έΰζβν αππ έκυ,νσϊίία κν1γν πλδζέκυνβί1γ π ηία δεόμνκαλ δκζόΰκμ, θν δ υγυθ άμνγνκαλ /εάμ ΚζδθδεάμΝ υλωεζδθδεάμν

Transcription

1 ΝΠθ ζζάθδκνσθϋ λδκν έΰκ μνεδν ιωθκ κεκη δεάμνι λδεάμ έΰζβν έκ,νσϊίί κν1γν λδζέκνβί1γ Α Α φ ; έζ δκμννένσθόμ ηί δεόμνκλ δκζόΰκμ, θν δ γθ άμνγνκλ /εάμ ΚζδθδεάμΝ λωεζδθδεάμν ένivus Scientific Director, Mediolanum Cardiac Research (MCR), ΜδζΪθκ

2 Η If I had an enemy I would teach him angioplasty Andreas Gruentzig, 1980 (ref: Kereiakes et.al.,jacc 2005: )

3 Η Δ Α φ stent «stand-by» ζ φ ( θ Ϋθω β) θ

4 Α stent

5 Stent: Η Greater Acute Lumen Gain Half the restenosis rate of Balloon Angioplasty at midterm fu Benestet, N Engl J Med 1994

6 E φ > U.S.A. Europe CABG M. Rotter et al, Eur Heart Journal 2003 PCI

7 ! Α «,,»

8 :Η In-stent restenosis is the result of either Stent underexpansion or Development of Intimal Hyperplasia or Both mechanisms V Spanos et al. The challenge of in-stent restenosis: insights from intravascular ultrasound review article (Eur Heart J Jan;24(2): )

9 φ stent (drug-eluting stents) Stent Polymer Sousa JE et al. Lack of Neointimal Proliferation After Implantation of Sirolimus-Coated Stents in Human Coronary Arteries : A Quantitative Coronary Angiography and Three-Dimensional Intravascular Ultrasound Study ( Circulation. 2001;103: )

10 Ηέ έαέ βίίθ Ηέ έαέ 1λλλ R. Lange et al, N Engl J Med 2006

11 φ If fibrous cap ruptures, coagulation factors in blood can gain access to thrombogenic, tissue factor containing lipid core, causing thrombosis on nonocclusive atherosclerotic plaque. φ Occlusive thrombi may arise from superficial erosion of endothelial layer. Resulting mural thrombus can cause acute myocardial infarction. P. Libby: Current Concepts of the Pathogenesis of the Acute Coronary Syndromes (Circ. 2001;104: )

12 φ «Acute coronary syndrome has evolved as a useful operational term to refer to any constellation of clinical symptoms that are compatible with acute myocardial ischaemia. It encompasses AMI (STsegment elevation and depression, Q wave and nonq wave) as well as UA» ACC/AHA 2002 Guideline Update for Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction ( J Am Coll Cardiol 2002; 40: )

13 Spanos V, et al.: Treatment of Acute Myocardial Infarction (AMI) with Embolus Aspiration. (In: Rothman M, ed. Case Studies in Interventional Cardiology. 6th ed: Martin Dunitz Ltd; 2003:86-91) Μ

14 Α vs. Θ Μ 14,0% 9,0% 7,0% P = Θ Α 8,0% P < Θ ή φ ή φ Θ Keeley EC et al. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials ( Lancet Jan 4;361(9351):13-20 )

15 Α Procedure Μ Indication If thrombolysis failed within min after starting the administration IB Routine post-thrombolysis coronary angiography and PCI Up to 24 h after thrombolysis, independent of angina and/or ischaemia IA Ischaemia-guided PCI after successful thrombolysis Pre-discharge angina and/or ischaemia after (first) STEMI treated with thrombolysis IB Rescue PCI Silber S. et al. Guidelines for percutaneous coronary interventions: the task force for percutaneous coronary interventions of the European society of cardiology(eur Heart J Apr;26(8):804-47)

16 Α Μ REACT φ ή φ φ ή Μ ST λί φ ή θ ρηίσ φ 1κΣ vs. 9% Silber S. et al. Guidelines for percutaneous coronary interventions: the task force for percutaneous coronary interventions of the European society of cardiology(eur Heart J Apr;26(8):804-47)

17 φ φ, GRACIA 14,0% 12,0% 9,0% 7,0% P = 0.07 Θ / φ Angio/PCI P = Θ ή φ ήpci Ischemia guided Fernandez F. et al. Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for AMI with ST-segment elevation (Lancet Sep 18;364(9439): )

18 PCI) Μ Η 9% βίίλ ( (primary μ )- 30% βί11

19 Μ φ ή Μ Widimsky P, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial-prague-2(eur Heart J Jan;24(1): )

20 :Μ FINESSE, ASSENT 4 Α FINESSE Reteplase & abciximab vs Abciximab only vs. un-facilitated primary PCI ASSENT 4 TNK-facilitated primary PCI vs primary PCI with GP IIb/IIIa inhibitor as needed The ASSENT 4 steering committee today released a statement reporting that the trial was suspended on April 21, 2005, after the enrolment of 1635 of the planned 4000 patients, because of an unexpectedly superior outcome in patients randomised to the direct PCI-only arm ( 26 Α 2005)

