NEW TRENDS IN CARDIOLOGY 11-12 ΑΠΡΙΛΙΟΤ 2014, ΘΔΑΛΟΝΙΚΗ Πρωηογενής αγγειοπλαζηική: Καηάζηαζη ζηην Δλλάδα - Προοπηικές Ι. Κανακάκης Διεςθςνηήρ Αιμοδςναμικού Τμήμαηορ Θεπαπεςηική Κλινική Πανεπιζηημίος Αθηνών ΓΝΑ «Αλεξάνδπα»
Duration of Ischemia and Infarct Size Garcia-Dorado D, et al. Cardiovasc Res 1987;21:537-44.
Important delays and treatment goals in the management of acute STEMI Steg PG, et al. Eur Heart J 2012;33:2569-619
PATIENT (PUBLIC EDUCATION) Working together EMERGENCY MEDICAL SERVICES PPCI CENTRE ESC 2012 STEMI Guidelines www.escardio.org
System delay and long-term mortality (3.4 ys [1.8-5.3])
Min (range) Impact Upon Time Delays According to Number of Medical Parties Involved Before Hospital Admission French FAST-MI Registry 300 250 200 150 100 50 Median Time from First Call to Reperfusion 170 50 100 201 60 122 270 80 155 % 14 12 10 8 6 4 2 30-Day Mortality 5,5 7,1 12,1 0 0-1 2 3 Danchin: JACC Intv., 2009 Number of parties 0 0-1 2 3 Number of parties
% 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=0.006 5 days 1 year Steg PG, et al. Heart 2006;92:1378-83
Results of univariable logistic regression analysis Primary PCI Michel R. Le May, et al. J Am Coll Cardiol 2012;60:1223-30
Algorithm for the Treatment of ST-Segment Elevation Myocardial Infarction (STEMI) Bhatt DL, N Engl J Med 2013.
SFL - Greece
Primary PCIs per year per million inhabitants in European countries 2009
Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011
No reperfusion therapy per 1 000 000 inhabitants in 37 ESC Countries 2010/2011
Primary percutaneous coronary interventions per 1 000 000 inhabitants in 37 ESC countries
Primary PCI numbers in Greece 95 ppci / million / year in 2009 346 ppci / million / year in 2011 J Kanakakis et al. Euro-Intervention 2012;8:116-20.
Reperfusion Therapies in Greece Thrombolysis pts Rescue PCI 5,80% Pharmacoinvasive 7,30%
For 40% of the Greek population distance to cath lab covered in less than 2 hours Athens Network 13
Primary PCI Athens area J Kanakakis et al. Euro-Intervention 2012;8:116-20.
Ratio Total PCI/Primary PCI: 2007-2012 25000 20000 19566 19974 Total PCI Primary PCI 15000 16778 16120 15920 10000 8,8% 10,2% 15,5% 23% 25% 5000 0 3733 2611 1723 2056 2008 2009 2010 2011 2012
STEMI ppci patients Time Delays Thrombolysis 2011 2012 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
37%
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
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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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
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
Logistics of pre-hospital care
The 5 primary Danish PCI centres in 2009
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
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