«STEMI- Τρέχουσα θέση της...

Aθανάσιος Ν. Καρτάλης

Επιμελητής Α΄

Καρδιολογική Κλινική Γ.Ν.

Χίου

Αμφιθέατρο

Ελληνικής Καρδιολογικής Εταιρείας

Παρασκευή 21 Ιουνίου 2013, Αθήνα

«STEMI - Τρέχουσα θέση της

Θρομβόλυσης»

REPERFUSION THERAPY IN STEMI

PRIMARY PCI is defined as percutaneous intervention in the

setting of STEMI without previous or

concomitant fibrinolytic treatment.

FIBRINOLYSIS

Quantitative review of 23 trials of primary angioplasty

versus thrombolysis (n=7739)

5,0%

3,0%

1,0%0,1%

8,0%7,0% 7,0%

2,0%1,0%

14,0%

0,0%

5,0%

10,0%

15,0%

Death Re-MI Stroke Haem

stroke

Any event

Primary PCI

Thrombolysis

Keeley, Lancet 2003;361:13Keeley, Lancet 2003;361:13

Short-term clinical outcomesShort-term clinical outcomes

p=0.002 p<0.0001

p=0.0004

p<0.0001

p<0.0001

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.

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Time is Muscle

18% reduction

in mortality at 21 days

p=0.0002

GISSI trial

1986

Fibrinolytic Therapy Trialists Collaborative Group

35 Day Outcome in 58 600 patients (9 trials review)

9,6%

1,2% 1,1%

11,2%

0,8% 0,4%

Mortality Stroke Major bleed

fibrinolytic

control

Lancet 1994:343;311

11,5%

Fibrinolytic Therapy Trialists Collaborative Group

35 Day Outcome in 58 600 patients (9 trials review)

18% reduction in

mortality

18% reduction in

mortality

25% reduction

in 45.000 pts

with ST

elevation or

BBB

Thrombolysis: the ‘golden hour’

20

40

60

80

0

3 6 9 12 15 18 21 24

Treatment delay (h)

Absolute reduction in 35 day mortality per 1000 patients treated

FTT data - closed circles

Smaller trials - open circles

00

Boersma, Lancet 1996;348:771Boersma, Lancet 1996;348:771

Live

s sa

ve

d p

er

10

00

tre

ate

d p

ati

en

tsLi

ve

s sa

ve

d p

er

10

00

tre

ate

d p

ati

en

ts

Residual infract artery stenosis (%)

TIMI 4, 10A, 10B,14, trials, 2119 pts

Llevadot J, Giugliano R et al. Am J Cardiol 85:1409,2000

RESIDUAL STENOSIS IN THE INFRACT-RELATED ARTERY

AT 90 MINUTES AFTER THROMBOLYSIS

90’ AFTER

THROMBOLYSIS:

62% TIMI 3 FLOW

IN PRIMARY PCI:

88% TIMI 3 FLOW

4.6

87.9

15.7

0

2

4

6

8

10

12

14

16

TIMI 3 TIMI 0,1,2

Pa

tie

nt

Mo

rta

lity

(%

) 30 Days

2 Years

Ross AM, et al. Circulation. 1998;97:1549-1556.

90 min TIMI Flow Post-fibrinolytic

GUSTO-I Angiographic Investigators:

Post-lytic TIMI Flow Predicts Mortality

TIMI Flow 0,1,2 vs TIMI 3 : ~ ΜORTALITY X2

Coagulation and Fibrinolysis

FibrinolysFibrinolysisis

Fibrin

Coagulation Factors

Fibrinogen

Plasmin

Plasminogen

Tissue Plasminogen

Activator

Molecular structure of alteplase, reteplase, and TNK-tPA.

White H D , and Van de Werf F J J Circulation 1998;97:1632-1646

Τα θρομβολυτικά φάρμακα

στοχεύουν στη διάλυση

πρόσφατα σχηματισμένων

θρόμβων, ενεργοποιώντας το

πλασμινογόνο σε πλασμίνη, η

οποία αποδoμεί το ινώδες των

θρόμβων.

Brief Review of Thrombolytic Trials

GISSI-1: Streptokinase 18% reduction in mortality at 21 d

GUSTO-1: tPA 15% reduction in 30-day mortality compared

to Streptokinase

GUSTO-3: Reteplase had no benefit over tPA but is easier to

use (double bolus)

ASSENT-2: TNK was similar to tPA but with less non-cerebral

bleeding : Single bolus, fibrin selective, resistance to PAI-1

*Overall risk of ICH is 0.7%; Strokes occurred in 1.4%

Armstrong et al.: Circulation 2001

Thrombolysis equivalence trials

‘ceiling’ of benefit?

