I COSTI DELL'INFARTO MIOCARDICO ACUTO

1
TRATTAMENTO in RETE INTEROSPEDALIERA di un
INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee
Guida alla Realtà Clinica) Nazario
Carrabba Cardiologia 1 - Dipartimento del Cuore
e dei Vasi, Azienda Ospedaliera - Universitaria
di Careggi, Firenze Firenze, 15 Marzo
2008 EDUCATORIO del FULIGNO
Difendiamo il cuore Campagna Educazionale
Regionale ANMCO Toscana
2
Primary PTCA vs Thrombolysis for AMI Review of
23 Randomized Trials. Long- term Outcome

PTCA n 3872 Pz
plt 0.0001
Thrombolysis n 3867 Pz
plt 0.0001
p 0.0019
p 0.0053
plt 0.0001
Death
Death, Non Fatal MI or Stroke
Death excluding Shock
Non Fatal MI
Recurrent Ischemia
Keeley EC, Lancet 2003 361 13-20
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The Transfer for Primary AngioplastyThe
Evidences

• According to ESC guidelines (and AHA/ACC
  guidelines too) when primary angioplasty is
  available in a timely fashion and procedure can
  be performed by an experienced operator in a
  large volume centre, primary PCI should be
  considered the preferred reperfusion strategy
• However, which is the best modality of
  reperfusion treatment for patients admitted to
  community hospitals without invasive facilities
  is less clear

4
The Importance of Time to Transfer
The time delay for transferring patients to PCI
centers could reduce or even nullify the
potential benefit of reperfusion
Gersh, B. J. et al. JAMA 2005293979-986
5
ACC/AHA Guidelines for the Management of Patients
With ST-Elevation Myocardial InfarctionExecutive
Summary A Report of the American College of
Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to
Revise the 1999 Guidelines for the Management of
Patients With Acute Myocardial Infarction)
Writing Committee Members Elliott M. Antman,
MD, FACC, FAHA, Chair Daniel T. Anbe, MD, FACC,
FAHA Paul Wayne Armstrong, MD, FACC, FAHA Eric
R. Bates, MD, FACC, FAHA Lee A. Green, MD, MPH
Mary Hand, MSPH, RN, FAHA Judith S. Hochman, MD,
FACC, FAHA Harlan M. Krumholz, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA Gervasio A.
Lamas, MD, FACC Charles J. Mullany, MB, MS,
FACC Joseph P. Ornato, MD, FACC, FAHA David L.
Pearle, MD, FACC, FAHA Michael A. Sloan, MD,
FACC Sidney C. Smith, Jr, MD, FACC, FAHA
(Circulation. 2004110588-636.)
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ACC/AHA Guidelines for the Management of Patients
with ST-Elevation Myocardial Infarction
Class I. If immediately available, primary PCI
should be performed in patients with STEMI
(including true posterior MI) or MI with new or
presumably new LBBB who can undergo PCI of the
infarct artery within 12 hours of symptom onset,
if performed in a timely fashion (balloon
inflation within 90 minutes of presentation) by
persons skilled in the procedure (individuals who
perform more than 75 PCI procedures per year).
The procedure should be supported by experienced
personnel in an appropriate laboratory
environment (performs more than 200 PCI
procedures per year, of which at least 36 are
primary PCI for STEMI, and has cardiac surgery
capability). (Level of Evidence A)
(Circulation. 2004110588-636.)
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ACC/AHA Guidelines for the Management of Patients
with ST-Elevation Myocardial Infarction
Strict performance criteria must be mandated for
primary PCI programs so that long door-to-balloon
times and performance by low-volume or
poor-outcome operators/laboratories do not occur.
Interventional cardiologists and centers should
strive for outcomes to include
(1) door-to-balloon times less than 90 minutes
(2) TIMI 2/3 flow rates obtained in more than 90
of patients
(3) emergency CABG rate less than 2
(4) actual performance of PCI in gt85 of patients
brought to the lab
(5) risk-adjusted in-hospital mortality rate less
than 7 in patients without cardiogenic shock.
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Caso clinico numero 1
Nazario Carrabba, MD
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Caratteristiche Cliniche del Paziente

• Maschio, 59 anni
• Fattori di rischio cardiovascolare Fumatore,
  Ipercolesterolemia, Diabete
• Riferisce da circa 5 ore dispnea e dolore
  toracico posteriore
• Killip class 1

Nazario Carrabba, MD
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Primo ECG eseguito
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Iter Diagnostico-Terapeutico?

