Η αντιμετώπιση του ΟΕΜ στην Ευρώπη σήμερα

Transcript

1 10o ΒΟΡΕΙΟΕΛΛΑ ΙΚΟ ΚΑΡ ΙΟΛΟΓΙΚΟ ΣΥΝΕ ΡΙΟ Θεσσαλονίκη Μαΐου 2011 Η αντιμετώπιση του ΟΕΜ στην Ευρώπη σήμερα Ι. Κανακάκης ιευθυντής Καρδιολογίας Θεραπευτική Κλινική Πανεπιστημίου Αθηνών ΓΝΑ «Αλεξάνδρα»

2 Huynch T et al. Circulation 2009;119:3101.

3 Huynch T et al. Circulation 2009;119:3101.

4 Keely et al. Lancet 2003.

5 Mc Namare et al. JACC 2006;47: De Luca et al. Am J Cardiol 2005;95:

6 Are time delays to PCI NOT that important? Symptom to balloon and 1-year Mortality (%) <=2h 2-4h 4-6h >6h Adjusted RR (95% CI): ( ) 15 P= RR death increased by 7,5% for each 30-min 12 P= All patients (n=1791) P=NS Low risk (n=1246) High risk (n=545) Y=2.86(±1.46) X X 2 P< Ischemic time (min) Every min delay counts not only for lytics but also for PCI De Luca et al. JACC 2003 De Luca, Suryapranata Circulation 2004

7 Delays from symptom onset to ppci in pts with STEMI transported by the EMS n=6209 Field-triaged to a PCI center Symptom onset EMS call Patient delay Transportation delay Prehospital system delay Arrival at PCI center Primary PCI <90 min.57% Treatment delay Transferred from local hospitals Symptom EMS call Arrival at local onset hospital Patient delay Transportation delay Local hospital delay Departure from local hospital Interhospital delay Arrival at PCI center <90 min..19% Primary PCI Door-to-baloon delay Prehospital system delay (before arrival at PCI center) Treatment delay Time Terkelsten CJ, et al. JAMA 2010;304(7):

8

9 Terkelsten CJ, et al. JAMA 2010;304(7): Number of pts with STEMI stratified according to system delay n=6209 { { System delay * N (%) 0-60 min 347 (5%) min 2643 (43%) min 2092 (34%) min 1127 (18%) * System delay: time from contact with the health care system to the time of ppci

10

11

12 PCI < 2h NAI

13

14

15 Reperfusion Therapies Differ in Countries 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO P-PCI Thrombolysis No reperfusion

16 % of primary PCIs among all PCIs (measure of cathlab effectivity??) % of all PCIs are p-pcis for STEMI p-pci LIT PL SK CZ HU SLO SE DK HR NO DE CH PT SRB AT BG IT IL BE FR ES UK FIN TR RO LAT GR

17

18 Η αντιμετώπιση του ΟΕΜ στην Ευρώπη Τα συστήματα αντιμετώπισης διαφέρουν από χώρα σε χώρα ανία-τσεχία: Προνοσοκομειακή διάγνωση με ΗΚΓ-φο 12 απαγωγών, μεταφορά και ερμηνεία του ΗΚΓ-φήματος και προσανατολισμός προς Αιμοδυναμικό Κέντρο Παράκαμψη τμήματος επειγόντων περιστατικών και ΜΕΘ Μεγ. Βρετανία: ιαφορετική προσέγγιση κατά περιοχή (προνοσόκομειακή διάγνωση και primary PCI στο Λονδίνο, προνοσοκομειακή θρομβόλυση στη Σκωτία)

19

20 Hellenic Cardiology Society Government WG on Invasive Cardiology Media Industry

21

22 SERBIA

23 SERBIA Egypt

24

25

26 SFL at National Meetings - SFL Initiative is fully supported by Hellenic CS and WGIC. - SFL Objectives and ESC STEMI Guidelines presentations: February 18, Athens February 19, Thessaloniki February 26, 2010 Athens March 19, 2010 SFL Task Force Meeting March 20, 2010 WG IC, Cardio Athena 2010 May 17, 2010 SFL Steering Committee and Industry November 27, Thessaloniki December 5, 2010 SFL Steering Committee and Industry December 11, 2010 Ioannina

27 For 40% of the Greek population distance to cath lab covered in less than 2 hours 18

28 Majority of ACS Patients are arriving to nearest hospital by private transport HOSPITALS WITHOUT AVAILABLE CATH LAB TIME FOR FMC TO BALLOON : < 2 hrs* (STEMI, Symptoms < 12 hrs) Emergency transport to hospitals with available cath lab and CCU Transport to the hospital of initial admission within hrs Primary PTCA Transportation time < 60 min * Early presentation and large infarcts with low bleeding risk FMC to balloon < 90

