0.008 % Patients MI or Refractory Ischemia MI Mehta SR et al. Lancet 2001;358:527-533

24 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto van der Heijden et al. JACC 2004; 44:20 Clopidogrel Pre-Treatment and Myocardial Damage After Elective Stenting N = 203

25 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Pre-PCIPost-PCI TMPG 0/1 (%) Tissue Level Perfusion by TMPG pre and post-PCI UpstreamTirofiban HBD Tirofiban Abciximab p=0.015 TMPG 0/1 (%) UpstreamTirofibanHBDTirofibanAbciximab P= 0.0009 Bolognese L et. JACC 2006;47:522

26 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Giugliano RP. N Engl J Med 2009;360:2176-90

27 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto What Early ACS really showed? 1. The trial compared early vs delayed eptifibatide, rather than GPIIB/IIIa and control 2. Only 59% of the pts underwent PCI, and drug therapy was strikingly different between North America and Europe (pre- PCI clopid 50% NA, 85% Europe) Giugliano RP. N Engl J Med 2009;360:2176-90

28 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Giugliano RP. N Engl J Med 2009;360:2176-90 What Early ACS really showed? PE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 h SE: D+MI at 30 days

29 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Giugliano RP. N Engl J Med 2009;360:2176-90 What Early ACS really showed? PE: D+MI+ recurrent ischemia requiring urgent revasc, or thrombotic bailout at 96 h SE: D+MI at 30 days

30 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto death or MI 11.2 vs 12.3 0.89 (0.79–1.01) 0.079 Death 2.8 vs 2.6 1.10 (0.86–1.41) 0.46 Myocardial infarction 9.5 vs 10.6 0.88 (0.77–1.01) 0.073 Death, MI, RI req urg revasc12.5 vs 13.8 0.89 (0.79–1.01) 0.065 RI req urg revasc2.4 vs 2.9 0.80 (0.62–1.03) 0.083 30-day Primary Efficacy Results after shrinking the power Delayed Eptifibatide (n=4684) Early Eptifibatide (n=4722) OR (95% CI) P Giugliano RP. N Engl J Med 2009;360:2176-90

31 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto 30-day Death or MI 0.70.80.50.60.912 Overall 11.212.3 Men11.412.0 Women10.713.0 Age < 75 yr10.211.6 14.014.6 Troponin positive11.613.0 Troponin negative8.18.4 Diabetes 11.713.8 No Diabetes 10.911.7 Early clopidogrel intended 10.312.0 No early clopidogrel intended 13.713.4 Baseline Characteristic Early Eptifibatide BetterDelayed Provisional Eptifibatide Better Age> 75 yr Odds Ratio for Upstream Eptifibatide (95% CI) Routine Early Eptifibatide, % Delayed Provisional Eptifibatide, % Giugliano RP. N Engl J Med 2009;360:2176-90

32 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Medical Only (N=1706) Total Events = 71 CABG (N=251) Pre-CABG Events = 22 Post CABG Events = 46 PCI (N=2723) Pre-PCI Events = 87 Post-PCI Events = 243 Medical Only (N=1784) Total Events = 71 CABG (N=268) Pre-CABG Events = 33 Post-CABG Events = 52 PCI (N=2666) Pre-PCI Events = 82 Post-PCI Events = 201 Total Events on Medical Treatment = 71 + 82 +33 Total Events on Medical Treatment = 71 + 87 + 22 GroupEventsRiskRateGroupEventsRiskRate Medical 1864718 4.1%Medical1804680 4.0% Post PCI2012584 8.0%Post PCI243263610.5% Post CABG 52 23523.4%Post CABG 46 22920.6% Medical Only N=3490 PCIN=5389 CABGN=519 Medical Only N=3490 PCIN=5389 CABGN=519 Strategy During First 96 Hours Randomization N=9406 Delayed Provisional Eptifibatide (N=4680) Total Events = 469 Early Eptifibatide (N=4718) Total Events = 439 -24%

33 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Impact of abciximab on top of ASA and clopidogrel Death or MI at 30 days Kastrati A, NEJM 2004, JAMA 2006 20-18-16-14-12-10-8-6-4-2-0- Placebo Abciximab 4.04.0 4.64.6 13.1 18.3 ISAR REACT 1 ISAR REACT 2 TnT negative ISAR REACT 2 TnT positive P=0.98P=0.91 -28%P=0.02

34 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Giugliano RP. N Engl J Med 2009;360:2176-90 Bleeding events Early eptifibatide N=4722 Delayed eptifibatide N=4684

35 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Contemporary recommendations on Antiplatelet therapy in NSTEACS PCI

36 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto ACC/AHA NSTEACS Guidelines

37 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto ACC/AHA NSTEACS Guidelines

38 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto How would you treat this patient?

