Networking for optimal treatment of STEMI and NSTEMI. European Stent for life Project
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1 Networking for optimal treatment of STEMI and NSTEMI European Stent for life Project Dariusz Dudek on behalf of Department of Interventional Cardiology, Institute of Cardiology, Krakow, Poland The European Association on Percutaneous Cardiovascular Interventions (EAPCI)
2 Stent for Life a new initiative William Wijns
3 The value of PCI for stable CAD is being challenged In patients with stable CAD, PCI does not provide survival benefit, unless large proportions of the myocardium are at risk Health Technology Assessment of PCI for symptomatic indications is not favourable DEFER / COURAGE / SYNTAX / FAME
4 Scientific Evidence Urgent revascularisation, using PCI or bypass is a life-saving procedure in patients presenting with acute CAD and is recommended by ESC Guidelines for all patients with STEMI as well as for high-risk NSTEMI patients
5 Role of PCI for Acute CAD ESC Guidelines recommend PCI as an essential treatment modality for all forms of acute CAD (not just STEMI) Time constraints are variable, but significant in all instances Providing this service to the public will require re-engineering of existing invasive facilities in many areas William Wijns
6 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 7 1 Spectrum of Reperfusion Therapy for STEMI across Europe P-PCI TL No reperfusion P. Widimsky et al, submitted
7 In-hospital mortality of all STEMI patients in countries with p-pci dominance vs. countries with thrombolysis dominance % , ,5 All STEMI mortality PCI countries TL countries P. Widimsky et al, submitted
8 Guidelines on Treatment of Acute CAD Recommendations from ESC Practice Guidelines Class LOE PPCI for STEMI (< 12 hours & < 2 hours FMC to balloon) Rescue PCI for failed fibrinolysis (< 12 hours) I IIa A A PCI for STEMI with shock and contraindications to fibrinolytic therapy irrespective of time delay I B Angiography and PCI after successful lysis (< 24 hours) IIa A Urgent PCI for NSTE-ACS with hemodynamic instability (< 2 hours) I C Early PCI for high-risk NSTE-ACS (< 72 hours) I A
9 Reperfusion strategy paradox Most people think, that thrombolysis is a kind of treatment widely available everywhere, while p- PCI is limited in its availability The opposite is true: far more patients receive reperfusion treatment in countries with low use of thrombolysis and high use of p-pci Best practice examples demonstrate that urgent PCI can be delivered in different environments P. Widimsky et al, submitted
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11 Stent for Life Deliverables To increase the use of primary PCI towards >70% use among all STEMI patients To achieve primary PCI rates >600 / million per year in most European countries Empower PCI centers to offer 24/7 services for primary PCI William Wijns
12 Int J Cardiol Nov 24. [Epub ahead of print]
13 + Aortic dissection + Pulmonary embolism + Critical limb ischemia + Percutaneous AVR olkuski 114,7 tys. miechowski 51,5 tys. proszowicki 43,6 tys. Kraków + krakowski 998,8 tys. dąbrowski 58,6 tys. chrzanowski 128,7 tys. bocheński 99,7 tys. oświęcimski 153,1 tys. wadowicki 153,4 tys. wielicki 102,5 tys. brzeski 89,7 tys. Tarnów + tarnowski 310,5 tys. myślenicki 114,9 tys. suski 81,5 tys. limanowski 120,2 tys. nowotarski 179,9 tys. Nowy Sącz + nowosądecki 279,4 tys. gorlicki 106,4 tys. tatrzański 65,3 tys. NEWORK OF CATHLABS FOR DIAGNOSIS AND TREATMENT OF HIGH- RISK PATIENTS: LMCA, MVD, SURGERY, HYBRID PROCEDURES, ADVANCED IMAGING, STRUCTURAL HEART DISEASES
14 miechowski 51,5 tys. olkuski 114,7 tys. chrzanowski 128,7 tys. Kraków + krakowski 998,8 tys. proszowicki 43,6 tys. 1808,8 tys. bocheński 99,7 tys. dąbrowski 58,6 tys. 558,5 tys. oświęcimski 153,1 tys. wadowicki 153,4 tys. wielicki 102,5 tys. brzeski 89,7 tys. Tarnów + tarnowski 310,5 tys. suski 81,5 tys. myślenicki 114,9 tys. limanowski 120,2 tys. 506 tys. nowotarski 179,9 tys. 261,4 tys. Nowy Sącz + nowosądecki 279,4 tys. gorlicki 106,4 tys. tatrzański 65,3 tys. NETWORKS OF HOSPITALS FOR EARLY INVASIVE DIAGNOSIS AND TREATMENT OF ACUTE CORONARY SYNDROMES
