Acut coronaria syndroma A késés szerepe a STEMI ellátása során

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1 Acut coronaria syndroma A késés szerepe a STEMI ellátása során
Dr. Szőke Sándor Gottsegen György Országos Kardiológiai Intézet Budapest,

2 Akut koronária szindróma besorolása (szívroham)
Partially blocked artery Non-STE ACS Részleges elzáródás Csökkent vérellátás a szív egy részében Rizikó stratifikáció elengedhetetlen STE ACS Teljes érelzáródás Teljes vértelenség a szív egy részében Gyors reperfúzió elengedhetetlen Infarktust okozó ér megnyitása teljes reperfúzióval Completely blocked artery Coronary artery disease (CAD) and its most severe sequel -- acute myocardial infarction (AMI) or “heart attack” -- is the number one cause of mortality in western civilization. Risk factors for CAD are well described as modifiable- smoking, hypertension, hypercholesterolemia, and diabetes mellitus and those one can not modify -- genetics, increasing age, and male gender. STEMI accounts for approximately one third of patients presenting with acute coronary syndromes with an incidence of approximately 400,000/year in the Unites States. In this syndrome, an acute thrombosis adjacent to a ruptured atherosclerotic plaque completely occludes the coronary artery, resulting in ST-segment elevation in electrocardiogram leads overlying the involved myocardium. As muscle infarction and necrosis ensues, the treatment for STEMI involves rapid reestablishment of coronary flow by either primary percutaneous coronary intervention (PCI) (balloon angioplasty, usually accompanied by stenting) or by fibrinolysis- “clot-busting” drugs. Myocardial infarction may be divided into two types based on the presenting 12-lead electrocardiogram (ECG) – non-STEMI or STEMI. To summarize and differentiate between the two entities of non-STEMI and STEMI: In non-STEMI the pathogenesis is generally caused by a partially occlusive, platelet-rich thrombus in the coronary artery resulting in decreased blood flow to a portion of the heart. In STEMI the pathogenesis is generally caused by a completely occlusive thrombus in a coronary artery. It results from stabilization of a platelet aggregate at the site of plaque rupture by a fibrin mesh network. There is no blood flow to a potion of the heart. In this type of heart attack there is a critical need for quick reperfusion- restoration of blood flow by reopening the blocked artery. 2 2

3 Célok a STEMI kezelésében
Az áramlás visszaállítása Plaque ruptura→ thomboticus occlusio Iv Thrombolysis Primer PCI Hospital halálozás magas (~10%) A kezelés célja: a halálozás csökkentése, mód: coronaria áramlás visszaállítása Current goals for the management of patients with STEMI include early risk stratification and restoration of epicardial blood flow, with fibrinolytic therapy or primary/facilitated percutaneous coronary intervention (PCI), to reduce the incidence of mortality. More recently, research has demonstrated the added benefit of improving downstream microvascular coronary blood flow to further reduce long-term adverse ischemic events, including mortality.  Myocardial. perfusio Myocardialis Infarctus

4 Miért előnyös a reperfusios kezelés STEMI-ben?
Korai myocardialis reperfusio Késői (tartós) myocardialis reperfusio Az infarctus mérete csökken „Open Artery” (IRA) •Remodeling gátlás •Jobb elektromos stabilitás •Collateralis erek Jobb bal kamra funkció Jobb túlélés Jobb túlélés

5 PCI vs fibrinolysis STEMI-ben: Rövidtávú kimenetel
23 vizsgálat meta-analysise; N = 7739 25 20 Gyakoriság (%) 15 10 5 PCI vs fibrinolysis in STEMI patients: Short-term clinical outcomes Halál Halál SHOCK nélkül ReMI Recur ischemia Össz. stroke Hem stroke Major vérzés Halál, MI, stroke This meta-analysis combined data from 23 trials that compared primary PCI with fibrinolytic therapy for STEMI in 7739 patients. The findings indicate that primary PCI is better than thrombolytic therapy at reducing short-term major adverse cardiac events, including death, in individuals with STEMI. PCI was associated with fewer recurrent MIs, less recurrent ischemia, and fewer strokes compared with fibrinolysis. Primary PCI was associated with a better outcome regardless of which thrombolytic agent was used, and even when reperfusion was delayed because of transfer for primary PCI. When a composite endpoint of death, nonfatal recurrent MI, or stroke was analyzed, much of the superiority of a PCI strategy was driven by a reduction in the rate of nonfatal recurrent MI. PCI Fibrinolysis Antman EM et al. Circulation. 2004;110: Modified from Keeley EC et al. Lancet. 2003;361:13-20.

