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CHRISTOS GRAIDIS
Euromedica – Kyanous Stavros, Cardiology Department, Thessaloniki
Interventional Cardiovascular Education 2010
Congress Hall ‘Du Lac’
Ioannina, 9-11 December, 2010
PRIMARY PCI: Location, Presentation and Transfer
time change our decision
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Death From A Heart Attack
The most effective treatment of STEMI is timely restoration of blood flow to the
infarcting myocardium (reperfusion). The earlier this is achieved, the greater will
be the amount of myocardium saved, improving short- and long-term clinical
outcomes.
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The relationship among the duration of symptoms of STEMI
before reperfusion therapy, mortality reduction and extent of
myocardial salvage
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Reperfuse faster!
Reperfuse better!
- Stop myocardial injury
- Restore normal myocardial metabolism
- Prevent reperfusion injury
- Enhance myocyte recovery
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From the HELIOS data it is evident that, unfortunately, around 40% of STEMI patients
do not receive any form of reperfusion therapy and that prehospital fibrinolysis is
practically non-existent.
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It is well known that fibrinolytic therapy is less efficacious in restoring blood flow in the
IRA when the interval between the onset of symptom and treatment increases and this is
more evident beyond a cut-off of 3 h. In contrast, the successful opening of the infarct
related artery in patients undergoing primary PCI is less dependent on symptom duration,
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Symptom onset EMS call Arrival at
PCI centerPPCI
Treatment Delay
Transportation
delay
Local hospital
delay
interhospital
delay
Patient
delay
Healthcare system delay
D2B
delay
Arrive at local
hospital
Departure from
local hospital
Arrival at PCI
centerTransferred
from local
hospitals
Patient
delay Transportation
delay D2B delay
Healthcare system delay
PPCI
PCI center
Treatment Delay
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The relative risk of 1-year mortality increases by
7.5% for each 30-minute delay
“Saving Time, Saving Lives”
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Those presenting to a non-PCI-capable facility should be
triaged to fibrinolytic therapy or immediate transfer for PCI.
• Decision depends on multiple clinical observations that
allow judgment of:
– mortality risk of the STEMI
– risk of fibrinolytic therapy
– duration of the symptoms when first seen
– time required for transport to a PCI-capable facility
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Brodie BR JACC 2006
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NRMI 2,3,4
452,544
Reperfusion Eligible
STEMI Patients
1963 Hospitals
Transfer Out
Patients
n=119,235
Missing Time Intervals
n=13,137
Did Not Receive PCI
or Fibrinolytic Therapy
as Initial Reperfusion
n=89,524
Study Population
192,509 Patients
645 Hospitals
230,648 Patients
1860 Hospitals
≥20 STEMI Patients Treated
Treatment of ≥10 Patients With Primary PCI
and ≥10 Patients With Fibrinolytic Therapy
CM Gibson 2006. Pinto DS, et al. Circulation. 2006;114:2019-2025.
Implications of Hospital Delays for Selection
of Reperfusion Strategy in STEMI
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Acceptable PPCI-related delay (calculated as the difference of door-to-balloon
minus door-to-needle intervals) in relation to age of the patient, infarct
localisation and symptom duration in the NRMI registry.
Longer delays in the individual groups will result in a better outcome with
fibrinolysis compared to PPCI
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F rom an emerg enc y phys ic ian’s point of view, thes e
data are of outs tanding importanc e, s inc e it s eems to
be nearly impos s ible to trans fer a young er patient
with an anterior infarc tion from a non-P C I-c apable
hos pital to a P C I c entre and ac hieve firs t balloon
inflation within 40 min, as required.
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P rimary P C I -Data bas ed on:
a.Hig h volume c enters
b.E xperienc ed operators
c .S hort res pons e time(delay)
R eal world data
RESULTS DO NOT NECESSARILY APPLY IN OTHER
SETTINGS
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Nallamothu B K , B ates E R , Herrin J , et al. T imes to treatment in transfer patients undergoing
primary percutaneous coronary intervention in the US . National R egis try of Myocardial Infarction
(NR MI)-3/4 Analys is . C irculation 2005; 111:761-767
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Is hig h volume operators / c enter nec es s ary?
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Delays in time to treatment: it
may take longer to get to the
hospital at night.
F ewer doctors on duty so it
may take longer to be
assessed and treated.
P rocedure more likely to be
conducted by a low-volume
operator.
O perator would be less likely
to be able to get a second
opinion or help
Having a s trong team c an als o reduc e the impac t of individual
s kill levels bec aus e there are people available for help and
s ec ond opinions .
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A C C /A HA /S C AI G uideline update for perc utaneous c oronary
intervention 2005
T he numbers are very c rude meas ures , and many thing s are not fac tored in,
inc luding the c umulative lifetime experienc e of an operator. F or example,
an operator who has been in prac tis e for 10 years and has done 5000 c as es may
need fewer c as es per year than s omeone in the early s tag e of their c areer.
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F ac ilitated P C I is a s trateg y of thrombolys is immediately followed by P C I,
with a planned door-to-balloon time of 90 to 120 minutes
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Median time from lytics to PCI was 1.9 hours
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Meta-analysis:
Facilitated PCI vs
Primary PCI
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Pharmacoinvasive therapy means giving
thrombolysis at a non-PCI facility and then promptly and
systematically transferring the patient to a PCI facility, where
PCI is performed 3 to 24 hours after the start of thrombolytic
therapy, regardless of whether thrombolysis results in
successful reperfusion. Thus, the time to PCI is longer than
with facilitated PCI
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E arly routine perc utaneous c oronary intervention after
fibrinolys is vs . s tandard therapy in S T-s eg ment elevation
myoc ardial infarc tion: a meta-analys is
F ranc es c o B org ia, E uropean Heart J ournal (2010) 31, 2156–2169
A total of 2961 patients were enrolled, of whom 1471 patients
were randomized to s tandard S TE MI therapy and 1490 patients
to a routine invas ive s trateg y with early P C I within 24 h after
s uc c es s ful fibrinolys is .
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Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST
segment elevation myocardial infarction: a meta-analysis
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Median time from lytic s to P C I was 2.7
hours
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Median time from lytic s to P C I was 3.9 hours
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Rescue PCI refers to PCI that is performed urgently if
thrombolysis fails, failure being defined as:
�persistent hemodynamic or electrical instability,
�persistent ischemic symptoms,
�or failure to achieve at least a 50% to 70% resolution of
the maximal ST-segment elevation 90 minutes after the
infusion is started.
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R educ ing T ime to Treatment Delays : P re-hos pital
F ibrinolys is
Pre-hospital fibrinolysis was associated with 1 hour earlier reperfusion therapy and
1 life saved for every 62 patients treated pre-hospital
6434 patients
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Following pre-hospital fibrinolysis, the ambulance should transport the patient to a 24 h a day/7 days a week
PCI facility
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Finally, it is important to note that under certain circumstances, transfer may
remain the best option for reperfusion even when prolonged times to treatment
are anticipated.
Primary PCI is recommended for
patients:
1.ineligible for fibrinolytic
therapy
2.in cardiogenic shock
3.Delayed presentation
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Patients presenting between 12 and 24 h and possibly up to 60 h from symptom
onset, even if pain free and with stable haemodynamics, may still benefit from early
coronary angiography and possibly PCI.
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2010
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Even with an optimal network
organization, transfer delays may be
unacceptably long before primary PCI
is performed
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First Medical Contact
(FMC)-to –balloon <90
min
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Improving healthcare easier said than done