Evidencias sobre el tratamiento del IAM en 2010
Casa del Coraz贸n, 10 de junio de 2010
Hitos en el manejo del SCACEST 19601º etapa: MONITORIZACION
1980
- desfibrilador externo (Lown) - “Intensive Cardiac Care Unit” (Julian) - monitorizacion ECG ------ desfibrilación
2º etapa: RECANALIZACION
2010
- fibrinolisis - angioplastia primaria - coronariografia precoz
Recomendaciones Sociedades Científicas
Proteger del riesgo de muerte repentina por fibrilaci贸n ventricular Reperfundir el miocardio en v铆as de necrosis de forma inmediata
Beneficio de la trombolisis en funciĂłn del retraso inicio sĂntomas - tratamiento
retraso tto (h)
fibrinolisis mejor
control mejor
0-1 1-2 2-3 3-6 6-12 12-24 0.5
1.0
RRR Meta-anĂĄlisis: - 22 estudios (>100 pts) - 50.246 pts (1983-93)
1.5
vidas salvadas / 1000 pts tratados
Mortalidad (35 dĂas) 80 60 40 20 0 0
3
6
9
12
15
18
21
24
retraso tratamiento (horas) Boersma et al. Lancet 1996;348:771-75
Primary PCI vs Thrombolysis in STEMI: Meta-analysis (23 RCTs, N=7739) 25
Frequency (%)
20
Short-term Outcomes (4-6 weeks)
P<.0001
P<.0001 15 P=.0002
P<.0001
PCI
P=.032
10
Thrombolytic therapy
5 0
P<.0001
Death
Nonfatal MI
Recurrent HemorIschemia rhagic Stroke
Major Bleed
Death, Nonfatal Reinfarction, or Stroke
Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.
Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals
Rathore, S. S et al. BMJ 2009;338:b1807 Copyright Š2009 BMJ Publishing Group Ltd.
Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals
Door-to-balloon 30 minutes 60 minutes 90 minutes 120 minutes 150 minutes 180 minutes
Hospital mortality 3.0% 3.5% 4.3% 5.6% 7.0% 8.4% p<0.001
Rathore, S. S et al. BMJ 2009;338:b1807
p < 0.001 for trend comparison
Taher T, et al. J Am Coll Cardiol 2004;44:38â&#x20AC;&#x201C;43
CAPTIM: 1 Year Mortality Delay < 2 hours
Delay â&#x2030;Ľ 2 hours
P=0.057
P=0.47 5,7%
5,9%
5% 3,7% 2,2%
0%
Pre Hospital Lysis
Primary PCI
0%
Pre Hospital Lysis
Primary PCI
Steg P, et al Circulation 2003; 108:2851-6.
Fibrinolisis vs Angioplastia
Diferencias en mortalidad Riesgo Absoluto, %
Importancia de los retrasos 15
10
5 ACTP mejor
0
Fibrinolisis mejor
â&#x20AC;&#x201C;5 0
23 estudios (n= 7419) p=0.006
20
40
60
80
100
Retraso en la ACTP, min Nallamothu and Bates, AJC, 2003;92:824-6
2008 STEMI ESC GUIDELINES
Key questions at presentation:
?
- Delay from onset? - PCI capability at this time? - Lysis contraindicated?
Widinsky P, et al. Eur Heart J 2009
Reperfusion therapy for ST elevation MI Spain vs Europe (2004) 43% 32% 25%
36%
33% 26%
5%
Espinosa MA, et al. Rev Esp Cardiol 2009;9:3C-10C
P-PCI Lysis Facilitated PCI No Reperfusion
Reperfusion therapy for ST elevation MI in Spain (2008)
P-PCI* 7873
TNK** 12300
* Data from SHCI 2008 Spanish Registry ** Data provided by Boehringer Ingelheim Espa単a, S.A.
2008 STEMI ESC GUIDELINES