6 PCI vs fibrinolysis STEMI-ben: Hosszútávú kimenetel
23 vizsgálat meta-analysise 35 30 25 Gyakoriság (%) 20 15 10 PCI vs fibrinolysis in STEMI patients: Long-term clinical outcomes 5 Results of the meta-analysis comparing primary PCI with fibrinolysis for STEMI showed that the short-term improvement in outcomes with primary PCI are sustained during long-term follow-up. Primary PCI was associated with fewer deaths, fewer recurrent MIs, less recurrent ischemia, and a lower rate of the composite outcome of death, MI, and stroke. (Data on effects of treatment on stroke alone were not available.) Halál Halál SHOCK nélkül Recur MI Recur ischemia Halál MI stroke PCI Fibrinolysis Antman EM et al. Circulation. 2004;110: Modified from Keeley EC et al. Lancet. 2003;361:13-20.

7 ACC/AHA STEMI guidelines: Assessing reperfusion options
ACC/AHA STEMI guidelines: Szempontok a reperfusio módjának megválasztására Fibrinolysis Primer PCI Korai jelentkezés (tünetek kezdete óta ≤3 óra) Ha az invazív stratégia nem jön szóba Az invazív stratégiával járó késés Door-to-balloon idő >1 órával hosszabb a door-to-needle időnél >90 perces door-to-balloon idő Nagy gyakorlatú labor Nagy rizikójú STEMI Fibrinolysis kontraindikált Késői jelentkezés Tünetek kezdete óta >3 órája STEMI diagnózisa kétséges ACC/AHA STEMI guidelines: Assessing reperfusion options ACC/AHA Class I recommendations for STEMI indicate that if immediately available, primary PCI should be performed in patients with STEMI or MI with new left bundle branch block (LBBB) who can undergo PCI of the infarct artery ≤12 hours of symptom onset, if it is performed in a timely fashion by skilled personnel in a high-volume laboratory that has cardiac surgery capability as a backup. Primary PCI is preferred if symptom duration is >3 hours, as well as in high-risk patients. Door-to-balloon time should not exceed 90 minutes as the mortality benefit associated with PCI vs fibrinolysis rapidly diminishes with increasing time delay. The main point is that some type of reperfusion therapy should be selected for all appropriate patients with suspected STEMI and provided in a timely manner. Antman EM et al. Circulation. 2004;109:

8 Nagy rizikóra utaló tényezők a CARESS-in-AMI-ban
extensiv ST-elevatio újkeletű BTSZB megelőző MI Szívelégtelenség (Killip >2) LVEF <35% inferior AMI-ban Anterior AMI önmagában legalább 2 elvezetésben lévő 2 mm-es STE-val Di Mario et al. Lancet 2008;371. 8

9 PCI időfaktora az ajtó ballon idö
30 napos mortalitás (%) „door-to-balloon time” (perc) Circulation 1999; 100: 14-20

10 PCI időfaktora a teljes ischaemias idö
1 éves mortalitás (%) Ischaemiás idő (perc) Circulation 2004; 109:

11 PCI STEMI-ben: I. osztályú ajánlás
Amennyiben azonnal elvégezhető, PCI javasolt STEMI-ben (valódi posterior infarctusban is), ill. újkeletű(nek tartott) BTSZB-kal járó myocardialis infarctusban 12 órán belül fellépett panaszok esetén Ha a „door-to-balloon time” max. 90 perc Ha az operatőr min. 75 PCI-t végez évente Ha a laborban min. 200 PCI történik évente (min. 36 primer PCI)

12 PCI STEMI-ben: I. osztályú ajánlás
Cardiogen shockban PCI javasolt ST-elevatioval, vagy BTSZB-kal járó infarctusban 75 évnél fiatalabb betegekben Az infarctus első 36 órájában A shock első 18 órájában Revascularisatiora alkalmas betegekben Kivéve, ha a beteg nem egyezik bele, ill. nem alkalmas további intenzív kezelésre