21 Θ Μ STREAM φ 1892 pts with STEMI who presented within 3 hours and unable to undergo PCI within 1 hour Randomized to primary PCI or bolus tenecteplase before transport to a PCIcapable hospital The primary end point: composite of death, shock, congestive heart failure, or reinfarction up to 30 days. Armstrong P, et al. Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction (N Engl J Med 2013; 368: )

22 φ «Acute coronary syndrome has evolved as a useful operational term to refer to any constellation of clinical symptoms that are compatible with acute myocardial ischaemia. It encompasses AMI (STsegment elevation and depression, Q wave and nonq wave) as well as UA» ACC/AHA 2002 Guideline Update for Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction ( J Am Coll Cardiol 2002; 40: )

23 FRISC-II, ή φ 14,1% 12,1% 10,4% 9,4% P = P = β 6 Ά φ φ Π Cannon CP, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban ( N Engl J Med. 2001;344: )

24 TACTICS-TIMI 18, ή φ 9,5% 7,3% 7,0% 4,7% P < 0.05 P = Ά θ φ φ Π Cannon CP, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban ( N Engl J Med. 2001;344: )

25 φ φ ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (European Heart Journal 2011:32, )

26 φ φ Age Diabetes previous MI ST depression Hypertension body mass index and treatment strategy were found to be independent predictors of death and non-fatal MI There was a % absolute reduction in cardiovascular death or MI in the low and intermediate risk groups and an 11.1% absolute risk reduction in the highest risk patients Fox K, et al. Early Invasive vs Conservative Treatment Strategies in Women and Men With Unstable Angina and Non ST-Segment Elevation Myocardial Infarction: A Meta-analysis (JAMA. 2008;300(1):71-80)

27 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non STElevation Myocardial Infarction (J Am Coll Cardiol. 2012;60(7): doi: /j.jacc )

28 E : ISAR-COOL Neumann F. et al. Evaluation of Prolonged Antithrombotic Pretreatment ("Cooling-Off" Strategy) Before Intervention in Patients With Unstable Coronary Syndromes (JAMA. 2003;290: )

29 E : ISAR-COOL In the early intervention group only 1 event occurred before catheterization, whereas the longer duration of pretreatment in the prolonged antithrombotic pretreatment group resulted in 13 precatheterization events Neumann F. et al. Evaluation of Prolonged Antithrombotic Pretreatment ("Cooling-Off" Strategy) Before Intervention in Patients With Unstable Coronary Syndromes (JAMA. 2003;290: )

30 Ηέ έαέ βίίθ Ηέ έαέ 1λλλ R. Lange et al, N Engl J Med 2006

31 Α ( ); Δ Η φ!

32 Α vs. φ ACME : Μ 64% 46% 2.1min P < P < Angina free PCI 0.5min Increase in Exercise Time Medical Treatment Parisi A, et al. A comparison of angioplasty with medical therapy in the treatment of single vessel coronary artery disease (N Engl J Med. 1992;326:10 16 )

33 Α vs. φ : Μ COURAGE Time point PCI (%) Medical therapy (%) p Baseline NS Year <0.001 Year Year NS Boden WE, et al. Optimal medical therapy with or without PCI for stable coronary disease (N Engl J Med 2007;356: )

34 Μ COURAGE PCI Medical therapy p Physical limitation 6 mo 12 mo 36 mo Angina frequency 6 mo 12 mo 36 mo QoL 6 mo 12 mo 36 mo Boden WE, et al. Optimal medical therapy with or without PCI for stable coronary disease (ACC 2007, )

35 Κ COURAGE PCI (%) Medical Hazard therapy (%) ratio 95% CI p Death, MI Death, MI, stroke Death Nonfatal MI Stroke Hospitalization for ACS Revascularization (PCI or CABG) <0.001 Boden WE, et al. Optimal medical therapy with or without PCI for stable coronary disease (N Engl J Med 2007;356: )

36 Κ φ Pool Wilson P, et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial (Lancet, 364: )

37 Α ); Δ φ (!

38 Α ΝβΝ ΝγΝ Ε Δ CABG ΝΣ : χ ω Ν Ν Ν φ χ Ν Ν Ν Ν ΝΚ Ν( )Ν!

39 ESω Τ EχωTS Guidelines on Myocardial Revascularization Eur Heart J 2010; 31(20): 2501-

40 LMCA subgroup in SYNTAX trial 357 pts with PES vs. 348 pts with CABG 4 year results for Syntax in LM subsets

41 The EXCEL Trial (Xience Prime stent vs. CABG) Pts with LMCA disease and Syntax score <33 Primary end point: Death/MI/CVA (2600 pts/3 years fu/124 centres in 17 countries) IVUS strongly encouraged Direct stenting discouraged Provisional SB stenting encouraged Angiographic fu NOT permitted!

42 :Μ LIPS Lee C, et al. Beneficial effects of fluvastatin following percutaneous coronary intervention in patients with unstable and stable angina: results from the Lescol intervention prevention study (Heart 2004;90: )

43 Μ ΗΝ Α Ωφ Ν Α ΜΑ Α ( φ Ν ή φ Ε Ν Νχω Ν, ) Ν ΝST, Ν ΝST,

44 Μ ΗΝ Η Ν φ Α ΜΑ Α φ Ν χ Ν Ν Ν ω Ν Ν Ν Ν CABG ω Ν Ν Ν Ν Ν Ν Ν

45