Sergio Berti

1
Dal territorio alla preservazione della funzione
ventricolare
Versilia 7-8 ottobre 2011

• Sergio Berti
• Fondazione CNR-Reg. Toscana G. Monasterio
• Ospedale del Cuore, Massa

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(No Transcript)
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Importance of Prompt Treatment

• Prompt treatment increases the likelihood of
  survival for patients with myocardial infarction
  with ST-segment elevation (Berger et al., 1999
  Cannon et al., 2000, McNamara et al., 2006).

McNamara et al., JACC, 2006
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Mortality and Doorn to Balloon Time
Ting HH, et al. Circulation 2007116729-736
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Beyond a D2B of 90 minutes.Every 15-min delay
adds mortality
(Nallamothu 2007 NEJM 3571631)?
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2008 ESC STEMI GUIDELINESKey Messages remain
unchanged

• Early diagnosis
• Reperfusion therapy as soon as possible
• Optimal secondary prevention

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Ritardo Evitabile
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Fonti di possibili ritardi tra comparsa sintomi e
inizio terapia riperfusiva
Problema
Soluzione
Ritardo del paziente Tempo tra la comparsa
sintomi e chiamata 118
Educazione del paziente
Ritardo nel trasporto
Strategia organizzativa 118
Ritardo inizio del trattamento
Strategia organizzativa Inter-intraospedaliera
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Strategia concordata
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Modello di Rete per lemergenza coronarica
Obiettivi
Favorire una diagnosi precoce, un trasporto
rapido ed un ottimale trattamento riperfusivo a
tutti i pazienti
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La realtà italiana la Rete
Documento di consenso La rete interospedaliera
per lemergenza coronarica

• FIC
• SICI
• SIMEU
• SIS 118

IHJ Nov. 2005 Vol.6/Suppl.6
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365 Hospitals
E. H. Bradley, N Engl J. Med 13, 2006335
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32 Items
28 Key hospital strategies
Six strategies associated with a faster door to
balloon time
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Door to Balloon Times Achieving 90 Minutes and
Less

W. Douglas Weaver, MD President-Elect
ACC November 2007
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Strategies that Reduce Treatment Delays

• 1. ED physician activates the cath lab
• 2. Single call activates the cath lab
• 3. Cath lab team ready in 20-30 minutes
• 4. Prompt data feedback for case review
• Pre-hospital ECG to activate the cath lab while
  patient is en route
• Having attending cardiologist always on site

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D2B Alliance Goal

• Goal
• To achieve a door-to-balloon time of 90
  minutes for at least 75 of non-transfer primary
  PCI patients with STEMI

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D2B Alliance Participants

• Over 900 hospitals currently participating
• Representing 45 states and 8 countries

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2008-2010
CAMPAGNA RITARDO EVITABILE
RITARDO EVITABILE
La Campagna presentata in tutte le Regioni ha
proposto una semplice scheda di automisurazione
dei dati Disponibili i dati dei Centri che
hanno accettato di centralizzare i dati
Salvare il miocardio dei Pazienti con SCA
ottimizzando tempi e modalità di soccorso e
di intervento medico
In tutte le Regioni la Campagna ha coinvolto
Cardiologi, 118, Medicina Urgenza, Assessorati e
Agenzie
COORDINAMENTO F. Chiarella
L. Oltrona Visconti
A. Di Chiara
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Obiettivo
Un intervento mirato ai singoli Ospedali ed alla
rete.

• Ottenere nel 75 dei pazienti
• D2B entro 90 minuti
• D2N entro 30 minuti

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Bolzano Merano Rovereto - Trento
Milano Centri N. 4 - Treviglio Lecco Tradate
- Pavia Saronno - Varese - Lodi - Gravendona
Sondrio - Desenzano - Gallarate
Pordenone - Trieste Udine Gorizia -Tolmezzo
- San Daniele - Palmanova Latisana - San
Vito al Tagliamento
Bolzano Trento
FVG
Treviso -Castelfranco Veneto - Mestre
Veneto
Lombardia
Valle d'Aosta Piemonte
Ivrea - Novara Torino Centri N.2 Moncalieri
Emilia Romagna
Rimini - Sassuolo
Liguria