13 PCI STEMI-ben: III osztályú ajánlás
Nem az infarctust okozó éren, ha a beteg haemodynamikailag stabil állapotban van 12 órán túl fennálló myocardialis infarctusban, ha a beteg tünetmentes és haemodynamikailag, ill. elektromosan stabil állapotban van

14 PCI STEMI-ben Célparaméterek
„door-to-balloon time” max. 90 perc helyett a„first medical contact-to-ballon time < 90 perc Emergens CABG-re max. 2%-ban kerüljön sor PCI-ra a betegek min. 85%-ban kerüljön sor A kórházi halálozás legyen 7%-nál kevesebb (CS-t kivéve)

15

16 PCI STEMI-ben „real world”
A PCI a STEMI kezelésének arany standardja Logisztikai okból STEMI-ben világszerte a betegek max. 29%-a kerül primer PCI-ra Igen sok primer PCI-val kezelt STEMI-s beteg az ajánlásokban elfogadottaknál később kerül kezelésre NRMI-3, -4: 4267 beteg Median „door-to-balloon time”: 180’ ! „door-to-balloon time” <90’: 4,2% <120’: 15% Current Opinion in Cardiology 2005; 20(6): 530-5

17 May 30, 2007 Conference Proceedings published in Circulation and Mission: Lifeline Launched

18 The Ideal STEMI System of Care
Mission: Lifeline seeks to promote the ideal STEMI system of care in the United States. Public awareness and the patient factors of recognition of symptoms and calling will always be considered as important to the AHA and Mission: Lifeline. However, in the first phases of the initiative, the primary focus will be on: Creating an ideal system of response of the healthcare team in all components of the system; and Emergency Medical Services (EMS) and implementation of destination protocols for improving access to primary PCI by either EMS bypass of non-PCI hospitals for primary PCI hospitals or timely transfer from non-PCI hospitals to primary PCI hospitals. Each hospital in the United States should have a plan in place for reperfusion and a back-up plan. Involvement of payers; health agencies; and local, state, and national policy makers will be critical to this initiative. [OPTIONAL NOTE TO PRESENTER: Use Chain of Survival Picture?]

19 POE Point Of Entry Protocol (Belépési protkol)
Patient point-of-entry (POE) protocols should be developed with the understanding that a patient may call and be in an EMS zone that transports to a STEMI-referral or STEMI-receiving hospital. Also, patients may directly present to a non-PCI center and be in need of inter-hospital transfer or present to a primary PCI center. The ACC/AHA guidelines encourage EMS on scene be equipped with 12-Lead ECG technology. Advanced systems may consider pre-hospital fibrinolysis, but the majority in the U.S. EMS should have a destination protocol in place. [Note to Presenter: Following text from the 2004 Full Text STEMI ACC/AHA Guidelines caption (pg 19).] Patient transported by EMS after calling 1: Reperfusion in patients with STEMI can be accomplished by the pharmacologic (fibrinolysis) or catheter-based (primary PCI) approaches. Implementation of these strategies varies based on the mode of transportation of the patient and capabilities at the receiving hospital. Transport time to the hospital is variable from case to case, but the goal is to keep total ischemic time within 120 minutes. There are three possibilities: a) If EMS has fibrinolytic capability and the patient qualifies for therapy, pre-hospital fibrinolysis should be started within 30 minutes of EMS arrival on scene; b) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non-PCI-capable hospital, the hospital door-to-needle time should be within 30 minutes for patients in whom fibrinolysis is indicated; c) If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a PCI-capable hospital, the hospital door-to-balloon time should be within 90 minutes. Inter-hospital transfer: It is also appropriate to consider emergency inter-hospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if: 1: There is a contraindication to fibrinolysis; 2: PCI can be initiated promptly (within 90 minutes after the patient presented to the initial receiving hospital or within 60 minutes compared to when fibrinolysis with a fibrin-specific agent could be initiated at the initial receiving hospital); fibrinolysis is administered and is unsuccessful (i.e.,"rescue PCI"). Secondary non-emergency inter-hospital transfer can be considered for recurrent ischemia. Patient self transport: Patient self-transportation is discouraged. If the patient arrives at a non-PCI capable hospital, the door-to-needle time should within 30 minutes. If the patient arrives at a PCI-capable hospital, the door-to-balloon time should be within 90 minutes. The treatment options and time recommended after first hospital arrival are the same.

