1. 1 Controversia: La Terapia Facilitante con Trombolisi nellInfarto Acuto del Miocardico Alberto Genovesi Ebert Spedali Riuniti, Livorno Contro

2. 2 Teoria Teoria Metanalisi Metanalisi RCT RCT Controversia: La Terapia Facilitante con Trombolisi nellInfarto Acuto del Miocardico Contro

3. 3 Contro Teoria Teoria Metanalisi Metanalisi RCT RCT

4. 4 Sites of Anti-thrombotic Drug Action Tissue factor Plasma clotting cascade Prothrombin Thrombin FibrinogenFibrin Thrombus Platelet aggregation Conformational activation of GPIIb/IIIa Collagen Thromboxane A 2 ADP AT ATAspirinTiclopidineClopidogrel GPIIb/IIIainhibitors FactorXa BivalirudinHirudinArgatrobanLMWHHeparinThrombo-lytics Coagulationcascade Plateletcascade

5. 5 Copyright ©1998 American Heart Association Hoffmeister, H. M. et al. Circulation 1998;98:2527-2533 Levels of TAT complexes as marker of thrombin generation in patients with AMI and streptokinase, alteplase, or no thrombolytic therapy compared with control subjects (contr)

6. 6 Fibrinolisi e Coagulazione Granger CB JACC 98;31: 497

7. 7 Thromb Haemost 1997;78:214-219 Fibrinolisi, Coagulazione e Piastrine

8. 8 ASSENT IV Lancet 06: 367: 569 p=.027p=.0041

9. 9 Controversia: La Terapia Facilitante con Trombolisi nellInfarto Acuto del Miocardico Contro Teoria Teoria Metanalisi Metanalisi RCT RCT

10. 10 Keeley EC Lancet 06; 367: 579 PCI After Lytics Facilitated Angioplasty: Paradise Lost? Fac. Better PPI Better total

11. 11 Keeley EC Lancet 06; 367: 579 PCI After Lytics Facilitated Angioplasty: Paradise Lost? Fac. Better PPI Better total total

12. 12 Facilitazione con Fibrinolisi Intera? Facilitazione con Fibrinolisi Intera? No! No! Spazio per il mezzo e mezzo? Spazio per il mezzo e mezzo?

13. 13 Focus on ½ Lytics + Anti 2b/3a Sinno MCN AHJ 07; 153: 579

14. 14Sanguinamenti Fac. Better PPI Better Sinno MCN AHJ 07; 153: 579 Keeley EC Lancet 06; 367: 579

15. 15 PTCA Iaria vs Txlisi: Ictus Emorragici Keeley EC Lancet 2003;361:13 Lytic (n=3867) PTCA (n=3872) p=0.032

16. 16 PTCA Iaria vs Txlisi: Ictus Emorragici Keeley EC Lancet 2003;361:13 Lytic (n=3867) PTCA (n=3872) p=0.032 …e la facilitata?

17. 17 Strokes Keeley EC Lancet 06; 367: 579

18. 18 Teoria Teoria Metanalisi Metanalisi RCT RCT Controversia: La Terapia Facilitante con Trombolisi nellInfarto Acuto del Miocardico Contro

19. 19 Abciximab Placebo Follow up through 90 days and 1 year Primary PCI with Abciximab Infusion (12 h) FINESSE: Study Design Acute ST Elevation MI (or New LBBB) within 6h pain onset Presenting at Hub or Spoke with estimated time to Cath between 1 and 4 hours Placebo Reteplase (5U+5U)* Abciximab Placebo Abciximab Randomize 1:1:1 N=3000 *Only 5U if 75 yr Transfer To Cath Lab ASA, unfractionated heparin 40U/kg (max 3000U) or enoxaparin (0.5 mg/kg IV + 0.3 mg/kg SC) – substudy only Double Blind Double Dummy Ellis SG NEJM 08; 358: 2205

20. 20 Death/Cardiogenic Shock/CHF (H/ED)@90days/VF>48h

21. 21 Finesse: Efficacia Ellis SG NEJM 08; 358: 2205

22. 22 Finesse: Efficacia Ellis SG NEJM 08; 358: 2205

23. 23 Finesse: Sicurezza P<.05 P<.05P<.05 Ellis SG NEJM 08; 358: 2205

24. 24 FINESSE: Sanguinamenti e Prognosi Ellis SG NEJM 08; 358: 2205

25. 25 Facilitazione con Trombolisi? Vantaggi? No Rischi?Si

26. 26

27. 27 Copyright ©2008 American Heart Association White, H. D. Circulation 2008;118:219-222 Impact of PCI with fibrinolytic therapy

28. 28 Finesse: Sicurezza

29. 29

30. 30 ASSENT 4

31. 31

32. 32 ASSENT IV

33. 33 Keeley EC Lancet 06; 367: 579 PCI After Lytics Facilitated Angioplasty: Paradise Lost? Fac. Better PPI Better

34. 34 Keeley EC Lancet 06; 367: 579 PCI After Lytics Facilitated Angioplasty: Paradise Lost? Fac. Better PPI Better

35. 35 Ictus Emorragici Trombolisi e PTCA Primaria Keeley EC Lancet 2003;361:13 Lytic (n=3867) PTCA (n=3872) p=0.032

36. 36 Fibrinolisi e Coagulazione Granger CB JACC 98;31: 497

37. 37Sanguinamenti Fac. Better PPI Better Sinno MCN AHJ 07; 153: 579 Keeley EC Lancet 06; 367: 579

38. 38 PCI After Lytics Facilitated Angioplasty: Paradise Lost? Fac. Better PPI Better