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ACS and Thrombosis in the Emergency Setting

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Presentation on theme: "ACS and Thrombosis in the Emergency Setting"— Presentation transcript:

1 ACS and Thrombosis in the Emergency Setting

2 Q1: Which reperfusion strategy would you select as optimal for this patient if the nearest cardiac center were 3 hours drive away? a) Immediate transfer to cardiac cath lab for primary PCI b) Immediate fibrinolysis and then transfer to cardiac centre c) Immediate fibrinolysis with transfer only if no reperfusion

3 Choosing the Optimal Reperfusion Strategy
Goal is rapid reperfusion Time targets from first medical contact to treatment Fibrinolysis 30 minutes Primary angioplasty (PPCI) minutes Delayed reperfusion associated with increased mortality When time to PPCI will exceed minutes fibrinolysis should be given immediately Time delay for PPCI to achieve greater benefit than fibrinolysis may be less than 90 minutes when Anterior MI Patient age <65 yrs Time from symptom onset <120 minutes

4 Impact of Delay to Primary PCI
90 DAY MORTALITY RELATED TO DOOR-TO-BALLOON TIME (n=1071) (n=1354) (n=1186) (n=1762) <60 min 60-90 min min ≥120 min SURVIVAL (%) 99% 98% 97% 96% 95% 94% 93% 92% 100% 3.2% 90-day mortality 4.0% 4.6% 5.3% P<0.0001 10 20 30 40 50 60 70 80 90 DAYS Hudson MP et al. Circ Cardiovasc Qual Outcomes 2011;4:183-92

5 Which Patients Cannot Afford a PPCI Delay?
PCI RELATED DELAY (DB-DN) WHERE PCI AND FIBRINOLYTIC MORTALITY ARE EQUAL (MIN) NonAnt MI 65+ YRS 180 120 60 Ant MI 65+ YRS NonAnt MI < 65 YRS Ant MI < 65 YRS 0-120 Prehospital Delay (min) 121+ 40 43 58 103 107 148 168 179 20,424 10,614 9,812 3,739 41,774 16,119 19,517 5,296 Pinto DS et al. Circulation 2006; 114:

6 Prehospital and In-Hospital Management and Reperfusion Strategies
aThe time point the diagnosis is confirmed with patient history and ECG ideally within 10 min from the first medical contact (FMC). All delays are related to FMC (first medical contact). Cath = catheterization laboratory; EMS = emergency medical system; FMC = first medical contact; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction STEMI diagnosisa Primary-PCI capable center EMS or non primary-PCI capable center Preferably ˂60 min Primary-PCI Rescue PCI Coronary angiography NO YES Immediately Preferably 3-24 h PCI possible ˂120 min? Immediate fibrinolysis Successful fibrinolysis? Immediate transfer to PCI center Preferably ≤90 min (≤60 min in early presenters) Immediate transfer to PCI center Preferably ≤30 min ESC STEMI Guidelines 2012

7 Q2: In the event that the patient receives fibrinolysis, which anticoagulant is preferred?
a) UHF b) Enoxaparin c) Fondaparinux Q3: Which would be the optimal antiplatelet agent to add to the anticoagulant? a) clopidogrel b) ticagrelor c) prasugrel

8 Anticoagulation and Antiplatelet Therapy with Fibrinolysis
Initiate UFH, enoxaparin or fondaparinux immediately after administration of fibrinolytic agent UFH 70u/kg iv Enoxaparin <75yrs old 30mg iv bolus followed by s/c 1mg/kg >75yrs old no iv bolus, s/c 1mg/kg Fondaparinux 2.5mg s/c Antiplatelet Therapy ASA mg po Clopidogrel <75 yrs old 300mg load followed by 75mg daily > 75 yrs old no load, 75mg po daily NB Ticagrelor and Prasugrel should not be used with fibrinolysis as they have not been tested in this situation 4.2. Adjunctive Antithrombotic Therapy With Fibrinolysis See Table 5 for a summary of recommendations from this section. Adjunctive Antiplatelet Therapy With Fibrinolysis Class I 1. Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading dose for patients <75 years of age, 75-mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy.113,121,122 (Level of Evidence: A) 2. Aspirin should be continued indefinitely113,121,122 (Level of Evidence: A) and clopidogrel (75 mg daily) should be continued for at least 14 days121,122 (Level of Evidence: A) and up to 1 year (Level of Evidence: C) in patients with STEMI who receive fibrinolytic therapy. Class IIa 1. It is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses after fibrinolytic therapy.77,80,86,87 (Level of Evidence: B) Adjunctive Anticoagulant Therapy 1. Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours, and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed.123,124 (Level of Evidence: A) Recommended regimens include a. UFH administered as a weight-adjusted intravenous bolus and infusion to obtain an activated partial thromboplastin time of 1.5 to 2.0 times control, for 48 hours or until revascularization (Level of Evidence: C); b. Enoxaparin administered according to age, weight, and creatinine clearance, given as an intravenous bolus, followed in 15 minutes by subcutaneous injection for the duration of the index hospitalization, up to 8 days or until revascularization124– 127 (Level of Evidence: A); or c. Fondaparinux administered with initial intravenous dose, followed in 24 hours by daily subcutaneous injections if the estimated creatinine clearance is greater than 30 mL/min, for the duration of the index hospitalization, up to 8 days or until revascularization.110 (Level of Evidence: B) 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

