ΝΕΩΤΕΡΕΣ ΚΑΤΕΥΘΥΝΤΗΡΙΕΣ ΟΔΗΓΙΕΣ ΓΙΑ ΤΟ STEMI AΝΝΑ ΔΑΓΡΕ, FESC,FSCAI Κ α ρ δ ι ο λ ό γ ο ς Γ ε ν. Ν ο σ ο κο μ ε ί ο Ε λ ε υ σ ί ν α ς Θ ρ ι ά σ ι ο Πανελλήνιο Συνέδριο Ομάδων Εργασίας Θεσσαλονίκη, 20-22 Φεβρουαρίου 2014
Reperfusion Therapy, and Time-to-Treatment Goals
96,738 ppci, 7/05-6/09 515 Νοσοκομεία NCDR 2005-2009
Primary PCI Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours duration. Reperfusion therapy is indicated in all pts with symptoms <12h duration and ST elevation or new LBBB Primary PCI is the recommended reperfusion therapy over fibrinolysis if performed by an experienced team <120 min of FMC
Late primary PCI 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. Reperfusion therapy ( preferably primary PCI) is indicated if there is evidence of ongoing ischemia even if symptoms have started >12 hours beforehand if pain and ECG changes have been stuttering Primary PCI may be considered in stable pts presenting 12-14h after symptom onset
Primary PCI in non culprit artery PCI should not be performed in a non-infarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable Harm Primary PCI should be limited to the culprit vessel with the exception of cardiogenic shock and persistent ischemia after PCI of the supposed culprit lesion
CABG in pts with STEMI a b c Urgent CABG is indicated in patients with STEMI and coronary anatomy not amenable to PCI who have ongoing or recurrent ischemia, cardiogenic shock, severe HF, or other high-risk features. CABG is recommended in patients with STEMI at time of operative repair of mechanical defects.
ΑΝΤΙΑΙΜΟΠΕΤΑΛΙΑΚΗ ΑΓΩΓΗ ΣΤΟ STEMI
To πλεονέκτημα της θνητότητας της πρασουγρέλης σχεδόν εξαφανίζεται στο τέλος του FU www.accessdata.fda.org Serebruany V et al Thromb Haemost 2013;110:5-10 ΕΡΩΤΗΜΑΤΑ ΠΟΥ ΠΡΟΚΥΠΤΟΥΝ ΓΙΑ ΤΑ ΝΕΩΤΕΡΑ ΑΝΤΙΑΙΜΟΠΕΤΑΛΙΑΚΑ ΣΤΟ STEMI Πως ερμηνεύεται το μεγαλύτερο ποσοστό θανάτων από την τικαγκρελόρη ( the life-saver ) σε σχέση με την πρασουγρέλη 4.9% vs 3.28% σε παρόμοιο πληθυσμό STEMI ασθενών σε PLATO και TRITON αντίστοιχα; Πως ερμηνεύεται το χαρακτηριζόμενο απο το FDA early PCI ticagrelor paradox ; PLATO trial,nejm 2009 TRITON-TIMI 38 NEJM 2007
Aναστολείς υποδοχέων GPIIb/IIIa
Reperfusion at a Non PCI-Capable Hospital Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy
Use of Stents in Patients With STEMI
De Luca G et al,arch Intern Med 2012;172(8):611-21 Sabate M et al Lancet 2012;380:1482-90
Use of DES in Patients With STEMI BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year. *Balloon angioplasty without stent placement may be used in selected patients. DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents. Δεν υπάρχει οδηγία για ασθενείς χαμηλού αιμορραγικού κινδύνου, με ικανότητα συμμόρφωσης σε DAPT για ένα χρόνο, και χωρίς αναμενόμενη χειρουργική επέμβαση στον χρόνο αυτόν.
Access site for primary PCI
Rival trial, Lancet 2011;377:1409-1420
Access site for primary PCI Radial artery access site may decrease bleeding complications and should be considered whenever feasible, but procedural success with this technique is dependent on operator experience If performed by an experienced radial operator, radial access should be preferred over femoral access
Aspiration Thrombectomy
Aspiration Thrombectomy TAPAS, total mortality at 1y Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. Routine thrombus aspiration should be considered Vlaar PJ et al NEJM 2008;371:1915
Distal protection device No recommendation Routine use of distal protection device is not recommended
Cardiogenic Shock
Thiele H, NEJM 2012 Thiele H,Lancet 2013
Intra Aortic Balloon pump The use of intra-aortic balloon pump counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological. Intra aortic balloon pump may be considered for shock
Plateau G.Stone, TCT 2013
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