• Ascoli Piceno - Pesaro

Genova Centri N. 2 Pietra Ligure - Sanremo
Marche
Toscana
Città di Castello - Foligno Gubbio - Perugia
- Terni
Empoli - Grosseto Lucca Massa - Piombino -
Pisa
Umbria
Avezzano - Pescara Teramo - Vasto
Abruzzo
Lazio
Roma Centri N.6 AlbanoTerme Rieti
Andria Bari - Gallipoli Scorrano - Terlizzi
Puglia
Campania
Salerno Vallo della Lucania Nocera
Inferiore Pozzuoli
Basilicata
Sardegna
Cagliari Olbia Carbonia
Lagonegro - Matera Policoro - Potenza
Calabria
Catanzaro - Cosenza Crotone - Vibo Valentia
Sicilia
Siracusa Ragusa
Cardiologie aderenti alla raccolta dati n 78
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Zona Apuane-Versilia
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Zona Lunigiana
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Triage direttoPaziente con IMA
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MobiMed System
La Trasmissione ECG
HWS SERVER
Hospital 1
Hospital 2
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(No Transcript)
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Matrix Network STEMI 1227 Pazienti
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Network STEMI Zona Apuane-Versilia
D2B (1227 Pz)
109.7 n219
107.5 n166
107.7 n220
plt0.0001
99.7 n238
82.3 n247
2006
2007
2008
2009
2010
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Network STEMI Zona Apuane-Versilia
pazienti con DtB 90 min (1227 Pz)
104 (72.3)
plt0.0001
89 (46.3)
81 (40.0)
80 (36.4)
58 (34.9)
2006
2007
2008
2009
2010
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Network STEMI Zona Apuane-Versilia
1227 pts
EF
DtB (minutes)
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Network STEMI Zona Apuane-Versilia
1227 pts
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How Effective is the Hub?
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Reperfusion Therapy Primary PCI
Recommendations
Class
LoE
A
I

• Preferred reperfusion treatment if performed by
  an experienced team as soon as possible after FMC

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Physician Volume and Hospital Volume and
Mortality during Primary PCI
Srinivas VS J Am Coll Cardiol 2009 53574-9
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Physician Volume and Hospital Volume and
Mortality during Primary PCI
Physicians High Volume Low Volume (N92) (N 174) Odds Ratio (95 CI)
Mortality 3.25 4.9 0.66 (0.48-0.92)
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Physician Volume and Hospital Volume and
Mortality during Primary PCI
Hospitals High Volume Low Volume (N23) (N 18) Odds Ratio (95 CI)
Mortaliy 3.4 5.4 0.58 (0.38-0.88)
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PCI for STEMI Less Safe, Effective When Performed
Off-Hours
Off Hours Routine Hours p
Device use
Stent 76 82.4 0.04
IVUS 0.8 4.6 0.005
Thrombectomy 1.9 6.3 0.007
Periprocedural Clopidogrel 48.2 58.2 0.01
Major Dissections 10.3 5.2 0.2
Glaser R J Am Coll Cardiol Intv 20081681-8
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PCI for STEMI Less Safe, Effective When Performed
Off-Hours
Combined End Point In HospitalDeath, MI, Target
Vessel Revascularization Off Hours 16.2
p0.002 Routine
Hours 6.8
Glaser R J Am Coll Cardiol Intv 20081681-8
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Mechanical strategies to prevent distal
embolization
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TAPAS Trial Primary endpoint Myocardial Blush
Grade
P lt 0.001
Patients ()
Thrombus aspiration
Conventional PCI
Svilaas T, et al N Engl J Med 2008358557
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TAPAS 1,071 pts with STEMI undergoing PCI
randomized to thrombus aspiration vs control
Vlaar P et al. Lancet 2008 3711915
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Thrombus aspiration during Primary Percutaneous
Coronary Intervention myocardial reperfusion and
infarct size The EXPIRA (Thrombectomy With
Export Catheter in Infarct-Related Artery During
Primary Percutaneous Coronary Intervention)
Prospective, Randomized Trial
Cardiac Magnetic Resonance Imaging Results
G Sardella, MD, M Mancone, MD, C
Bucciarelli-Ducci, MD et al JACC Vol. 53, No. 4,
2009
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Thrombus Aspiration Reduces Microvascular
Obstruction After Primary Coronary Intervention
A Myocardial Contrast Echocardiography Substudy
of the REMEDIA Trial
p 0.05 vs. control patients
p 0.05 compared to 24 h
In thrombus-aspiration patients, at each time
point, ejection fraction was significantly better
compared with control patients, and it further
improved at 1 week and 6 months
L Galiuto, MD, PHD, B Garramone, MD, F Burzotta,
MD, PHD et al, JACC Vol. 48, No. 7, 2006
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Illusion of reperfusion
In 1993, at the peak of the thrombolytic era,
Lincoff and Topol wrote a provocative editorial
wondering whether reperfusion was just an
illusion. At that time, they estimated that
only 25 or less of patients treated by
thrombolysis had an optimal reperfusion.
Lincoff AM, Topol EJ. Illusion of reperfusion.
Does anyone achieve optimal reperfusion during
acute myocardial infarction? Circulation
199388136174.
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The No-Reflow Phenomenon Defining the Problem
The no-reflow phenomenon is the inability to
reperfuse a portion of the myocardium after
re-establishment of patency of previously
occluded epicardial coronary artery
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The No-Reflow Phenomenon Defining the Problem
The no-reflow phenomenon is the inability to
reperfuse a portion of the myocardium after
re-establishment of patency of previously
occluded epicardial coronary artery
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Agents studied to reduce reperfusion injury
Agent Mechanism proposed Trial
Fluosol Neutr.inhib., O2 delivery TAMI 9
Magnesium Membrane stabilisation ISIS4,MAGIC
RheothRX O2 delivery CORE
Trimetazidine H, free radicals, neutr. EMIP-FR
hSOD Prevent free radicals Flaherty
Cylexin Inhib.p-selectin, neutr. CALYPSO
Adenosine Neutr.inhib, vasodil, metab. AMISTAD I,II
ANTI CD-18 Neutr.inhib. HALT, LIMIT
Eniporide Na/H exchange inhib. ESCAMI
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Agents studied to reduce reperfusion injury
Trial N Primary endpoint Result
TAMI 9 430 Infarct size, EF ? (22 v.17)
ISIS4 58,050 35 d. mortality ? (7.6 v. 7.2)
CORE pilot 114 Infarct size ? (16 v.26)
CORE 2,607 Death, shock, reMI ? (14 v. 26)
EMIP-FR 19,665 35 d.mortality ? (12.2 v.12.3)
CALYPSO 153 Infarct size ? (larger)
AMISTAD I 236 Infarct size ? (ant. 20 v.13)
AMISTAD II 2,118 30-d.death, CHF ? (18 v. 16) ISz
HALT MI 420 Infarct size ? (no effect)
LIMIT MI 413 Patency, infarct size ? (no effect)
ESCAMI 1389 Infarct size ? (no effect)
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Ormoni tiroidei ed IMA evidenze cliniche