• Ricovero nellUTIC più vicina per eseguire
  fibrinolisi
• 2. Fibrinolisi in ambulanza (pre-ospedaliera)
• 3. PCI facilitata (trombolitici/inibitori
  IIb/IIIa prima del trasferimento per PCI - 2
  ambulanze -)
• 4. Trasferimento diretto in sala di emodinamica
  per una PCI (2-ambulanze)

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Trasferimento per una PCI una scelta appropriata?
13
Coronaria destra
14
ECG post-angioplastica primaria
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The Florence Reperfusion Experience
Spontaneous organization with Spoke centers
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FLORENCE DISTRICT REGISTRYLocation of the
Participating Hospitals
Florence District 2,205 Kmq 798.000 residents 33
municipalities Careggi Hospital 2 PCI centers 5
community
hospitals Distance range 5-33 Km
N
Mugello H 33 km/20 miles
Careggi 2 PCI centers
OSMA 12 km/7 miles

NSGD 7 km/4 miles
SMN 5 km/3 miles
Historic area
Urban area
Figline H 33 km/20 miles
Chianti area
Mugello area
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Use of Reperfusion Treatment March 1, 2000 to
February 28, 2001
746 reperfusion treatment eligible patients (lt12h)
No reperfusion treatment n274 (36.7 )
Reperfusion treatment n472 (63.3 )
91.5 with P- PCI (n432 patients)
7.4 with thrombolysis (n35 patients)
1.1 rescue PCI (n5 patients)
Buiatti E. Eur Heart J. 2003241195-203
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Underuse of Reperfusion Therapy in Registry
Studies
60

50
40
No Reperfusion
30
20
10
0
Delay (h)
Period
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AMI-Florence Registry In-hospital and 6-month
Mortality
30
Plt.000
25
20
Plt.000

15
14.9
24.4
10
9.1
5
5.7
0
In hospital
6 months
Reperfusion therapy
No reperfusion therapy
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Factors Influencing the use of Reperfusion by
Multivariate Regression Analysis
HR 95 CI 0.97 0.96 -
0.99 0.26 0.11 - 0.65
0.55 0.33 - 0.93 0.91
0.84 - 0.99 0.32 0.21 -
0.50 0.44 0.24 - 0.83
0.59 0.39 - 0.88 7.8 5.1
- 11.8
Age (years) Previous CHF Previous MI Time
delaygt6 h Non anterior MI Killip gtII Non-office
hours Hospitals with P-PCI facilities
0
3
6
1
9
0.5
Increased probability
Reduced probability
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Caso clinico numero 2
Nazario Carrabba, MD
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Caratteristiche Cliniche del Paziente

• Donna, 62 anni
• Fattori di rischio cardiovascolare Ipertensione
  arteriosa, ipercolesterolemia,
• Riferisce da gt12 ore fastidio epigastrico,
• Killip class 3

Nazario Carrabba, MD
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Primo ECG eseguito
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Iter Diagnostico-Terapeutico?

• Ricovero nellUTIC più vicina per eseguire
  fibrinolisi
• 2. Fibrinolisi in ambulanza (pre-ospedaliera)
• 3. PCI facilitata (trombolitici/inibitori
  IIb/IIIa prima del trasferimento per PCI - 2
  ambulanze -)
• 4. Trasferimento diretto in sala di emodinamica
  per una PCI (2-ambulanze)

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Trasferimento per una PCI una scelta appropriata?
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Coronaria Destra
27
Coronaria Sinistra
28
ECG post-angioplastica primaria
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Study Population
746 Patients
Admitted to hospitals with PCI facilities n351
(47)
Admitted to hospitals without PCI facilities
n395 (53)
On-site P-PCI n286 (81.5)
Transf. for P-PCI n146 (37)
Presented ESC-2006
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Kaplan-Meier Survival Curves by Hospital of
Admission

