Evidencias sobre el tratamiento del IAM en 2010

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