• Wiersinga WM et al. Thyroid hormones in acute
  myocardial infarction. Clin Endocrinol 1981 14
  367-74.
• Friberg L et al. Association between increased
  levels of reverse triiodothyronine and mortality
  after acute myocardial infarction. Am J Med.
  2001 111 699-703.
• Friberg L et al. Rapid down-regulation of thyroid
  hormones in acute myocardial infarction is it
  cardioprotective in patients with angina? Arch
  Intern Med. 2002 162 1388-94.

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Tiride e Cuore

• Nei pazienti con STEMI la riduzione dei livelli
  di fT3 durante la degenza correla con un peggiore
  recupero funzionale delle aree infartuali, come
  ben evidenziato dallo scarso recupero in termini
  di WMSI alla dimissione

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Recommended Logistics

• Pre-hospital triage/care
• EMS
• unique telephone number
• tele-consultation
• Ambulance
• 12-ECG recorder/defibrillator
• staff able to provide basic and advanced life
  support

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Recommended Logistics

• Pre-hospital triage/care
• EMS
• unique telephone number
• tele-consultation
• Ambulance
• 12-ECG recorder/defibrillator
• staff able to provide basic and advanced life
  support
• Networks
• implementation of a network of hospitals with
  different levels of technology connected by an
  efficient ambulance service using the same
  protocol
• Targets
• lt 10 min ECG transmission
• lt 5 min tele-consultation
• lt 120 min to first balloon inflation
• lt 30 min start fibrinolytic therapy

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Mille ragioni per vivere, Dom Helder Camara
(Profeta del Terzo Mondo)
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Dal territorio alla preservazione della funzione
ventricolare
Versilia 7-8 ottobre 2011

• Sergio Berti
• Fondazione CNR-Reg. Toscana G. Monasterio
• Ospedale del Cuore, Massa