Αντιμετώπιση Οξέος Εμφράγματος του Μυοκαρδίου με Ανάσπαση ST σε Νοσοκομείο χωρίς Αιμοδυναμικό Εργαστήριο Treatment of an Acute STEMI in a Hospital

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1 Αντιμετώπιση Οξέος Εμφράγματος του Μυοκαρδίου με Ανάσπαση ST σε Νοσοκομείο χωρίς Αιμοδυναμικό Εργαστήριο Treatment of an Acute STEMI in a Hospital without Cath Lab Ι. Βογιατζής / I. Vogiatzis ΕΒ Γ.Ν.ΗΜΑΘΙΑΣ-Υγ Μον Νάουσας Σχολιαστής / Commentator: Α. - Δ. Μαυρογιάννη /A. - D. Mavrogianni

2 ΔΕΝ ΥΠΑΡΧΟΥΝ ΑΝΤΙΚΡΟΥΟΜΕΝΑ ΣΥΜΦΕΡΟΝΤΑ

3 May 2014

4 J Am Coll Cardiol. 2013;61(4):e78-e140. doi: /j.jacc Age- and sex-adjusted incidence rates of acute MI, 1999 to I bars represent 95% confidence intervals. MI indicates myocardial infarction; STEMI, ST-elevation myocardial infarction.

5 Outcome of patients with acute myocardial infarction admitted in hospitals with or without catheterization laboratory: results from the HELIOS registry. Eur J Cardiovasc Prev Rehabil Feb;16(1): doi: /HJR.0b013e32831e954e To compare the treatment and outcomes of myocardial infarction patients and without catheterization laboratory. in hospitals with METHODS AND RESULTS: The Hellenic Infarction Observation Study was a countrywide registry of acute myocardial infarction, conducted during The registry enrolled 1840 patients with myocardial infarction from 31 hospitals with a proportional representation of all types of hospitals and of all geographical areas. Out of these patients, 645 (35%) were admitted in 11 hospitals with and 1195 (65%) in 20 hospitals without catheterization laboratory. Patients admitted in hospitals with catheterization laboratory in comparison with patients admitted in hospitals without were younger (66+/-14 vs. 68+/-13, P<0.004) with less diabetes (27 vs. 33%, P<0.001), but without other baseline differences (female 27 vs. 25%, prior myocardial infarction 20 vs. 17%, Killip class>1 22 vs. 23%). Reperfusion rates for ST-segment elevation myocardial infarction were 67% (43% lytic, 24% primary percutaneous coronary interventions) versus 56% (55% lytic, 1% percutaneous coronary interventions; P<0.01). In-hospital outcomes in hospitals with versus in hospitals without laboratory were: mortality 6.5 versus 8.3% (NS), stroke 2.2 versus 1.1% (NS), major bleeding 1.1 versus 0.6% (NS), and heart failure 11 versus 16% (P<0.01). In multivariate regression analysis, being admitted in a hospital without catheterization laboratory was not an independent predictor of increased in-hospital mortality (odds ratio=1.18, 95% confidence interval: , P=0.505). CONCLUSION: Although the majority of acute myocardial infarction patients was admitted in hospitals without catheterization laboratory, these patients do not have a survival disadvantage, provided they are treated with lytic therapy, medical secondary prevention drugs, and eventual revascularization according to current guidelines. PMID:

6 Διάγνωση Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012;126:

7 Διάγνωση Οξέος Εμφράγματος με ανάσπαση του ST Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012;126: Το κλινικό σύνδρομο ορίζεται από την παρουσία χαρακτηριστικών συμπτωμάτων μυοκαρδιακής ισχαιμίας και εμμένουσας ανάσπασης του ST τμήματος του ΗΚΓ και ακόλουθη απελευθέρωση στην κυκλοφορία βιοδεικτών μυοκαρδιακής νέκρωσης. Σε απουσία υπερτροφίας της Αρ.κοιλίας και LBBB ως έμφραγμα ορίζεται : Νέα ανάσπαση του ST στο σημείο J δύο τουλάχιστον συνεχόμενων/ σχετιζόμενων απαγωγών 2mm (0.2 mv) στους άνδρες ή 1.5 mm (0.15 mv) στις γυναίκες στις απαγωγές V2 V3 και/ή 1 mm 0.1mV) σε άλλες σχετιζόμενες προκάρδιες ή των άκρων απαγωγές. Η πλειοψηφία των ΗΚΓ των ασθενών εξελίσσεται με εμφάνιση κυμάτων Q. H παρουσία LBBB που δεν προυπήρχε σε συνδυασμό με την παρουσία συμπτωμάτων ισχαιμίας θεωρείται ισοδύναμο STEMI (σε περίπτωση που υπάρχει παλαιότερο ΗΚΓ).

