Πρωηογενής αγγειοπλαζηική: Καηάζηαζη ζηην Δλλάδα - Προοπηικές

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1 NEW TRENDS IN CARDIOLOGY ΑΠΡΙΛΙΟΤ 2014, ΘΔΑΛΟΝΙΚΗ Πρωηογενής αγγειοπλαζηική: Καηάζηαζη ζηην Δλλάδα - Προοπηικές Ι. Κανακάκης Διεςθςνηήρ Αιμοδςναμικού Τμήμαηορ Θεπαπεςηική Κλινική Πανεπιζηημίος Αθηνών ΓΝΑ «Αλεξάνδπα»

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4 Duration of Ischemia and Infarct Size Garcia-Dorado D, et al. Cardiovasc Res 1987;21:

5 Important delays and treatment goals in the management of acute STEMI Steg PG, et al. Eur Heart J 2012;33:

6 PATIENT (PUBLIC EDUCATION) Working together EMERGENCY MEDICAL SERVICES PPCI CENTRE ESC 2012 STEMI Guidelines

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8 System delay and long-term mortality (3.4 ys [ ])

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10 Min (range) Impact Upon Time Delays According to Number of Medical Parties Involved Before Hospital Admission French FAST-MI Registry Median Time from First Call to Reperfusion % Day Mortality 5,5 7,1 12, Danchin: JACC Intv., 2009 Number of parties Number of parties

11 % death Organisation of care in STEMI patients: Impact of admission through the ER USIC 2000 Admission via ER is an independent correlate of early mortality P=0.02 P=0.04 P=0.03 P= days 1 year Steg PG, et al. Heart 2006;92:

12 Results of univariable logistic regression analysis Primary PCI Michel R. Le May, et al. J Am Coll Cardiol 2012;60:

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14 Algorithm for the Treatment of ST-Segment Elevation Myocardial Infarction (STEMI) Bhatt DL, N Engl J Med 2013.

15 SFL - Greece

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17 Primary PCIs per year per million inhabitants in European countries 2009

18 Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011

19 No reperfusion therapy per inhabitants in 37 ESC Countries 2010/2011

20 Primary percutaneous coronary interventions per inhabitants in 37 ESC countries

21 Primary PCI numbers in Greece 95 ppci / million / year in ppci / million / year in 2011 J Kanakakis et al. Euro-Intervention 2012;8:

22 Reperfusion Therapies in Greece Thrombolysis pts Rescue PCI 5,80% Pharmacoinvasive 7,30%

23 For 40% of the Greek population distance to cath lab covered in less than 2 hours Athens Network 13

24 Primary PCI Athens area J Kanakakis et al. Euro-Intervention 2012;8:

25 Ratio Total PCI/Primary PCI: Total PCI Primary PCI ,8% 10,2% 15,5% 23% 25%

26 STEMI ppci patients Time Delays Thrombolysis Symptoms FMC FMC needle 136,91 min 62,17 min ppci Symptoms FMC 142,41 min 131,26min FMC PCI center 129,11 min 119,21 min Door Balloon 53,41 min 53,1 min FMC Balloon 182,52 min 172,31 min

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28 ΠΡΟΣΔΡΑΙΟΣΗΣΔ ΠΡΟΓΡΑΜΜΑΣΟ SFL ΣΗΝ ΔΛΛΑΓΑ 1. Γημόζια καμπάνια εςαιζθηηοποίηζηρ ηος κοινού με ηο ζύνθημα «ΓΡΑΔ ΣΩΡΑ ΩΔ ΜΗΑ ΕΩΖ» 2. Γημιοςπγία δικηύων ανηιμεηώπιζηρ ηων Ο ζηο πλαίζιο ηων καηεςθςνηηπίων οδηγιών 3. Ππονοζοκομειακή ΖΚΓ-θική διάγνωζη ηων STEMI και καθοδήγηζη ππορ PCI κένηπα 4. Δξοπλιζμόρ και εκπαίδεςζη πποζωπικού ηος ΔΚΑΒ 5. Νέο ανηιπποζωπεςηικό registry για ηα Ο

29 Recommended logistics Pre-hospital triage / care: EMS Unique telephone number Tele-consultation Ambulance: 12-ECG recorder / defibrillator Staff able to provide basic and advanced life support Networks: Implementation of a network of hospitals with different levels of technology connected by an efficient ambulance service using the same protocol Targets: < 10 min ECG transmission < 5 min tele-consultation < 120 (< 90) min from FMC to first balloon inflation < 30 min start fibrinolytic therapy

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32 ΗΛΔΚΣΡΟΝΙΚΑ ΜΔΑ Vita.gr Healthpro.gr Healthreport.gr Iatropedia.gr Iatro.gr Ygeia360.gr Iatrikesexelixeis.gr Iatronet.gr Health.in.gr Healthierworld.gr Protothema.gr Inews.gr Virus.com.gr Pathfinder.gr Newsbeast.gr Life2day.gr Youtube.com (PhB Ethos media channel) Boro.gr Dou.gr Pharmacorner.gr Onmed.gr

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36 ΠΡΟΝΟΟΚΟΜΔΙΑΚΗ ΥΟΡΗΓΗΗ ΑΝΣΙΘΡΟΜΒΩΣΙΚΗ ΘΔΡΑΠΔΙΑ ATOLL ON-TIME-2 EUROMAX STEAM Δνοξαπαπίνη vs UFH iv Σιποθιμπάνη vs placebo Μπιβαλιποςδίνη vs UFH/LMWH ± GPI Θπομβόλςζη (80% ππονοζοκομειακά) vs PPCI

37 ATLANTIC N = 1770 STE ACS planned for PCI RANDOMIZED DOUBLE BLIND Written informed consent in mobile care unit Symptoms of acute MI of more than 30 min but less than 6 hours New persistent ST-segment elevation 1 mm in two or more contiguous ECG leads Ticagrelor 180mg loading dose Pre-Hospital Loading dose placebo Loading dose placebo In-Hospital Ticagrelor 180mg loading dose Primary Objective: - TIMI flow grade 3 of MI culprit vessel at initial angiography or - 70% ST-segment elevation resolution pre-pci Ticagrelor 90mg/bid 30d

38 Logistics of pre-hospital care

39 The 5 primary Danish PCI centres in 2009

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41 ΘΔΡΑΠΔΙΑ ΔΠΑΝΑΙΜΑΣΩΗ Δ ΠΔΡΙΟΥΔ Δ ΜΔΓΑΛΗ ΑΠΟΣΑΗ ΑΠO PCI ΚΔΝΣΡΟ (FMC-balloon > 2 h) ΓΙΑΡΚΔΙΑ ΤΜΠΣΩΜΑΣΩΝ 120 min TNK < 75 yr πλήπηρ δόζη 75 yr ½ δόζη > 120 min Rescue ηεθανιογπαθία DAPT PCI + PCI Pharmacoinvasive - Κλινικές μελέηες STREAM GRACIA 1, TRANSFER AMI CAPITAL-AMI, NORDISTEMI SIAM, WEST PCI

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44 EMS in STEMI and PPCI Conclusion Effective modern STEMI management and PPCI requires an integrated heart attack team of patient, EMS and PPCI centre The EMS is at the centre of the team, and effectively is a mobile CCU requiring a high level of on-going training, and integration to meet current and continually evolving challenges in pre-hospital care