ΕΜΠΕΙΡΙΑ ΑΠΟ ΕΝΑ ΚΕΝΤΡΟ ΠΡΩΤΟΓΕΝΟΥΣ ΑΓΓΕΙΟΠΛΑΣΤΙΚΗΣ Χ. Γραΐδης 1, Δ. Δηµητριάδης 1, Β. Καρασαββίδης 1, Θ. Μπίτσης 1, Γ. Αηδονίδης 1, Γ. Δηµητριάδης 2 Α.Αντώνιου 3, Γ. Τσινόπουλος 3, Ι. Μποστανίτης 2 1 Euromedica, Γενική Κλινική Κυανούς Σταυρός 2 Καρδιολογική Κλινική, Γ.Ν. Κατερίνης 3Καρδιολογική Κλινική, Γ.Ν. Σερρών
περίοδος 2013-2015 - 82 ασθενείς - Νοσηλευόμενοι / εξωτερικοί ασθενείς - εικόνα οξέως στεφανιαίου επεισόδιου STEMI
<10 min ΗΚΓ και κλινική εξέταση - λήψη ατομικού και οικογενειακού ιστορικού - ECHO καρδιάς
Καταγραφή - ηλικίας - φύλου - χρόνοι door to ballon time (mean) - symptoms onset- ballon time (mean) - συμμετοχή μυοκαρδιακού τοιχώματος - συμμετοχή στεφανιαίας αρτηρίας - χρήση ενδοαρτικού ασκού - συχνότητα θρομβοαναρρόφησης - ανάγκη για CABG - επίτευξη ροής TIMI 3
Συχνότητα µείζονων ανεπιθύµητων καρδιαγγειακών συµβαµάτων (MACE) θνητότητα ενδονοσοκοµειακή θνητότητα στο 6µηνο αγγειακό εγκεφαλικό επεισόδιο σακχαρώδης διαβήτης
ΑΠΟΤΕΛΕΣΜΑΤΑ Μέση Ηλικία: 55 (30-87ετών) Φύλο (άρρεν-θήλυ): 70% door to balloon time (mean): 15 min symptoms onset- balloon time (mean): 35 min Μυοκαρδιακό τοίχωµα πρόσθιο: 41% πλάγιο: 15% κατώτερο: 44%
Στεφανιαία αρτηρία LAD: 42% LcX: 15% RCA: 38% LM: 5% Ενδοαρτικός ασκός: 3% MACE: 2.5% Αγγειακό εγκεφαλικό επεισόδιο: 1,2% Θροµβοαναρρόφηση: 60% Παραποµπή για CABG λόγω µηχανικών επιπλοκών STEMI: 1% TIMI 3: 94% Στηθάγχη στο 6µηνο: 5% Θνητότητα ενδονοσοκοµειακή: 1,2% Θνητότητα στο 6µηνές: 1,2% Σακχαρώδης Διαβήτης: 31%
ΣΥΜΠΕΡΑΣΜΑΤΑ Μέση Ηλικία Φύλο TIMI 3 ροή MACE Συχνότητα εντόπισης µυοκαρδιακού τοιχώµατος Ποσοστό ασθενών µε καρδιογενή καταπληξία παρόμοιο με αντίστοιχες μελέτες χρόνος απόκρισης (door to balloon) < 20% µικρότερος από αντίστοιχες µελέτες
BRAVE-2 Trial 365 patients with MI presenting >12 hours after symptom onset Without ongoing chest pain or Killip class 3/4 Invasive Angiography, then PCI if necessary Mean randomization to PCI time: 1.5 hrs Conservative Conventional medical therapy Endpoints:! Primary Infarct size determined by SPECT at 5-10 days! Secondary Death, MI, stroke, at 30 days www. Clinical trial results.org ACC 2005
BRAVE-2: Primary endpoint 15% Infarct Size (% of left ventricle) 8,0% p = 0.002 13,0% The primary endpoint of infarct size determined by SPECT at 5-10 days was significantly lower in the invasive arm compared to the conservative arm. 0% Invasive 1 Conservative www. Clinical trial results.org ACC 2005
Thrombus Remains Following Thrombolysis Van Belle et al. Circulation. 1998;97:26-33.
2013 ACCF/AHA Guideline for the Management of ST- Elevation Myocardial Infarction Developed in Collaboration with American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions American College of Cardiology Foundation and American Heart Association, Inc.
Primary PCI in STEMI I IIa IIb III A Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration. I IIa IIb III B Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC. I IIa IIb III B Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset.
Primary PCI in STEMI I IIa IIb III B Primary PCI is reasonable in patients with STEMI if there is clinical and/ or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset. I IIa IIb III B PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable Harm
Reperfusion Therapy for Patients with STEMI *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). Angiography and revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
2015 ACC/AHA/SCAI Focused Update on Primary PCI for Patients with STEMI: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Developed in Collaboration with the American College of Emergency Physicians American College of Cardiology Foundation, American Heart Association, and Society for Cardiovascular Angiography and Interventions
Culprit Artery Only Versus Multivessel PCI COR LOE Recommendation IIb B-R PCI of a noninfarct artery may be considered in selected patients with STEMI and multivessel disease who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. 1 1. Modified recommendation from 2013 Guideline (changed class from III: Harm to IIb and expanded time frame in which multivessel PCI could be performed).
Aspiration Thrombectomy COR LOE Recommendations IIb C-LD The usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established. 1 III: No Benefit A Routine aspiration thrombectomy before primary PCI is not useful. 2 1. Modified recommendation from 2013 guideline (Class changed from IIa to IIb for selective and bailout aspiration thrombectomy before PCI) 2. New recommendation
Culprit Artery Only Versus Multivessel PCI Previous clinical practice guidelines recommended against PCI of nonculprit artery stenoses at the time of primary PCI in hemodynamically stable patients with STEMI, based primarily on the results of nonrandomized studies and meta-analyses and safety concerns. Four RCTs (PRAMI, CvLPRIT, DANAMI 3 PRIMULTI, PRAGUE-13) have since suggested that a strategy of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure, may be safe and beneficial in selected patients with STEMI. On the basis of these findings, the prior Class III-harm recommendation with regard to multivessel primary PCI in hemodynamically stable patients with STEMI has been upgraded and modified to a Class IIb recommendation to include consideration of multivessel PCI, either at the time of primary PCI or as a planned, staged procedure. The writing committee emphasizes that this change should not be interpreted as endorsing the routine performance of multivessel PCI in all patients with STEMI and multivessel disease. Rather, when considering the indications for and timing of multivessel PCI, physicians should integrate clinical data, lesion severity/complexity, and risk of contrast nephropathy to determine the optimal strategy.
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