29 For 90% of the Greek population distance to cath lab covered in less than 2-3 hours 1

30 HOSPITALS WITHOUT AVAILABLE CATH LAB TIME FOR EMERGENCY TRANSPORT TO CATH LAB : 2-3 hrs (STEMI, symptoms 12 hrs) Duration of symptoms: >2 hrs Duration of symptoms: 2hrs Emergency transport to hospitals with available cath lab and CCU Reperfusion failure Thrombolysis Reperfusion * Primary PCI *Trombolysis in Anterior AMI and young age) Transport to the hospital of initial admission within hrs Emergency transport to hospitals with available cath lab and CCU Rescue PCI PCI 3-24 hrs post thrombolysis

31 PATRAS UNIVERCITY HOSPITAL (PUH) 24 hours / 7 days covered Time interval from first medical contact to revascularization (min) Geographical Area Covered by the catheterization laboratory of UH Patras for ppci GH Agrinio 3,5% Cath Lab PUH Current Guidelines GH Mesolongi 9% HC K. Achaia 2% GH Pyrgos 3% UH Patras 62% HC Krestena 0,5% GH Ag. Andreas 5% HC Nafpaktos 7% GH Aigio 8%

32 National Strategy for STEMI Attica Pilot Program of ppci

33 PCI Centers: Total Athens Metro Thess/niki Metro Rest of Greece 5 Hospitals Government Private University ICE 2010-Georgios Papaioannou

34 PCI Procedures Total Athens Metro Thess/niki Metro Rest of Greece ICE 2010-Georgios Papaioannou

35 Primary PCI numbers: Greece Athens Metro Thess/niki Metro Rest of Greece ICE 2010-Georgios Papaioannou

36 Reperfusion Therapies Differ in Countries 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO P-PCI Thrombolysis No reperfusion 40% P-PCI (private hospital included) in the region of Athens 20% in Greece generally

37 Ratio Total PCI/Primary PCI: ,2% 7,4% 8,8% Total PCI Primary PCI ICE 2010-Georgios Papaioannou

38 % of primary PCIs among all PCIs (measure of cathlab effectivity??) % of all PCIs are p-pcis for STEMI p-pci LIT PL SK CZ HU SLO SE DK HR NO DE CH PT SRB AT BG IT IL BE FR ES UK FIN TR RO LAT GR 10,2% of primary PCIs among all PCIs in Greece

39 Hellenic PCI Registry (2/ /2010) n=225 STEMI Primary PCI Patients: Times 42% DTB<90 min DTB>90 min 58% Mean symptom to door (min) 249 Mean door to balloon (min) 140 Door to balloon < 120 min 147 (65.3%) Door to balloon < 90 min 130 (57.7%) ICE 2010-Georgios Papaioannou 39

40 EMS RELATED BARRIERS Barrier Goal Action Possible difficulties EMS call - EMS arrival min Majority of pts transferred to the nearest non-pci hospital Ambulance is not equipped with ECG Paramedics are not well trained EMS call-ems arrival min Ambulance equipped with 12 leads ECG Trained paramedics to diagnose AIM Transfer of pts directly to PPCI hospitals By pass Non-PCI hospitals and ICUs Organization of EMS (call to arrival time) Ambulance will be equiped with ECG Education of EMS staff Better coordination with ppci center on duty Financial deficit Cath lab overload with STEMI pts

41 PATIENTS RELATED BARRIERS Barrier 50% patients by pass EMS and go directly to nearest hospital Goal The majority of patients call EMS Action Education & Media campaign when the network with PPCI center will be established Possible difficulties False calls Lack of capacity

42

43 STrategic STREAM rategic Reperfusion Early After Myocardial Infarction Patients presenting with STEMI <3 3 hrs from onset of symptoms that cannot reliably undergo primary PCI <60 min Ambulance <75 years: TNK Routine ASA clopidogrel: LD 300 mg + 75 mg QD enoxaparin: 30 mg i.v. + 1 mg/kg s.c. 75 years: TNK Routine ASA 75 mg QD No bolus 0.75 mg/kg s.c. No lytic anticoagulation treatment according to local standards Ambulance hospital Cath lab ECG at 90 min: ST resolution 50% yes Diagnostic angiography recommended + PCI/stent, if indicated > 12 hrs/< 24 hrs Presentation to OPUs, February 19, 2007 no Rescue angiography + PCI/stent immediately Standard angiography + PCI/stent immediately Cath lab

44 ΣΥΜΠΕΡΑΣΜΑ H εφαρμογή δικτύων πρωτογενούς PCI (PCI, non PCI Νοσοκομείο και ΕΚΑΒ) είναι απαραίτητη για τη σύγχρονη αντιμετώπιση του Ο.Ε.Μ. Απαραίτητα βήματα για την επιτυχία ενός Εθνικού Προγράμματος Πρωτογενούς Αγγειοπλαστικής πρέπει να είναι η εθνική καταγραφή για το OEM, η συνεχής ποιοτική βελτίωση των προγραμμάτων, η ακριβής καταγραφή των χρόνων μέχρι την διενέργεια της αγγειοπλαστικής και η καλή συνεργασία όλων των συμμετεχόντων. Οι ασθενείς μετά από θρομβολυτική θεραπεία πρέπει να μεταφέρονται άμεσα σε Νοσοκομείο με Αιμοδυναμικό Εργαστήριο. Στεφανιογραφία και PCI πρέπει να διενεργούνται εντός 24h