www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
The new ESC Guidelines in STEMI
Stefan James,
Dept. of Cardiology and Uppsala Clinical Research center
Uppsala Sweden
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Potential conflicts of interest
• AstraZeneca Pharmaceuticals Research grant/consultant, Ad board
• Daiichi Sankyo Company Research grant/consultant,
• Eli Lilly and Company Research grant/consultant. Ad board
• Sanofi-Aventis Honoraria. Ad board
• The Medicines Company Honoraria
• BMS Research grant/consultant
• Merck Honoraria/consultant
• Medtronic Research grant/consultant, Ad board
• Boston Scientific Research grant/consultant
• Cordis Honoraria/consultant
• Terumo Inc Research grant/consultant
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Indicated
Not
recommendedMay
consider
Should
consider
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Logistics of pre-hospital care
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Procedural aspects of primary PCI
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Procedural aspects of primary PCI
Death, MI, Stroke or non-CABG major Bleed
Subgroups: Primary OutcomeR I V A L
0.251.00 4.00
Radial better Femoral better
Hazard Ratio (95% CI)
<75≥75
FemaleMale
<2525-35>35
≤70
70-142.5>142.5
Lowest TertileMiddle TertileHighest Tertile
NSTE-ACSSTEMI
Age
Gender
BMI
Radial PCI Volume by Operator
Radial PCI Volume by Centre
Diagnosis at presentation
Overall
0.786
0.356
0.637
0.536
0.021
0.025
Interactionp-value
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Procedural aspects of primary PCI
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Procedural aspects of primary PCI
TAPAS, total mortality at 1 year
Vlaar, P.J. et al. NEJM 2008, 371: 1915
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
SWEDE HEART
SCAAR
Randomized
All primary PCI:s
6846 patients
TASTE
Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia
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Periprocedural anti thrombotic medication in
primary PCI
HR 0.84
(0.77–0.92)
p=0.0003
NNT = 54
Days after randomization
0 60 120 180
12
11
10
9
8
7
6
5
4
3
2
1
0
Cu
mu
lati
ve
in
cid
en
ce
(%
)
9.8
11.7Clopidogrel
Ticagrelor
Wallentin L, et al. N Engl J Med. 2009;361:1045-57.
Primary Endpoint
(CV death, MI, Stroke)
CV deathClopidogrel
Ticagrelor
4.0
5.1 HR 0.79
(0.69–0.91)
p=0.001
NNT = 90
N=18,624
0
5
10
15
0 30 60 90 180 270 360 450
HR 0.81
(0.73-0.90)
P=0.0004
Prasugrel
Clopidogrel
Days
En
dp
oin
t (%
)
12.1
9.9
HR 1.32
(1.03-1.68)
P=0.03
Prasugrel
Clopidogrel1.8
2.4
138
events
35
events
Balance of
Efficacy and Safety
CV Death / MI / Stroke
TIMI Major
NonCABG Bleeds
NNT = 46
NNH = 167
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Periprocedural anti thrombotic medication in
primary PCI, con’t
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
FINESSE
Ellis et a NEJM 2008
Platelet Aggregation results
J.J. Smit et al. Am Heart J 2006
OnTIME-2 HD tirofiban
OnTIME-1 LD tirofiban
HD
R. Hermanides et al. Heart 2010
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Periprocedural anti thrombotic medication in
primary PCI, con’t
30 Day Mortality
Number at risk
Bivalirudin 1800 1758 1751 1746 1742 1729 1666
Heparin + GPIIb/IIIa 1802 1764 1748 1736 1728 1707 1630
Death
(%
)
Time in Days
3.1%
2.1%
HR [95%CI] =
0.66 [0.44, 1.00]
P=0.048
Heparin + GPIIb/IIIa inhibitor (n=1802)
Bivalirudin monotherapy (n=1800)
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Periprocedural anti thrombotic medication in
primary PCI, con’t
Main Secondary Endpoint (ischemic) Death, Recurrent ACS or Urgent Revascularization
0 5 10 15 20 25 30
0.0
00
.05
0.1
00
.15
Days
Ma
in s
eco
nda
ryE
Pra
te
UFHENOX
Log-Rank Test
p=0.0111.3%
6.7%
30d rate (%)
i41%
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Routine therapies in the acute, subacute and long term phase of STEMI
Primary Endpoint
No. at Risk
24-Month Clopidogrel 987 925 884
6-Month Clopidogrel 983 919 881
Overall Death, MI or CVA
24 mo DAPT 6 mo DAPT%
10.0
Hazard Ratio: 0.98 (0.74-1.29)
10.1
0 180 360 540 720
12
8
4
0
P=0.91
CEC adjudicated
Key Safety Endpoint
No. at Risk
24-Month Clopidogrel 987 925 884
6-Month Clopidogrel 983 919 881
Type II, III or V BARC bleeding
24 mo DAPT 6 mo DAPT%
3.5
Hazard Ratio: 0.46 (0.1-0.69)
7.4
P=0.00018
CEC adjudicated
0 180 360 540 720
12
8
4
0
Peterson et al, ACC 2004
Link Between Overall ACC/AHA Guidelines Adherence and Mortality
Every 10% in guidelines adherence
11% in mortality
www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215
Conclusion
The STEMI guidelines aim to guide towards
evidenced based therapies
Review them critically
Consider updating your local protocols and
personal preferences
Adherence to guidelines improves outcomes