Acute MI A Balanced and Rational Approach

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Acute MI A Balanced and Rational Approach

• Haim Hammerman MD, FESC
• RAMBAM Health Campus
• Rappaport Faculty of Medicine
• Israel Institute of Technology - Technion
• Haifa, ISRAEL

Tel Aviv 5.12.2006
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Acute MI A Balanced and Rational Approach

• The quality of care provided to patients
  hospitalized STEMI leaves room for improvement.
• Recent studies provide evidence of shortfalls in
  the overall use of guideline-recommended
  treatment and inappropriate variations in
  treatment, including by race, gender, geographic
  location, and time and day of presentation

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PTCA vs FibrinolysisShort Term Clinical
Outcomes (23 RCTs)
PTCA
Plt0.0001
Fibrinolysis
Plt0.0001
Frequency ()
P0.0002
P0.0003
Plt0.0001
P0.032
P0.0004
Plt0.0001
Death
Death, no SHOCKdata
ReMI
Rec. Isch
Total Stroke
Hem. Stroke
Major Bleed
DeathMICVA
N 7739
Keeley E. et al., Lancet 2003 36113-20.
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STEMI 30 years of established reperfusion

• The important thing is not to stop questioning.
  
• Einstein

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Is primary PCI superior to fibrinolysis for all
patients ?

• Although primary PCI may yield better clinical
  outcomes than fibrinolytic therapy when delivered
  promptly and at experienced centers, a large
  number of patients may not accrue this benefit
• Despite growing evidence that PCI yields better
  outcomes, fibrinolysis remains the most common
  form of reperfusion therapy in AMI because of
  limited capacity for primary PCI at most
  hospitals in the world

NO !
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REAL WORLD MI THERAPY
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Type of reperfusion treatment MINAP ( Myocardial
Infarction National Audit)
Birkhead JS
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Management of STEMI in Israel
ACSIS ACS Israeli Surveys 2000-2006
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Acute MI A Balanced and Rational Approach

• However beautiful the strategy, you should
  occasionally look at the results
• Winston Churchill

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Pre-hospital, in-hospital fibrinolyis or PCI
Boersma E. NEJM 2000342890-892
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Pre Hospital Lysis versus Prim PCI for STEMI
Impact of Time in CAPTIM
PNS
PNS
P0.058
P0.007
lt 2 hours(N 460)
gt 2 hours(N 374)
Symp-Rand
G Steg et al Circulation 2003
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CAPTIM Mortality at different time points
26 of patients had rescue PCI
Steg PG. Circulation 20031082828-2830
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French USIC 2000 survey real world
USIC. Circulation 20041101909-1915
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n 1,922
USIC. Circulation 20041101909-1915
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STEMI Transport for Primary PCI
study DANAMI-2 PRAGUE-1 PRAGUE-2 LIMI AIR-PAMI
CAPTIM TOTAL
transported (n) 559 101 429 75 71 421 1656
distance 3-150 km 5-74 km 5-120 km 25-50
km 10-69 km 1-100 km 3-150 km
death transport 0 0 2 0 0 0 2 (0.1)
randomization to first balloon 90 min
80 min 97 min 85 min 155 min
82 min gt50 lt 90 min
Without PAMI
Medium
Mean
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Door to Balloon Times Among Patients Transferred
in NRMI 4
Data to Cath Lab Arrival 50th 132 Min. 25th
88 Min. 75th 219 Min.
Door to Data 50th 9 Min. 25th 4 Min. 75th 16
Min.
Cath Lab to Balloon 50th 37 Min. 25th 28
Min 75th 50 Min.
9
132
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Total Door 1 to Balloon Time 185 minutes
(25th 137 75th 276) Percent of Patients with
Door to Balloon Time lt 90 Min. 3.0
Sample Size 1,346 Time Period January 2002
December 2002
www.acc.org/clinical/ guidelines/stemi/index.pdf.
pg.61
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In-hospital mortality and DBT in patients
stratified by risk factor status.
Risk factors include anterior/septal location,
diabetes mellitus, heart rate gt100 beats/min,
systolic blood pressure lt100 mm Hg.
McNamara et al. J Am Coll Cardiol 2006472180
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Short-term mortality referral trials
Referral trials
Primary PCI
Fibrinolysis
PRAGUE-1(n 200)
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14
7
10
PRAGUE-2(n850)
8
12
AIR-PAMI(n138)
LIMI(n150)
7
7
DANAMI-2(n1129)
6.5
8.5
total
6.8
9.6
P 0.01
P NS for each trial respectively
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Fibrinolysis vs Transfer for PCI
Pre Hosp Primary In Hosp
Lysis PCI
Lysis CAPTIM CAPTIM DANAMI 2 DANAMI
2 Death () 3.8 4.8 6.6 7.6 1yr
5.4 7.3 Reinfarction () 3.7 1.7 1.6 6.3 Disa
bling CVA () 1.0 0.0 1.1 2.0 Any of Above
() 8.2 6.2 8.0 13.7 ( P lt
0.003) Vahanian ESC, 2002
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OR and 95 CI for 30-day death in pts. randomized
to PPCI when compared with FL according to
presentation delay and PCI-related delay
Boersma, E. et al. Eur Heart J 2006 27779-788
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Comparision of Mortality Among STEMI Patients
Receiving Prehospital Thrombolysis or Primary PCI
With In-Hospital Thrombolysis, 1999-2004
Stenestrand, U. et al. JAMA 20062961749-1756.
.
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Unadjusted Cumulative Mortality During the First
Year After the Index Event Admission
Stenestrand, U. et al. JAMA 20062961749-1756.
.
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Estimated Cumulative Mortality for Patients
Receiving Reperfusion Treatment Within or After 2
Hours of Symptom Onset
Stenestrand, U. et al. JAMA 20062961749-1756.
.
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Age-Adjusted and Propensity Score-Adjusted
Mortality According to Time to Reperfusion and
Type of Therapy
Stenestrand, U. et al. JAMA 20062961749-1756.
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PCI- related delay in STEMI