Thrombolysis equivalence trials

‘ceiling’ of benefit?

6,3%

7,2%6,6%

6,2%

7,3% 7,5%6,8%

6,2%

0%

2%

4%

6%

8%

10%

GUSTO-I GUSTO-III In-TIME Assent-2

acc alteplase streptokinase reteplase

lanoteplase tenecteplase

6,3%

7,2%6,6%

6,2%

7,3% 7,5%6,8%

6,2%

0%

2%

4%

6%

8%

10%

GUSTO-I GUSTO-III In-TIME Assent-2

acc alteplase streptokinase reteplase

lanoteplase tenecteplase

30 d mortality30 d mortality

over 5 sec

over 2 min

Platelets

Antiplatelet Antiplatelet

therapytherapy

-- aspirinaspirin

--

dihydropyridinesdihydropyridines

-- GP IIb/IIIaGP IIb/IIIa

inhibitorsinhibitors

Fibrin

Plasminogen

activators

- t-PA

- r-PA

- TNK-tPA

ThrombinAntithrombin therapy

- heparin

-LMWH

-Fondaparinux

STEMI: Fighting with the clot

Adjunctive Antiplatelet Therapy With

Fibrinolysis

Aspirin (162- to 325-mg loading dose) and clopidogrel (300-mg loading

dose for patients ≤75 years of age, 75-mg dose for patients >75 years

of age) should be administered to patients with STEMI who receive

fibrinolytic therapy.

I IIa IIb III

• aspirin should be continued indefinitely and

I IIa IIb III

• clopidogrel (75 mg daily) for at least 14 days

o and up to 1 year

I IIa IIb III

I IIa IIb III


Adjunctive Antithrombotic Therapy to Support Reperfusion

With Fibrinolytic Therapy


Adjunctive Antithrombotic Therapy to Support PCI After

Fibrinolytic Therapy (cont.)

*Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide

P2Y12

inhibitor therapy to patients with STEMI undergoing balloon angioplasty after fibrinolysis alone according to the

recommendations listed for BMS. (Level of Evidence: C)


Reperfusion therapy is reasonable for patients with STEMI and

symptom onset within the prior 12 to 24 hours who have

clinical and/or ECG evidence of ongoing ischemia. Primary PCI is

the preferred strategy in this population.

I IIa IIb III


If PCI is not available, a fibrinolytic agent may be considered, if there is a large infarct and

the patient is young and the risk of bleeding is not high

10,711,8

4,3

14,615,7

6,5

2,7

7,8

0

5

10

15

20

Mortality ReMI Major Bleed Minor Bleed

Repeat fibrinolysis Conservative treatment

10,711,8

4,3

14,615,7

6,5

2,7

7,8

0

5

10

15

20

Mortality ReMI Major Bleed Minor Bleed

Repeat fibrinolysis Conservative treatment

p = 0.14p = 0.14

p = 0.09p = 0.09

p = 0.03p = 0.03

Repeat fibrinolysis was Repeat fibrinolysis was

not associated with not associated with

significant significant

improvements in allimprovements in all--

cause mortality or cause mortality or

reinfarction, and it also reinfarction, and it also

showed an increased showed an increased

risk for minor bleeding.risk for minor bleeding.

Reinfarction:Repeat Fibrinolysis vs Conservative Treatment

REACT trial Outcomes

Wijeysundera HC, et al. JACC. 30 Jan 2007:49(4): 422-30.Wijeysundera HC, et al. JACC. 30 Jan 2007:49(4): 422-30.

Pa

tie

nts

(%

)

p = 0.42p = 0.42

If there is evidence of reinfarction with recurrence of ST-segment elevation the patient should be

immediately transferred to a hospital with PCI capabilities. If PCI is not available, a second administration of

a non-immunogenic fibrinolytic agent may be considered, if there is a large infarct and if the risk of bleeding

is not high

ΚΙΝΔΥΝΟΣ ΓΙΑ ΕΓΚΕΦΑΛΙΚΗ ΑΙΜΟΡΡΑΓΙΑ

ΑΠΟ ΘΡΟΜΒΟΛΥΣΗ

ΑΡΙΘΜΟΣ ΠΑΡΑΓΟΝΤΩΝ ΚΙΝΔΥΝΟΥ ΓΙΑ ΕΓΚΕΦΑΛΙΚΗ

ΑΙΜΟΡΡΑΓΙΑ

Simons et al: Lancet 1993

ΠΑΡΑΓΟΝΤΕΣ

ΚΙΝΔΥΝΟΥ:

1. ΑΥΞΗΜΕΝΗ

ΗΛΙΚΙΑ

2. ΥΠΕΡΤΑΣΗ

ΚΑΤΑ ΤΗΝ

ΠΡΟΣΕΛΕΥΣΗ

3. ΧΑΜΗΛΟ

ΣΩΜΑΤΙΚΟ

ΒΑΡΟΣ

Μέσο ποσοστό ενδοκρανιακής

αιμορραγίας 0,75%

Fibrinolytic Therapy in Patients 75 Years and Older With ST-Segment–Elevation

Myocardial Infarction: One-Year Follow-up of a Large Prospective Cohort

Arch Intern Med. 2003;163(8):965-971.

(n = 6891) by multiple Cox regression analysis at the mean of all covariates; relative risk, 0.87; 95% confidence

interval, 0.80 to 0.94; P = .001. Adjusted probability of death or cerebral bleeding in patients receiving and not

receiving fibrinolytic therapy at 30 days was 23% and 26% and at 1 year was 32% and 36%, respectively.

p=0.00113%

Comparison of primary PCI and prehospital

thrombolysis in acute MI (CAPTIM n=840)

4,8%

6,2%

3,8%

8,2%

0%

2%

4%

6%

8%

10%

Death Death, re-MI, CVA

Primary PCI

Pre-hospital alteplase (rescue PCI 26%)

Bonnefoy, Lancet 2002;360:825Bonnefoy, Lancet 2002;360:825

Events at 30 daysEvents at 30 days

Planned 1200 patients

Symptoms to lysis 130 min

Symptoms to balloon 190 min

Planned 1200 patients

Symptoms to lysis 130 min

Symptoms to balloon 190 min

P=0.61 P=0.29

Indications for fibrinolytic therapy

Benefit seen

despite high

cath/PCI rates in

Standard

Treatment group

(~40% rescue PCI)

ACC, 2013

After 20% of the planned recruitment,

the TNK dose was reduced by 50%

among patients ≥75 years of age.

1892 patients

randomized

by 99 sites in 15 countries

STREAM STUDY - 30 days RESULTS:

STREAM STUDY: STROKE RATES

STREAM STUDY:IN-HOSPITAL BLEEDING COMPLICATIONS

STEMI: In hospital mortality in Greece

HELIOS - 2006 STENT FOR LIFE - 2011

M.O

TLP-PCI

REPERFUSION THERAPIES IN GREECE

Thrombolysis pts:

Rescue PCI: 7,4%

Pharmacoinvasive: 6,4%

THROMBOLYSIS

P-PCI

25

2

1

1

1

2

Centers with cath-lab ONLY 12

Non STOP(24H/7D)

p-PCI CENTERS

2

8

1

1

42

1

1

13

• However, in many areas of the world, like Greece primary PCI cannot be performed within the recommended time limits(<90-120 min).

• In these remote areas, thrombolysis is still the treatment of choice.

• Primary PCI is the preferred

treatment of ST-elevation

myocardial infarction.

IN GREECE:Most cath labs non 24h/day, 7d/week p-PCI facility centers.

Often Early Admission in non p-PCI Centers and difficult to transfer.

PHARMACOINVASIVE

STRATEGY?

Delayed Primary PCI is more Delayed Primary PCI is more ““DELAYEDDELAYED”” than than ””PRIMARYPRIMARY”” Reperfusion Reperfusion

especially in the case of postponed lytic therapy due to plannedespecially in the case of postponed lytic therapy due to planned

Primary PCIPrimary PCI

Α. Διαχωριστικό ανεύρυσμα αορτής

Β. Γαστρορραγία τον τελευταίο μήνα

Γ. Ανθεκτική υπέρταση

(συστολική> 180mmHg και διαστολική> 110mmHg)

Δ. Ισχαιμικό εγκεφαλικό τους τελευταίους 6 μήνες

Ε. Προηγούμενο αιμορραγικό εγκεφαλικό επεισόδιο 2 χρόνια πριν

1. ΠΟΙΟ ΑΠΟ ΤΑ ΠΑΡΑΚΑΤΩ ΔΕΝ ΕΙΝΑΙ ΑΠΟΛΥΤΗ

ΑΝΤΕΝΔΕΙΞΗ ΘΡΟΜΒΟΛΥΣΗΣ ;