20 Nemzeti Infarktus Regiszter
GOKI ACS 507 UA/NSTEMI† STEMI 200 (42%) 307 (48%) .

21 Koronarográfia aránya Infarct Registry GOKI 11.01.01-11.12.31.

22 Revaszkularizáció módja Infarct Registry GOKI 11.01.01-11.12.31
STEMI n= 307

23 PCI STEMI-ben Célparaméterek
„door-to-balloon time” max. 90 perc helyett a„first medical contact-to-ballon time < 90 perc Emergens CABG-re max. 2%-ban kerüljön sor PCI-ra a betegek min. 85%-ban kerüljön sor A kórházi halálozás legyen 7%-nál kevesebb (CS-t kivéve)

24 STEMI D2BT rates Infarct Registry GOKI 11.01.01-11.12.31.
D2B from 90 to 60 minutes associated with 0.8% Mortality D2B from 60 to 30 minutes associated with 0.5% Mortality (Rathore et al, 2009 BMJ 338:b1807)

25 PCI STEMI-ben Célparaméterek
„door-to-balloon time” max. 90 perc helyett a„first medical contact-to-ballon time < 90 perc Emergens CABG-re max. 2%-ban kerüljön sor PCI-ra a betegek min. 85%-ban kerüljön sor A kórházi halálozás legyen 7%-nál kevesebb (CS-t kivéve)

26 Kórházi halálozás Infarct Registry GOKI 11.01.01-11.12.31.
STEMI n=307

27 PCI STEMI-ben Célparaméterek
„door-to-balloon time” max. 90 perc helyett a„first medical contact-to-ballon time < 90 perc Emergens CABG-re max. 2%-ban kerüljön sor PCI-ra a betegek min. 85%-ban kerüljön sor A kórházi halálozás legyen 7%-nál kevesebb (CS-t kivéve)

28 Point of entry: FIRST MEDICAL CONTACT Infarct Registry GOKI 10. 01

29 TRANSPORT: SPRINT VS. WALKING Infarct Registry GOKI 10.01.01-12.31

30 STEMI TRANSZPORT: PANASZ-AJTÓ KÉSÉS mediánja Infarct Registry GOKI 11

31 STEMI TRANSZPORT : PANASZ-BALLON KÉSÉS (teljes ischaemiás késés) MEDIÁNJA INFARCT REGISTRY GOKI „ Real world” PRIMER TRANSPORT: = min SECUNDER TRANSPORT: = 477 min Primer vs. Secunder : min „ Ideal world”

32 STEMI SYSTEME: Mit jelent a késés? „az idő szívizom”

33 A teljes ischaemiás késés megoszlása betegeinknél

34 Ideális ellátás: mindössze 9%. Infarct Registry GOKI 11. 01. 01-11

35 Mit jelent a késés? 1 éves mortalitás (%) Ischaemiás idő (perc)
Circulation 2004; 109:

36 Infarct Registry GOKI: üzenet 01.01.11-12.31.11
Ideális ellátásban a betegek töredéke részesült annak ellenére, hogy intézetünk mortalitási és kezelési mutatói jók. A STEMI ellátás szervezése túlmutat az ajtó –ballon idő problematikáján. A teljes ischaemias késés csökkentése a cél. Sürgető a prehospitális késési idő csökkentése és így a STEMI ellátás minőségének javítása. A média és az orvosok szerepe kulcsfontosságú a lakosság tájékoztatásában (tartós fájdalom esetén hívj mentőt….. )

37 Nemzeti Infarktus Regiszter a STEMI (ACS) ellátás indikátora
„ Primary Percutaneous Coronary Intervention (PPCI) is the most complex, multi-disciplinary, and time-sensitive therapeutic intervention in the world of medicine. - Our process is measured in Minutes -Our outcomes are measured in terms of Mortality Teamwork and smooth Transitions are essential” Ivan C. Rokos, MD, FACEP, FAHA, (FACC) Emergency Physician Asst. Clinical Professor, UCLA Staff Physician, Olive View-UCLA Staff Physician, Northridge Hospital Los Angeles, CA