39 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Probability of 30-D death by sum of ST depression on the admission ECG: the GUSTO IIb ECG corelab 0 0,05 0,1 0,15 0,2 0,25 0,3 0,35 051015202530354045 sum of ST depression (mm) Probability of 30-day death Probability of death 95% confidence limits Savonitto S et al: Eur Heart J 2005;26: 2106 1+2 Q (n=2493) 3 Q (n=1366) 4 Q (n=1333) 50- 40- 30- 20- 10- 0- % 3-vessel disease % LM disease Incidence of 3VD and LMCA disease by quartiles of  ST depression

40 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto The Lipsia NSTEACS randomised trial Thiele H. Eur Heart J 2012;33:2035

41 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto ACUITY: Invasive Management UFH/Enoxaparin + GP IIb/IIIa (N=4,603) Bivalirudin + GP IIb/IIIa (N=4,604) Bivalirudin alone (N=4,612) Angiography99.2%98.8%98.9% Adm. to angio (h)19.7 (7.0-29.3) † 19.5 (7.0-28.2) † 19.8 (7.3-29.0) † Drug* to angio/interv (h)5.6 (1.6-22.5) † 5.0 (1.4-21.4) † 5.2 (1.5-22.5) † Actual procedure PCI55.6%56.7%56.8% CABG11.9%10.8%10.6% Medical therapy32.4%32.5%32.6% †median (IQR) Stone GW, Presented at 2006 ACC Meeting. Available at www.Clinicaltrialsresults.org Stone GW, Presented at 2006 ACC Meeting. Available at www.Clinicaltrialsresults.org

42 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Berger JS. JACC 2008;52:1693 Predictors of reoperation in ACS patients undergoing CABG Clopidogrel <5 days 4.6011.454-14.5540.009 Pre-op aspirin 0.6160.109-3.4830.584 Pre-op GPI 1.8250.504-6.6130.360 Prior CABG 5.2991.050-26.7340.043 Odds ratio95% CIP-value

43 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Outcome 300mg Loading Dose (n=148) >600mg Loading Dose (n=48) P Major bleeding,70 (47%)35 (73%)0.002 Re-operation for bleeding, 7 (5%)6 (12%)0.09 Tamponade4 (3%)2 (4%)0.64 Mean 24h Chest tube loss 391 ± 251 mL536 ± 354 mL0.01 Post-operative MI8 (5%)5 (11%)0.31 Post-operative CVA6 (4%)1 (2%)0.34 LOS in surgical intensive care, days 4.3 ± 4.15.0 ± 3.10.0001 In-hospital death7 (5%)1 (2%)0.68 Clopidogrel loading dose and bleeding in NSTEACS patients undergoing urgent CABG Cruden NL. Am Heart J 2011;161:404

44 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

45 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Transfusions from time of CABG Any transfusion 0.88 (0.67, 1.16) Platelets 1.03 (0.88, 1.20) PRBC or whole blood* 0.83 Transfusions within 7 days post-CABG 0.98 (0.85, 1.14) Fresh frozen plasma 1.05 (0.84, 1.31) 0.69 0.37 0.67 Transfusions post CABG-related bleeding 1.25 (0.70, 2.23) >5 units whole blood/ PRBC (2 days) 1.12 (0.83, 1.53) >4 units blood Chest tube output >2L (24 hours) 1.24 (0.61, 2.52) 0.45 0.49 0.62 Ticagrelor betterClopidogrel better 0.51.02.00.2 *Median (range) units transfused within 7 days post-CABG: tic 3.0 (2.0–4.0) vs. clop 3.0 (2.0–4.0); p=0.86 p-value Hazard/Odds Ratio (95% CI)Ticagrelor (n=632) Clopidogrel (n=629) 15.317.3 52.751.2 55.255.8 25.224.0 4.94.0 17.916.2 3.32.7 Characteristic Held C, JACC 2011;57:672

46 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Time from CABG to CV death 0 1 2 3 45 67 89 10 1112 876543210876543210 Months from CABG procedure HR: 0.52 (95% CI = 0.32–0.85), p<0.01 7.9 4.1 Clopidogrel (n=629) Ticagrelor (n=629) K-M estimated rate (%) Held C, JACC 2011;57:672

47 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Smith PK. JACC 2012; epub ahead of print 24 May 2012 Bleeding and mortality after isolated CABG Clopidogrel vs prasugrel mean 12-h chest tube blood loss (655 + 580 ml vs. 503 + 378 ml; p 0.050)

48 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Event rates for patient undergoing CABG in PURSUIT (< 72 h of GP IIb/IIIa discontinuation) Marso SP et al; Circulation 2000;102:2952-8 15% 35% 0306090120150180 days from randomization 33.6% 23.8% RRR 30% p = 0.002 25% cumulative incidence (%) placeboeptifibatide

49 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Caso clinico 13 settembre 2012 Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio. Maratoneta amatoriale fino a un anno fa. Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicale e vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci La mattina successiva, CKMB 75 ng/ml Evoluzione ECG

50 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

51 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

52 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

53 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto

54 Data: 9 Novembre 2012 Evento: Genova Titolo: added value of GPIIb/IIIa RB in ACS Autore: Stefano Savonitto Caso clinico 13 settembre 2012 Uomo di 72 anni senza precedenti cardiovascolari né rilevanti fattori di rischio. Maratoneta amatoriale fino a un anno fa. Il 12 settembre esegue nel nostro Ospedale intervento di litotrissia endovescicale e vaporizzazione prostatica “green light laser” per calcolosi vescicale e IPB ostruente Lo stesso pomeriggio, lieve epigastralgia durata 15 minuti, a risoluzione spontanea Visita cardiologica (sintomatologia aspecifica) + ECG – richiesti enzimi cardiaci La mattina successiva, CKMB 75 ng/ml Evoluzione ECG Flectadol 500 mg – Trasferimento in UTIC Eseguita coronarografia: occlusione trombotica coronaria destra distale Eseguita tromboaspirazione + POBA con ottimo risultato angiografico Tirofiban 24 ore post-procedura in vista di stenting 17 Settembre.


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