Α. Να περιμένει και να αξιολογήσει εκ νέου το ΗΚΓ σε 30 λεπτά

Β. Να χορηγήσει αναστολείς αιμοπεταλίων IIb – IIIa

Γ. Να διακομίσει άμεσα τον ασθενή για αγγειοπλαστική

Δ. Να χορηγήσει ξανά θρομβόλυση

2. Ασθενής με πρόσθιο STEMI προσήλθε 1ώρα από την έναρξη των

ενοχλημάτων σε non-PCI Νοσοκομείο, που βρίσκεται σε απόσταση 130

λεπτών από PCI Νοσοκομείο. Τρεις ώρες μετά από την αρχικά επιτυχημένη

θρομβόλυση ο ασθενής παρουσιάζει επανέμφραγμα. Ποια είναι η επόμενη

ενέργεια του εφημερεύοντα με βάση τις τελευταίες κατευθυντήριες οδηγίες;

Α. Να περιμένει και να αξιολογήσει εκ νέου το ΗΚΓ στα 90 λεπτά

Β. Να διακομίσει άμεσα τον ασθενή για αγγειοπλαστική

διάσωσης

Γ. Να χορηγήσει αναστολείς αιμοπεταλίων IIb – IIIa

Δ. Να διακομίσει τον ασθενή για αγγειοπλαστική 3 ώρες

μετά τη χορήγηση της θρομβόλυσης

3. Ασθενής με πλάγιο STEMI θρομβολύθηκε σε non-PCI Νοσοκομείο. Στα 60 λεπτά

μετά τη χορήγηση θρομβολυτικής θεραπείας οι αρχικές ανασπάσεις έχουν

ελαττωθεί 30%. Ποια είναι η επόμενη ενέργεια του εφημερεύοντα με βάση τις

τελευταίες κατευθυντήριες οδηγίες, με δεδομένο ότι το πλησιέστερο PCI-

Νοσοκομείο βρίσκεται σε απόσταση 130 λεπτών;

Back up slides

total dose is 100 mg for patients weighing more than 67 kg. This is the most common alteplase infusion

parameter used for AMI.

Reteplase

First, reconstitute two 10-U vials with sterile water (10 mL) to 1 U/mL. The adult dose of reteplase for AMI

consists of 2 IV boluses of 10 units each; there is no weight adjustment. The first 10 U IV bolus is given over 2

minutes; 30 minutes later, a second 10 U IV bolus is given over 2 minutes. Administer normal saline (NS) flush

before and after each bolus.

Tenecteplase

To reconstitute tenecteplase, mix the 50-mg vial in 10 mL sterile water (5 mg/mL). Tenecteplase is admini

in a 30-50 mg IV bolus over 5 seconds. The dosage is calculated on the basis of the patient’s weight, as follows:

< 60 kg - 30 mg (6 mL)

60 to 69 kg - 35 mg (7 mL)

70 to 79 kg - 40 mg (8 mL)

80 to 89 kg - 45 mg (9 mL)

≥ 90 kg - 50 mg (10 mL)

Streptokinase

The adult dose of streptokinase for AMI is 1.5 million U in 50 mL of 5% dextrose in water (D5W) given IV over 60

minutes. Allergic reactions force the termination of many infusions before a therapeutic dose can be

administered.

APSAC

The adult dose of APSAC (anistreplase) for AMI is 30 U given IV over 2-5 minutes

Fibrinolytic Therapy in Patients 75 Years and Older With ST-Segment–Elevation

Myocardial Infarction: One-Year Follow-up of a Large Prospective Cohort

Complications of fibrinolytic therapy in relation to age. Number s above bars are numbers of patients.

Arch Intern Med. 2003;163(8):965-971.

RECURRENT MI RATES IN RECENT FIBRINOLYTIC TRIALS WHICH

UTILIZED A CONJUNCTIVE ANTITHROMBIN STRATEGY.

Armstrong P W et al. Circulation 2003;107:2533-2537

Σχέση TIMI Ροής (90 min) και

Θνητότητας

8,9

7,4

4,4

0

1

2

3

4

5

6

7

8

9

10

TIMI 0-1 TIMI 2 TIMI 3

Mortality (%)

Simes, Circulation 1995.

p=0.009

MORTALITY %

APPROPRIATE PROCEDURAL VOLUME FOR p-PCI

• Operators

More than 75 interventional procedures per year, ideally at least 11 p-PCI per year.