8 Αρχική αντιμετώπιση ασθενούς EHJ (2012) 33, doi: /eurheartj/ehj215

9 Αρχική αντιμετώπιση ασθενούς Οποιοειδή (π.χ. μορφίνη) είναι τα κατεξοχήν αναλγητικά. Αποφυγή ενδομυικής χορήγησης. Ανεπιθύμητες ενέργειες : ναυτία, έμετος,υπόταση με βραδυκαρδία, αναπνευστική καταστολή. Χορήγηση αντι-εμετικών, ατροπίνης και ναλοξόνης ( mg / 15 min όπου ενδείκνυται). EHJ (2012) 33, doi: /eurheartj/ehj215

10 Οξυγόνο Cochrane Database Syst Rev Aug 21;8:CD doi: / CD pub3. Oxygen therapy for acute myocardial infarction.c abello JB1, Burls A, Emparanza JI, Bayliss S, Quinn T. Although it is biologically plausible that oxygen is helpful, it is also biologically plausible that it may be harmful. Potentially harmful mechanisms include the paradoxical effect of oxygen in reducing coronary artery blood flow and increasing coronary vascular resistance, measured by intracoronary Doppler ultrasonography (McNulty 2005; McNulty 2007); reduced stroke volume and cardiac output (Milone 1999); other adverse haemodynamic consequences, such as increased vascular resistance from hyperoxia; and reperfusion injury from increased oxygen free radicals (Rousseau 2005). The 2013 ACCF/AHA Guideline for the Management of STElevationMyocardial Infarction have a similar change in emphasis: Few data exist to support or refute the value of the routine use of oxygen in the acute phase of STEMI, and more research is needed. A pooled Cochrane analysis of 3 trials showed a 3-fold higher risk of death for patients with confirmed acute MI treated with oxygen than for patients with acute MI managed on room air. Oxygen therapy is appropriate for patients who are hypoxaemic (oxygen saturation 90% ) and may have a salutary placebo effect in others. Supplementary oxygen may, however, increase coronary vascular resistance. Oxygen should be administered with caution to patients with chronic obstructive pulmonary disease and carbon dioxide retention. (O Gara 2013).

11 Συστατικά στοιχεία της καθυστέρησης στο χρόνο θεραπείας EHJ (2012) 33, doi: /eurheartj/ehj215

12 Διαχείριση Στρατηγικές Επαναιμάτωσης εντός 24h Wijns et al. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010;31:

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15 Daniel Muñoz, and Christopher B. Granger Circulation. 2011;124:

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17 Προ-νοσοκομειακή φροντίδα This image cannot currently be display ed. Heart Nov;91(11): Epub 2005 Mar 17. Time to treatment and the impact of a physician on prehospital management of acute ST elevation myocardial infarction: insights from the ASSENT-3 PLUS trial. Welsh RC1, Chang W, Goldstein P, Adgey J, Granger CB, Verheugt FW, Wallentin L, Van de Werf F, Armstrong PW; ASSENT-3 PLUS Investigators Karim Kalla et al. Implementation of Guidelines Improves the Standard of Care.The Viennese Registry on Reperfusion Strategies in ST-Elevation Myocardial Infarction (Vienna STEMI Registry) CirculationVolume113(20): May 23, 2006

18 Προ-νοσοκομειακή φροντίδα Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, Krumholz HM. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study.br Med J 2009;338:b1807. Nielsen PH, Terkelsen CJ, Nielsen TT, Thuesen L, Krusell LR, Thayssen P, Kelbaek H, Abildgaard U, Villadsen AB, Andersen HR, Maeng M. System delay and timing of intervention in acute myocardial infarction (from the DanishAcute Myocardial Infarction-2 [DANAMI-2] trial). Am J Cardiol 2011;108:

19 Προ-νοσοκομειακή φροντίδα EHJ (2012) 33, doi: /eurheartj/ehj215

20 Cardiac Arrest EHJ (2012) 33, doi: /eurheartj/ehj215

21 Επαναιμάτωση Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996;348: Boersma E. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 2006;27:

22 Αντενδείξεις Ινωδόλυσης Relative Transient ischaemic attack in the preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 week postpartum Refractory hypertension (systolic blood pressure >180 mmhg and/or diastolic blood pressure >110 mmhg) Advanced liver disease Infective endocarditis EHJ (2012) 33, Active peptic ulcer doi: /eurheartj/ehj215 Prolonged or traumatic resuscitation

