Riyadh 14th February 2013
Changing Pattern of STEMI and the New European Guidelines Carlo Di Mario, MD, PhD, FACC, FRCP, FESC Consultant Cardiologist Royal Brompton & Harefield Trust, London UK EAPCI Past-President; ESC Councillor Member Executive Committee SfL Programme
FAST-MI Registry
(STEMI patients only)
USIK 1995
1536 STEMI
USIC 2000
1844 STEMI
FAST-MI 2005
FAST-MI 2010
1611 STEMI
1716 STEMI
6707 patients in all 4 surveys N. Danchin | Munich ESC 2012
Current smoking
Obesity
Men
Women
N. Danchin | Munich ESC 2012
ESC STEMI Guidelines 2003
Frans van der Werf
Reperfusion therapy in STEMI patients (changes over time)
Early/Rescue PCI: 9.9% Any PCI after lysis: 15%
24% 60%
58% 84%
N. Danchin | Munich ESC 2012
55% 87%
30-d Mortality
(changes over time)
Evolution
Multivariable-adjusted risk Adjusted for age, sex, BMI, risk factors, previous history, and use and type of reperfusion therapy
N. Danchin | Munich ESC 2012
Evolution of 30-day mortality according to use and type of reperfusion therapy
N. Danchin | Munich ESC 2012
11
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
STEMI 2012 Guidelines: Regional Network is recommended for STEMI patients management
Di Mario, Kristensen, Wijns, Widimsky, Fajadet Eds EuroIntervention 2012, SfL Supplement
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
Di Mario, Kristensen, Wijns, Widimsky, Fajadet Eds EuroIntervention 2012, SfL Supplement
UK STEMI Mortality
Di Mario et al (Eds) EuroIntervention 2012, SfL Suppl.
Di Mario et al (Eds) EuroIntervention 2012, SfL Supplement
New treatment timing goals
Radial access and culprit lesion treatment are recommended in pPCI
Study 2010 ESC-EACTS RIVAL Myocardial Revascularisation Guidelines
Study 2010 ESC-EACTS RIVAL Myocardial Revascularisation Guidelines
EuroIntervention, on-line February 2013
Thrombus aspiration but not liberal use IABP are recommended in pPCI
TAPAS: 1,071 pts with STEMI undergoing primary PCI randomized to manual aspiration (Export) vs. control Aspiration nonused/totally ineffective in ~ 40% pts!
Vlaar, Zijlstra et al. Lancet 2008
Residual Thrombus after 3 Passes
10 Days post-BMS After withdrawal ASA/Clop for GI Bleed
Residual Thrombus after 3 aspirations
Small thrombus prolapse post-stent
Proximal edge dissection
Thrombus residual (as percentage of pre-treatment amount detected with OCT)
Residual Thrombus expressed as Percentage of the initial thrombus Mass
Inefficiency of Drug Delivery and Manual Thrombectomy
ReoPro
Infuse
Abiciximab Infusion Prati et al.
Imola et al.
ExportPost-PCI Magro et al.
From Prati, Imola et al 2010
Aspiration Trials to Decrease Infarct Size Infarct Size (Nuclear) and Thrombectomy 25
Control
Aspiration
100
20
) V L (% e iz ts rc fa In
5
7.5
9
63
58
50
CPK
11
- M B
15
15 10
75
25
P=0.004
P=0.20
0
P=0.46 0
Kaltoft et al (n=225)
Expira (n=175)
TAPAS (n=1071)
Rescue catheter
Export catheter
Export catheter
Kaltoft A et al. JACC 2006;114:40-47
Sardella G et al. JACC 2009;53:309–15
Svilaas T et al. NEJM 2008;358;-557-67
INFUSE-AMI Trial 452 pts with anterior STEMI Anticipated Sx to PCI <5 hrs, TIMI 0-2 flow in prox or mid LAD Primary PCI with bivalirudin anticoagulation Pre-loaded with aspirin and clopidogrel 600 mg or prasugrel 60 mg
R 1:1
Stratified by symptoms to angio <3 vs ≥3 hrs, and prox vs mid LAD occlusion
Manual aspiration
No aspiration
R 1:1
R 1:1
IC Abcx
No Abcx
IC Abcx
No Abcx
Primary endpoint: Infarct size at 30 days (cMRI) 2º endpoints: TIMI flow, blush, ST-resolution, MACE (30d, 1 yr) Stone GW et al. JAMA 2012
INFUSE-AMI: Infarct size at 30 days Median [IQR]
Median [IQR]
17.0%
17.3%
Infarct size, %LV
[9.0, 22.8]
[7.1, 25.5]
P=0.51
Aspiration N=229
No aspiration N=223 Stone GW et al. JAMA 2012
Thrombus aspiration but not liberal use IABP are recommended in pPCI
CRISP AMI Study RIVAL Study 2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
Results
Primary Study Endpoint (30-Day Mortality) 50 Control
Mortality (%)
40
41.3% 39.7%
IABP 30
20 P=0.92 by log-rank test Relative risk 0.96; 95% CI 0.79-1.17; P=0.69 by Chi 2-Test 10
0
0
5
10
15
20
25
30
Time after Randomization (Days) H. Thiele | DE | 2799
Thiele et al N Engl J Med. 2012;367:1287-96.
2010 ESC-EACTS Myocardial Revascularisation Guidelines
2010 ESC-EACTS Myocardial Revascularisation Guidelines
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