når biomarkører bidrager til præhospital diagnostik · esc guidelines selection of...
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AARHUSUNIVERSITET
Når biomarkører bidragertil præhospital diagnostik
Christian Juhl Terkelsen,Overlæge, Dr.med., PhD,
Hjertesygdomme,Aarhus Universitetshospital.
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AARHUSUNIVERSITET
Aarhus University Hospital, Denmark
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AARHUSUNIVERSITET
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AARHUSUNIVERSITET
STEMI NSTEMIOHCA
Bedre overlevelseOptimale patientforløb
Kortere indlæggelse / Undgå indlæggelseUndgå dobbeltundersøgelser
Mere sundhed for samme midler
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AARHUSUNIVERSITET
Kilde: En ”Helhjertet indsats”,
Hjerteforeningen
NSTEMI
STEMI
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AARHUSUNIVERSITET
Kilde: En ”Helhjertet indsats”,
Hjerteforeningen
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AARHUSUNIVERSITET
Overlevelse blandt patienter med præhospitalthjertestop for de enkelte regioner
Kilde: En ”Helhjertet indsats”,
Hjerteforeningen
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AARHUSUNIVERSITET
STEMI NSTEMIOHCA
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AARHUSUNIVERSITET
ESC guidelines
Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS) treatment strategy and timing according to initial risk stratification.2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
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AARHUSUNIVERSITET
KAG < 2 timer
KAG < 24 timer
KAG < 72 timer
ESC guidelines
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AARHUSUNIVERSITET
STEMI NSTEMIOHCAKan vi ikke bare diagnosticere dem iambulancen og køre direkte til center ?
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AARHUSUNIVERSITET
NONSTEMI-I
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AARHUSUNIVERSITET
Design:
500 patients, randomized,
open labelled, intention to treat,
prehospital/acute hospital randomization
Primary endpoint:
Composite of death, re-infarction and
readmission with congestive heart
failure within one year from
randomization
NONSTEMI trial
Either Point-of-care
Troponin-T ≥ 50 ng/L
orSignificant ST-
segment depression
Randomization
Acute
angiography
Conventional
therapy
Acute
chest pain
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AARHUSUNIVERSITET
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Final diagnosis
Acute coronary syndrome 86.5%
NSTEMI 66.9%
STEMI 9.5%
STEMI visible at
inclusion7.7%
STEMI after inclusion 1.8%
BBB myocardial infarction 1.0%
Unstable angina pectoris 9.1%
Other 13.5%
NSTEMI
STEMI
BBBMI
Unstable AP
Other
0%
10%
90%
70%
80%
100%
60%
50%
40%
20%
30%
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AARHUSUNIVERSITET
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99.7
90.6
51.1
1.3
47.8
1.0
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AARHUSUNIVERSITET
NONSTEMI-II
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AARHUSUNIVERSITET
NONSTEMI-2: Data from all-comers
17
Cases in total 18,712
POC-cTnT ≥ 50 ng/L 2,150(11,5%)
POC-cTnT< 50 ng/L 16,562(88,5%)
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AARHUSUNIVERSITET
Prehospital POC-cTnT measurementsN = 18,712
POC-cTnT ≥ 50 ng/LN = 2,150
AMIN = 966
No AMIN = 1,184
POC-cTnT < 50 ng/LN = 16,562
AMIN = 1,221
No AMIN = 15,341
Diagnostic properties
POC-cTnT ≥ 50 ng/L
(N=2,150)
Sensitivity 44.2
Positive predictive value 44.9
POC-cTnT < 50 ng/L
(N=16,562)
Specificity 92.8
Negative predictive value 92.6
POC-cTnT measurements performed
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AARHUSUNIVERSITET
Mortality
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AARHUSUNIVERSITET
Mortality
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AARHUSUNIVERSITET
NONSTEMI-III
Routine use of “NONSTEMI”- algorithm: All suspected high-risk NST-ACS patients triaged for tertiary PCI capable center. Acute/subacute CAG.
Støttet af Hjerteforeningen
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AARHUSUNIVERSITET
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AARHUSUNIVERSITET
Case – ”Gunnars”story
›61years old, active life
›AMI x 2 (last 2007), normal LVEF
28km
116km
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AARHUSUNIVERSITET
Case – ”Gunnars”story
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AARHUSUNIVERSITET
KAG
Før Efter
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AARHUSUNIVERSITET
Case – ”Gunnars”story
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AARHUSUNIVERSITET
NONSTEMI-III
Routine use of “NONSTEMI”- algorithm: All suspected high-risk NST-ACS patients triaged for tertiary PCI capable center. Acute/subacute CAG.
Aktuelt omvisiteres ca. 350 patienter med NSTEMI direkte til AarhusUniversitetshospital hvert år.
Sparer vi 700 indlæggelsesdage ?
Kan det kopieres til øvrige regioner ?
Støttet af Hjerteforeningen
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AARHUSUNIVERSITET
AROMI
Kan vi helt undgå indlæggelse ?
90% med brystsmerter jo ikke AMI !
Accelerated Rule Out of acute Myocardial Infarction
- using prehospital Copeptin and in-hospital hs-Troponin
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AARHUSUNIVERSITET
Biomarker kinetics in AMI:copeptin + troponin
• Copeptin rises early- covers blind period
• Copeptin is optimally bemeasured early – troponin late
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AARHUSUNIVERSITET
AROMI
Randomization
Standard rule-out:In-hospital hs-cTn at arrival
+ In-hospital hs-cTn at 3 hours
Suspected AMI
Accelerated rule-out:Pre-hospital copeptin
+ In-hospital hs-cTn at arrival
In both groups:- AMI is ruled out if both biomarkers are normal
- Further diagnostics, incl. hs-troponin in discretion of the attending physician
Design:RCT, N=4800 (ca. 4000 inkluderet)
Aim:To evaluate:
1. Length of stay2. MACE-rate.
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AARHUSUNIVERSITET
AROMI
Kan vi helt undgå indlæggelse ?
Hvis normal Copeptin + Troponin i ambulance ?
Accelerated Rule Out of acute Myocardial Infarction
- using prehospital Copeptin and in-hospital hs-Troponin
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AARHUSUNIVERSITET
STEMI NSTEMIOHCA
Bedre overlevelseOptimale patientforløb
Kortere indlæggelseUndgå indlæggelse
Undgå dobbeltundersøgelserMere sundhed for samme midler