• Cath lab

More than 200 coronary interventional procedures are performed each year, at least 36 of them being primary in nature.

An institution with a volume of fewer than 200 procedures per year, unless in a region

that is underserved because of geography, should carefully consider whether it should

continue to offer this service.

(Level of Evidence: B)

From: 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College

of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

J Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019

Age- and sex-adjusted incidence rates of acute MI, 1999 to 2008. I bars represent 95% confidence intervals. MI indicates myocardial infarction; STEMI,

ST- eleva�on myocardial infarc�on.

1/3

1/2

1/4

Convincing evidence of the effectiveness of aspirin was demonstrated by the ISIS-2

trial,79 in which the benefits of aspirin and streptokinase were additive. The first dose of

150–325 mg should be chewed (no enteric-coated aspirin because of slow onset of

action) and a lower dose (75–100 mg) given orally daily thereafter. If oral ingestion is not

possible, aspirin can be given i.v. (250–500 mg). In the CLARITY trial, patients ≤75 years

were treated with a standard fibrinolytic regimen and randomized to 300 mg clopidogrel

loading dose followed by 75 mg per day or placebo on top of aspirin up to and including

the day of angiography with a maximum of 8 days (mean duration 3 days). By 30 days,

clopidogrel therapy reduced the odds of the composite end-point of death from

cardiovascular causes, recurrent myocardial infarction, or recurrent ischaemia, leading to

a reduction of the need for urgent revascularization of 20%. The rates of major bleeding

and intracranial haemorrhage were similar in the two groups.52 In the COMMIT

study,80 45 852 Chinese patients of any age (but <1000 patients >75 years) with

suspected myocardial infarction (93% with STEMI) were randomized to clopidogrel 75 mg

(no loading dose) or placebo in addition to aspirin. Clopidogrel significantly reduced the

odds of the composite of death, myocardial infarction, or stroke, corresponding to nine

fewer events per 1000 patients treated for ∼2 weeks. Accordingly, there is a good case

for the routine use of clopidogrel in the acute phase

MORTALITY AMONG FIBRINOLYTIC-TREATED AND CONTROL

PATIENTS ACCORDING TO TREATMENT DELAY

White H D , and Van de Werf F J J Circulation 1998;97:1632-1646

STREAM STUDY - CONCLUSIONS

A strategy of fibrinolysis with bolus tenecteplase and

contemporary antithrombotic therapy given before

transport to a PCI-capable hospital coupled with timely

coronary angiography :

�circumvents the need for an urgent procedure in about

two thirds of fibrinolytic treated STEMI patients.

�is associated with a small increased risk of intracranial

bleeding.

�is as effective as primary PCI in STEMI patients presenting

within 3 hours of symptom onset who cannot undergo

primary PCI within one hour of first medical contact.

Fibrinolytic Therapy When There Is an Anticipated Delay Fibrinolytic Therapy When There Is an Anticipated Delay Fibrinolytic Therapy When There Is an Anticipated Delay Fibrinolytic Therapy When There Is an Anticipated Delay

to Performing Primary PCI Within 120 Min of FMC to Performing Primary PCI Within 120 Min of FMC to Performing Primary PCI Within 120 Min of FMC to Performing Primary PCI Within 120 Min of FMC

Reperfusion at a Non–PCI-Capable Hospital

When fibrinolytic therapy is indicated or chosen as the primary

reperfusion strategy, it should be administered within 30 minutes of

hospital arrival.*

I IIa IIb III


Indications for Fibrinolytic Therapy When There Is a >120-

Minute Delay From FMC to Primary PCI

REPERFUSION THERAPY IN STEMI

In this trial, 1572 STEMI patients were randomized within 12 hours of symptom onset to a fibrinolytic versus

a primary percutaneous coronary intervention (PCI) strategy in both community (n=1129) and primary PCI

(n=443) hospitals.19 This study integrated an inter-institutional transfer policy for those randomized to

primary PCI if it could be achieved within 3 hours. The Data and Safety Monitoring Board prematurely

terminated DANAMI 2 because of the perception of “clear benefit” of primary PCI. Although DANAMI 2 did

show a substantial reduction in the composite 30-day endpoint of death, re-MI, and disabling stroke (13.7%

versus 8.0%; P=0.003) in favor of the primary PCI strategy, this outcome was overwhelmingly influenced by

the reduction in reinfarction (from 6.3% to 1.6%; P<0.0001). Importantly, this reduction in reinfarction

occurred in a clinical environment where transfer from a community hospital was considered