• Pinto, D. S. et al. Circulation
  20061142019-2025

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Adjusted analysis illustrating significant
heterogeneity in the PCI-related delay (DB-DN
time) for which the mortality rates with primary
PCI and fibrinolysis were comparable after the
study population was stratified by prehospital
delay, location of infarct, and age
Pinto, D. S. et al. Circulation 20061142019-2025
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Multivariable analysis estimating the treatment
effect of reperfusion therapy with PCI or
fibrinolysis based on increasing PCI-related delay
Pinto, D. S. et al. Circulation 20061142019-2025
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PCI- related delay in STEMI

• In the total study population, there was a 10
  increase in RR of in-hospital death with every
  30-minute increase in the PCI-related delay.
• The survival benefit of primary PCI over
  fibrinolytic therapy was lost when the
  PCI-related delay was 114 min. ( in-hospital
  mortality equipoise),

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PCI- related delay in STEMI

• PCI-related delay beyond which the survival
  benefit of primary PCI was lost varied
  considerably, depending on the patients
  characteristics.
• The shortest mortality equipoise (less than 1
  hour) was found in patients lt65 years anterior
  MI within 2 hours after symptom onset
• The longest (almost 3 hours) in patients gt65
  years nonanterior MI gt 2 hours after symptom
  onset.

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Mortality rates with primary PCI as a function of
PCI-related delay
Circle sizes sample size of the individual
study. Solid line weighted meta-regression.
BenefitFavors PCI
62 min
HarmFavors Lysis
For Every 10 min delay to PCI 1 reduction in
mortality difference towards lytics
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Multivariate analysis strategies to reduce D-B
time

• Activation of cath lab by ED - 8.2 min.
• Single call to central page operator -13.8 min.
• Activation by ED while patient en-route to
  hospital 15.4 min.
• Expecting arrival within 20 min. 19.3 min.
• Attending cardiologist on site - 14.6 min.
• Real time data feedback 8.6 min.
• Despite the effectiveness of these strategies,
  only a minority of hospitals use them

Bradely EH et al.
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Who should we treat ?
Is primary angioplasty for some as good as
primary angioplasty for all?
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Kent DM et al. JGIM 200217887
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Is primary angioplasty for some as good as
primary angioplasty for all?

• Assuming a constant relative risk reduction, 68
  of all mortality benefits in our community-based
  patient sample could be captured by treating only
  those patients in the highest quartile of
  mortality risk and 87 of the benefit could be
  captured by treating those in the highest half.
• Meta-regression of the results from the 10
  clinical trials suggests that patients with a
  mortality risk of less than 2 may be unlikely to
  receive any mortality benefit.
• Most of the incremental benefits of primary
  angioplasty can be achieved by treating high-risk
  patients.

Kent DM et al. JGIM 200217887
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An inverse relationship was observed between the
rate of PCI and the risk status of the patients,
irrespective whether the patient sustained UA,
NSTEMI or STEMI
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Conclusions
A Balanced and Rational Approach

• Primary PCI is a better reperfusion therapy for
  STEMI than in-hospital fibrinolytic therapy when
  it is performed soon after the onset of symptoms
  by an experienced team.
• Both the American and the European guidelines
  recommend that PPCI should be done within 90 min.
  of presentation or "PCI - related delay of
• 60 minutes
• It is hard to beat the results of fibrinolysis in
  the first hour!

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A Balanced and Rational Approach
Conclusions

• The decision in hospitals with PCI facultiesPPCI
  is the preferred form of therapy, but the systems
  need to be in place to perform this
  expeditiously, 7 days a week and 24 h a day.
• Poor outcomes associated with a long PCI-related
  delay are not because of the long delay time
  alone but also because of the overall quality of
  care offered to the patients
• Realistic considerations of the time it takes to
  implement such a strategy in a specific real
  world clinical setting are crucial
• Decisions regarding triage of patients for PPCI
  should thus be based on an assessment of time and
  risk

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Thank You