15 Malopolska Registry of Acute Coronary Syndromes Time delays in small network 0.5 million population Nowy Sacz limanowski 120,2 tys. 506 tys. Nowy Sącz + nowosądecki 279,4 tys. gorlicki 106,4 tys. FMC cathlab Cathlab balloon 34 ± 23 min (median = 30 min) 32 ± 9 min (mediana = 30 min) FMC balloon 66 ± 26 min (mediana = 60 min) EUROTRANSFER Registry Nowy Sacz < 90 min < 120 min < 150 min
16 Malopolska Registry of Acute Coronary Syndromes Treatment strategies in small Network 0.5 million population Nowy Sacz limanowski 120,2 tys. 506 tys. STEMI < 12 godz. Nowy Sącz + nowosądecki 279,4 tys. gorlicki 106,4 tys. 1% 11% PRIMARY PCI THROMBOLYSIS 88% NO REPERFUSION Dudek D. et al. Kardiol. Pol. 2008;66:
17 Malopolska region Primary PCI Networks for STEMI & NSTEMI treatment olkuski 114,7 tys. miechow ski 51,5 tys. Kraków + krakowsk i 998,8 tys. proszowi cki 43,6 tys. dąbrows ki 58,6 tys. bocheńsk i wielicki 99,7 tys. Tarnów + 102,5 tys. brzeski 89,7 tys. tarnowski 310,5 tys. miechow ski 51,5 tys. olkuski 114,7 tys. proszowi Kraków + cki dąbrows ki 43,6 tys. 58,6 tys. krakowsk i 998,8 tys. bocheńsk i wielicki 99,7 tys. Tarnów + 102,5 tys. brzeski 89,7 tys. tarnowski 310,5 tys. limanows ki 120,2 tys. gorlicki 106,4 tys. limanows ki 120,2 tys. gorlicki 106,4 tys. STEMI: 340 PPCIs / 1 mln STEMI:737 PPCIs / 1 mln STEMI & NSTEMI PPCIs/1 mln increased availability, of delays NSTEMI:347 PPCIs / 1 mln
18 NSTEMI Should the strategy be different than in STEMI patients?
19 STEMI vs NSTEMI rokowanie w ciągu roku od wypisu ze szpitala ESC Guidelines 2007
20 Algorithm for the management of patients with NSTEACS Initial evaluation STEMI ACS possible Other diagnosis Validation and risk assessment Urgent strategy Persistent or recurrent angina with/without ST changes ( 2mm) or deep negative T resistant to antianginal treatment Clinical symptoms of heart failure or progressing hemodynamic instability Life-threatening arrhythmias (VF,VT) Early strategy (<72 h) Elevated troponin levels Dynamic ST/T changes (symptomatic or silent) Diabetes mellitus Renal dysfunction (GFR <60 ml/min/1.73m 2 ) Reduced LV function (EF<40%) Early post-infarction angina Prior MI Prior PCI within 6 months Prior CABG Intermediate to high GRACE risk score No / elective No reccurrence of chest pain No signs of heart failure No new ECG changes (arrival and at 6-12 h) No elevation of troponins (arrival and at 6-12 h) Eur Heart J Jul;28(13):
21 Malopolska region Primary PCI for NSTEMI / 1million population olkuski 114,7 tys miechow ski 51,5 tys. Kraków + krakowsk i 998,8 tys proszowi cki 43,6 tys dąbrows ki 58,6 tys. bocheńsk i 0 wielicki 99,7 tys. Tarnów + 102,5 tys brzeski 89,7366 tys. tarnowski ,5 tys limanows ki 120,2 tys gorlicki 106,4 tys PPCIs / 1 mln
22 TIMACS: early (<24h) vs delayed invasive (>36h) strategy in UA and NSTEMI patients Early strategy Delayed strategy 30 HR 1.14 ( ) HR 0.65 ( ) death, MI, or stroke (six months) ,7 P=0.43 6,7 P= ,6 14,1 0 Low/intermediate risk (n=2070) High risk (n=961) GRACE score <140 GRACE score 140 AHA 2008
23 Future directions Shortening of time delays Patient with STEMI / NSTEMI in remote hospital/ ambulance Cath lab Angiography PCI Adjunctive pharmacotheraphy Prasugrel, Bivalirudin
24 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines GPIIb/IIIa Inhibitors in STEMI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) Type of GPIIb/IIIa Inhibitor abciximab - IIa A tirofiban IIb B eptifibatide IIb C abciximab IIa A tirofiban IIa B eptifibatide IIa B Upfront use of GPIIb/IIIa Inhibitor no recommendation IIb B 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
25 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Thienopyridines during primary PCI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) Clopidogrel at least 300 mg, preferably 600 mg (I C) at least 300 to 600 mg (I C) Prasugrel no recommendation 60 mg as soon as possible (I B) 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
26 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Anticoagulation during primary PCI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) Antithrombin therapy during primary PCI UFH (I C) Bivalirudin (IIa B) Fondaparinux (III B) UFH (I C). Bivalirudin (I B) Bivalirudin in patients with high risk of bleeding (IIa B) Switch from UFH to Bivaluridin allowed 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