9 Need for PCI after Fibrinolysis
Rescue PCI Failed fibrinolysis Persistence of chest pain Failure of ST elevation to decrease more than 50% at 1 hr after fibrinolysis Pharmaco-Invasive strategy Consider routine transfer patients to cardiac centre for PCI within 2-24 hrs of fibrinolysis Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable§ and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.133–138 (Level of Evidence: B) 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

10 Impact of Routine Early Transfer for PCI after Fibrinolysis
DEATH, REINFARCTION, WORSENING HEART FAILURE, OR CARDIOGENIC SHOCK 0.20 0.15 0.10 0.00 0.05 5 30 DAYS 10 15 20 25 Standard treatment Routine early PCI Death, reinfarction, or recurrent ischemia HR 0.65 (95% CI 0.44–0.96) HR 0.64; 95% CI, Early PCI hrs Standard treatment PCI hrs Cantor et al N Eng J Med 2009;360:2705

11 Primary PCI for STEMI Improved outcomes if PPCI performed in timely manner Delayed PPCI worse than timely fibrinolysis Goal Patient contact to PCI < 90 minutes for most patients Adjuvant anticoagulation / antiplatelet agents By agreement with local interventional cardiology team

12 Oral Antiplatelets in STEMI
TRITON TIMI 38 Prasugrel vs Clopidogrel CV death / MI / Stroke CUMULATIVE INCIDENCE (%) DAYS FROM RANDOMISATION HR % CI p=0.0221 15 10 5 50 300 100 150 200 250 350 400 450 Clopidogrel Prasugrel P=0.0017 P=0.0221 PLATO Ticagrelor vs Clopidogrel CV death / MI / Stroke Clopidogrel Ticagrelor CUMULATIVE INCIDENCE (%) 1 2 3 4 5 6 7 8 9 10 11 12 MONTHS HR 0.87; 95% CI ; P= 0.07 At risk 60% Primary PCI 30% Secondary delayed PCI No reduction of mortality, MI HR 0.70 p=0.01 Stent thrombosis HR 0.58 p=0.23 No increase in TIMI major or life threatening bleeding All primary PCI Mortality HR, 0.82; P= MI HR 0.80 p=0.03 Stent thrombosis HR 0.60 p=0.03 Stroke increased 1.7% vs 1.0% HR 1.63 p=0.02 No increase in major bleeding Montelescot et al Lancet 2009; 373: 723 Steg et al Circulation. 2010;122:2131

Pre-Hospital Fibrinolysis + PCI vs Primary PCI for Patients Unable to Undergo Primary PCI within 1 Hour RR 0.86; 95% CI, ; P = 0.21 DEATH, SHOCK, CHF, OR REINFARCTION % 20 15 10 5 30 DAYS 25 Primary PCI Fibrinolysis STREAM Study Armstrong et al N Eng J Med 2013;368:1379

14 Q4: How would you have handled this patient if in addition to medical history described, he also had a recent (past 6 months) CVA? a) Administer fibrinolysis b) Transfer to regional cardiac centre for PCI c) Manage medically with UFH and ASA

15 2013 STEMI Management Early identification of STEMI- pre hospital preferred Performing 12-lead ECG by EMS personnel or at site of first medical contact Early decision for reperfusion strategy and administration within 12 hours of symptom onset for all eligible STEMI patients Primary PCI preferred if can be performed in timely manner (First medical contact to PCI < min) Consider fibrinolysis in young anterior STEMI presenting < 120 minutes from symptom onset if PCI not available within 60 minutes O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary

16 2013 STEMI Management (cond’t)
Following fibrinolysis consider referral for early PCI Choice of anticoagulant / antiplatelet agent depends upon reperfusion strategy and policy of PCI centre (P2Y12 receptor inhibitor therapy prior to PCI and maintenance for a year; ASA mg loading and 81mg maintenance; UHF, bivalirudin with or without prior UHF) O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary

17 candidate for reperfusion
2013 STEMI Management STEMI patient who is a candidate for reperfusion Initially seen at a PCI-capable hospital Initially seen at a non-PCI-capable Hospital* Send to cath lab for primary PCI FMC-device time ≤90 min (Class 1, LOE: A) Diagnostic angiogram PCI CABG Medical therapy only DIDO time≤30 min Transfer for primary PCI FMC-device time as soon as Possible and ≤120 min (Class 1, LOE: B) Administer fibrinolytic agent within 30 min of arrival when anticipated FMC- device >120 min Transfer for angiography and revascularization within 3-24 h for other patients as part of an invasive strategyϮ (Class IIa, LOE: B) Urgent transfer for PCI for patients with evidence of failed reperfusion or reocclusion Figure 1. Reperfusion therapy for patients with STEMI. The bold arrows and boxes are the preferred strategies. Performance of PCI is dictated by an anatomically appropriate culprit stenosis. *Patients with cardiogenic shock or severe heart failure initially seen at a non-PCI-capable hospital should be transferred for cardiac catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Ϯangiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. CABG indicates coronary artery bypass graft; DiDO, door-in-door-out; FMC, first medical contact; LOE, Level of Evidence; MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction. O’Gara et al 2013 ACCF/AHA STEMI Guideline Executive Summary

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