23 Αξία Ινωδόλυσης Η αξία της ινωδολυτικής θεραπείας σε ασθενείς με STEM είναι τεκμηριωμένη : συγκριτικά περίπου 30 πρώιμοι θάνατοι προλαμβάνονται ανά 1000 ασθενείς εφόσον χορηγηθεί εντός 6 h από την έναρξη των συμπτωμάτων. Το όφελος είναι μεγαλύτερο σε υψηλού κινδύνου ασθενείς και επίσης συμπεριλαμβάνονται και οι ηλικιωμένοι > 75 ετών. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists (FTT) Collaborative Group. Lancet 1994;343: White HD. Thrombolytic therapy in the elderly. Lancet 2000;356(9247):

24 Ινωδόλυση Fibrinolytic therapy is recommended within 12h of symptom onset in patients without contraindications if primary PCI cannot be performed by an experienced team within 120 min of FMC. IA DOI: First published online: 13 November 2008 Pinto DS, et all. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 2006;114:

25 Ινωδόλυση In patients presenting early (<2 h after symptom onset) with a large infarct and low bleeding risk, fibrinolysis should be considered if time from IIa B FMC to balloon inflation is >90 min. Pinto DS, et all. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 2006;114: Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, Leizorovicz A, Touboul P. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomizedclinical trial. Circulation 2003;108: Bonnefoy E, Lapostolle F, Leizorovicz A, Steg G, McFadden EP, Dubien PY, Cattan S, Boullenger E, Machecourt J, Lacroute JM, Cassagnes J, Dissait F,Touboul P. Primary angioplasty vs. pre-hospital fibrinolysis in acute myocardialinfarction: a randomised study. Lancet 2002;360:

26 Ινωδόλυση If possible, fibrinolysis should start in the prehospital setting. IIa A Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ. Mortality and pre-hospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA 2000;283: Bjorklund E, Stenestrand U, Lindback J, Svensson L, Wallentin L, Lindahl B. Prehospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction. Eur Heart J 2006;27:

27 Ινωδόλυση A fibrin-specific agent (tenecteplase, alteplase, reteplase) is recommended (over non-fibrin specific agents). IB Van De Werf F, et all. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 doubleblind randomised trial. Lancet 1999;354: An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators. N Engl J Med 1993; 329:

28 Ινωδόλυση Oral or i.v. aspirin must be administered. IB Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988;2:

29 Ινωδόλυση Clopidogrel is indicated in addition to aspirin. IA Chen ZM, Jiang LX, Chen YP, Xie JX, Pan HC, Peto R, Collins R, Liu LS. Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005;366: Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, Claeys MJ, Cools F, Hill KA, Skene AM, McCabe CH,Braunwald E. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005;352:

30 Ινωδόλυση αντιθρομβωτικά EHJ (2012) 33, doi: /eurheartj/ehj215

31 Ινωδόλυση Όλοι οι ασθενείς χρήζουν μεταφοράς σε κέντρο με δυνατότητα PCI μετά την ινωδόλυση ΙΑ EHJ (2012) 33, doi: /eurheartj/ehj215

32 Παρεμβάσεις μετά την Ινωδόλυση EHJ (2012) 33, doi: /eurheartj/ehj215 Borgia F, et all. Early routine percutaneous coronary intervention after fibrinolysisvs. standard therapy in STsegment elevation myocardial infarction: a meta-analysis. Eur Heart J 2010;31:

33 Δόσεις Ινωδολυτικών EHJ (2012) 33, doi: /eurheartj/ehj215

34 Ινωδόλυση και Αντιαιμοπεταλιακή θεραπεία Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988;2: Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, Claeys MJ, Cools F, Hill KA, Skene AM, McCabe CH,Braunwald E. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005;352:

35 Αντιαιμοπεταλιακή θεραπεία χωρίς θεραπεία επαναιμάτωσης EHJ (2012) 33, doi: /eurheartj/ehj215

36 Αντιθρομβωτική θεραπεία στην Ινωδόλυση EHJ (2012) 33, doi: /eurheartj/ehj215

37 Eιδικά Θέματα EHJ (2012) 33, doi: /eurheartj/ehj215

38 Υπεργλυκαιμία στην οξεία φάση του εμφράγματος EHJ (2012) 33, doi: /eurheartj/ehj215

39 Διαχείριση κατά τη νοσηλεία EHJ (2012) 33, doi: /eurheartj/ehj215

40 Απεικόνιση κ Stress Testing EHJ (2012) 33, doi: /eurheartj/ehj215

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42 Flowchart for numeric and alphabetic phases of the index (acute cardiac care and aftercare). Robyn A. Clark et al. Circulation. 2012;125: Copyright American Heart Association, Inc. All rights reserved.

43 Cardiac Accessibility and Remoteness Index for Australia (ARIA) categories mapped by location. Robyn A. Clark et al. Circulation. 2012;125: Copyright American Heart Association, Inc. All rights reserved.

44 Ευχαριστώ TIME Door to Baloon Minus Door to Needle