“investigational” if a mechanical intervention after fibrinolysis was needed. Hence, urgent PCI occurred in

only 2.5% of patients, even though 28% of the patients were randomized in interventional institutions. An

additional study, interpreted by some as impetus to move to an overall primary PCI strategy, was conducted

by the Cardiovascular Patients Outcomes Research Team (C-PORT) investigators who randomized 451 STEMI

patients within 12 hours of symptom onset to primary PCI versus tPA.20 Although there was no difference in

mortality, there was a substantial reduction in the composite endpoints of death, re-MI, and stroke with

primary PCI (17.7% versus 10.7% with tPA; P=0.03); this was again largely accounted for by a reduction in an

unusually high reinfarction rate amongst fibrinolytic-treated versus PCI-treated patients (8.8% versus

4%; P=0.04). Hence, in both the aforementioned studies, which used unfractionated heparin as the

antithrombin fibrinolytic partner, the recurrent infarction rate was by far the most important element in the

composite endpoint and seemed unusually high relative to other trials. This is well demonstrated in Figure 2,

where we compare the incidence of recurrent infarction in a number of recent STEMI studies that evaluated

fibrinolysis and antithrombin therapy; it is useful to evaluate them in the context of the frequency with

which mechanical cointervention with PCI was used.

J Am Coll Cardiol 2010;55:102–10

Kaplan-Meier curve for Secondary Endpoint12-month Death, Reinfarction or Stroke

Conservative

Early invasive

15.9

6.0

HR =0.36 (0.16 – 0.81); p= 0.01

Clinical outcome at 30 days

Death, re-MI, stroke,

new ischemia

Death, re-MI,

strokeDeath

RR 0.49 (0.27-0.89)

p=0.03

RR 0.45 (0.18-1.16)

p=0.14

Invasive

Conservative

Di Mario C et al. Lancet 2008; 371: 559–568.

CARESS-in-AMI: Major results

Outcome Immediate PCI (%)

Rescue PCI (%)

p

Death, re-MI, or refractory ischemia at 30 days*

4.4 10.7 0.004

Major bleed 3.4 2.3 0.47

Stroke 0.7 1.3 0.50*Primary outcome

ENROLMENT AND KEY DATES

• First patient in: March

19, 2008

• Last patient in: July 26,

2012

• Last patient out: Sep 7,

2012

Enrolment setting

PATIENTS PER COUNTRY

62

Sx onset

1st Medical

contact

61

1 Hour 2 Hoursn=1892

29

Randomize IVRS

9

Rx TNK

31 86

Sx onset

Rx PPCI

100

min

178 min

MEDIAN TIMES TO TREATMENT (min)

1st Medical

contact

78 min

differenceRandomize IVRS

Fibrinolysis with tenecteplase and contemporary antithrombotic therapy given before

transport to a PCI-capable hospital coupled with timely coronary angiography is as

effective as primary PCI in STEMI patients presenting within three hours of symptom

onset who cannot undergo primary PCI within one hour of first medical contact

INVASIVE PROCEDURES

62

Sx onset

61

1 Hour 2 Hours

29 9

Rx TNK

31 86

Sx onset

Rx PPCI

100 min

178 min

MEDIAN TIMES TO TREATMENT (min)

36% Rescue PCI at 2.2h

n=1892

64% non-urgent cath at 17h

1st Medical

contactRandomize IVRS

1st Medical

contact Randomize IVRS

There was a

significant increase

in intracranial

hemorrhage (ICH)

in the fibrinolysis

group, which led to

the dose of

tenecteplase being

halved in people

aged 75 years and

older fairly early on

in the course of the

trial, after which

the intracranial

hemorrhage rate in

the fibrinolysis

group was reduced

to 0.5%, which was

not significantly

different from the

PCI group.

Individual studies – Danami II trial long

term follow up.

Long term follow up CAPTIM trial

Prospective registries RIKS - HIA

Prospective registries - Vienna

Indications for Transfer for Angiography After Fibrinolytic

Therapy

*Although individual circumstances will vary, clinical stability is defined by the

absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade

ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent

ischemia.

Individual studies – Prague 2

«STEMI- Τρέχουσα θέση της...

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