27 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Triage and transfer for PCI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) The implementation of network of hospitals connected by an efficient ambulance (helicopter) service and using a common protocol is key an optimal management of patients with STEMI. With such a network in place, target delay times should be: <10 min for ECG transmission; 5 min for tele-consultation; <30 min for ambulance arrival to start fibrynolytic therapy; and 120 min for ambulance arrival to first balloon inflation. Quality of care, appropriateness of reperfusion therapy, delay times and patients outcomes should be measured and compared at regular times and appropriate measures for improvement should be taken. (discussed but no exact recommendations) Each community should develop a STEMI system of care that follows standards at least as stringent as those developed for the AHA s national initiative, Mission: Lifeline, to include the following: ongoing multidisciplinary team meetings that include emergency medical services, non PCI-capable hospitals/stemi referral centers, and PCI-capable hospitals/stemi receiving centers to evaluate outcomes and quality improvement data; a process for prehospital identification and activation; destination protocols for STEMI receiving centers; transfer protocols for patients who arrive at STEMI referral centers who are primary PCI candidates, are ineligible for fibrinolytic drugs, and/or are in cardiogenic shock. (IC) 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
28 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Triage and transfer for PCI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) Angiography during hospital stay after fibrynolytic therapy: Evidence of failed fibrynolysis or uncertainty about success: immediate (IIa B) Recurrent ischemia, reocclusion after initial successful fibrynolysis: immediate (I B) Evidence of successful fibrynolysis: within 3-24h after start of fibrynolytic therapy (IIa A) It is reasonable for high-risk patients who receive fibrinolytic therapy as primary reperfusion therapy at a non PCI-capable facility to be transferred as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (IIa B) KRAKOW Network Experience Patients who are not at high risk who receive fibrinolytic therapy as primary reperfusion therapy at a non PCI-capable facility may be considered for transfer as soon as possible to a PCI-capable facility where PCI can be performed either when needed or as a pharmacoinvasive strategy. Consideration should be given to initiating a preparatory antithrombotic (anticoagulant plus antiplatelet) regimen before and during patient transfer to the catheterization laboratory (IIb C). 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
29 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Use of Stents in STEMI ESC STEMI 2008 (1) ACC/AHA focused updates 2009 (2) (no exact recommendations) DES as an alternative to a BMS for primary PCI in STEMI (IIa B) 1 Eur Heart J. 2008;29(23): Circulation. 2009;120:
30 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Timing of Antiplatelet Therapy in UA/NSTEMI ESC NSTEACS 2005 (1) ACC/AHA focused updates 2009 (2) Aspirin (I A) Clopidogrel 300 mg loading-dose (I A); Clopidogrel 600 mg may be used to achieve more rapid inhibition of platelet function (IIa B) Aspirin (I A) Clopidogrel (before or at the time of PCI) (I A) no recomendation for prasugrel Prasugrel (at the time of PCI) (I B) 1 Eur Heart J Jul;28(13): Circulation. 2009;120:
31 Current ESC STEMI & PCI Guidelines vs Focused Updates of ACC/AHA STEMI Guidelines & ACC/AHA/SCAI PCI Guidelines Timing of Angiography in UA/NSTEMI ESC NSTEACS 2005 (1) ACC/AHA focused updates 2009 (2) Urgent for unstable patients (I C) Early (<72 h) in intermediate to highrisk patients (I A) Urgent for unstable patients Early (within 12 to 24 h) (IIa B) Shortening of the time to angiograhy/pci 1 Eur Heart J Jul;28(13): Circulation. 2009;120:
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