100
91.3
On-site P-PCI
89.7
Transf. P-PCI
75
50

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Log rank test p 0.305
0
0
2
4
6
Time (months)
Presented ESC-2006
31
Kaplan Meyer survival curves after 3 years
comparison between on-site and after transferal
primary PCI.
log-rank test plt0.20

Variables independently associated
with the risk of death at 3 years.
Paper submitted
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Transfer for Primary Angioplasty Evidences
Metanalysis considering five randomized Trials
(n2909) ( CAPTIM, n3750) showed a benefit of
transfer for primary PCI compared to on-site
fibrinolysis in term of combined endpoint (death,
reinfarction, stroke)
Dalby, M. et al. Circulation 20031081809-1814
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BRAVE-2 Trial Asymptomatic patients with STEMI
and symptom onset gt 12 h

13
Final Infarct size
8
Invasive strategy
Conservative strategy
Schömig, A. et al. JAMA 20052932865-2872
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Should patients with STEMI and symptom onset gt 12
h be treated with PCI?
Schömig, A. et al. JAMA 20052932865-2872
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Practical Messages

• The policy of transferring STEMI patients with
  symptom onset lt12 h initially admitted to
  community hospitals to centres which offer
  primary PCI seem feasible and safe, with the
  useful window for transfer of 90 min.

• For patients with STEMI and symptom onset ?12 h
  (8-31 of all patients with STEMI), the transfer
  from community hospitals to PCI centres could
  represent a missed opportunity. However, more
  trials are needed to confirm this policy.

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CONCLUSIONE
Indipendentemente dal tipo di rete
interospedaliera che si viene a realizzare,
deve essere perseguito lobiettivo di garantire
il trattamento riperfusivo più rapido ed efficace
al maggior numero possibile di pazienti.
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AHA Consensus Statement Recommendation to
Develop Strategies to Increase the Number of
ST-SegmentElevation Myocardial Infarction
Patients With Timely Access to Primary
Percutaneous Coronary Intervention The American
Heart Associations Acute Myocardial Infarction
(AMI) Advisory Working Group Alice K. Jacobs,
MD, FAHA, Chair Elliott M. Antman, MD, FAHA
Gray Ellrodt, MD David P. Faxon, MD, FAHA Tammy
Gregory George A. Mensah, MD, FAHA Peter Moyer,
MD Joseph Ornato, MD, FAHA Eric D. Peterson,
MD, FAHA Larry Sadwin Sidney C. Smith, MD, FAHA
(Circulation. 20061132152-2163)
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Guiding Principles

• Patient-centered care as the No. 1 priority
• High-quality care that is safe, effective, and
  timely
• Stakeholder consensus on systems infrastructure
• Increased operational efficiencies
• Appropriate incentives for quality, such as "pay
  for performance," "pay for value," or "pay for
  quality"
• Measurable patient outcomes
• An evaluation mechanism to ensure quality-of-care
  measures reflect changes in evidence-based
  research, including consensus-based treatment
  guidelines
• A role for local community hospitals so as to
  avoid a negative impact that could eliminate
  critical access to local health care
• A reduction in disparities of healthcare
  delivery, such as those across economic,
  education, racial/ethnic, or geographic lines

39
Guiding Principles

• Patient-centered care as the No. 1 priority
• High-quality care that is safe, effective, and
  timely
• Stakeholder consensus on systems infrastructure
• Increased operational efficiencies
• Appropriate incentives for quality, such as "pay
  for performance," "pay for value," or "pay for
  quality"
• Measurable patient outcomes
• An evaluation mechanism to ensure quality-of-care
  measures reflect changes in evidence-based
  research, including consensus-based treatment
  guidelines
• A role for local community hospitals so as to
  avoid a negative impact that could eliminate
  critical access to local health care
• A reduction in disparities of healthcare
  delivery, such as those across economic,
  education, racial/ethnic, or geographic lines

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Grazie