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Primary Percutaneous Coronary Intervention in Acute ST Elevation MI – A Pakistani Perspective

Primary Percutaneous Coronary Intervention in Acute ST Elevation MI – A Pakistani Perspective. 52 M Presents within 2 h of CP. In ER – VF Arrest – defibrillated. Cardiac Catheterization. Cardiac Catheterization. Cardiac Catheterization. Case. 55 M, ex smoker

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Primary Percutaneous Coronary Intervention in Acute ST Elevation MI – A Pakistani Perspective

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  1. Primary Percutaneous Coronary Intervention in Acute ST Elevation MI – A Pakistani Perspective

  2. 52 M Presents within 2 h of CP

  3. In ER – VF Arrest – defibrillated

  4. Cardiac Catheterization

  5. Cardiac Catheterization

  6. Cardiac Catheterization

  7. Case • 55 M, ex smoker • Right thalamic infarct one year ago • Within 2 hours of chest pain

  8. Initial EKG

  9. Offered primary PTCA –Taken to cath lab

  10. Cardiac Catheterization

  11. Cardiac Catheterization

  12. Cardiac Catheterization

  13. Case • 38 M • Acute IMI • Cath Lab

  14. Cardiac Catheterization

  15. Cardiac Catheterization

  16. Cardiac Catheterization

  17. Case • 69 physician • Acute IMI • Cath Lab

  18. Cardiac Catheterization

  19. Cardiac Catheterization

  20. Terminology Symptoms ArrivaltoHospital ImmediatePCI(Primary)

  21. Terminology Thrombolysis Symptoms ArrivaltoHospital ImmediatePCI(Primary) RescuePCI ElectivePCI

  22. Why Ask The Question ?

  23. Why Ask the Question ? • There are limitations of thrombolytic therapy

  24. Limitations of Thrombolytic Therapy Acute ST Elevation MI 30 % Thrombolytic Ineligible • Bleeding Issues • Late Presentation • LBBB • Too Old

  25. Limitations of Thrombolytic Therapy Intracranial Hemorrhage

  26. Limitations of Thrombolytic Therapy Mortality Reduction is Time Dependant

  27. Limitations of Thrombolytic Therapy Issues with Coronary Patency

  28. Thrombolytic Eligible Acute ST Elevation MI 100 30 Long Term Patent Artery

  29. Thrombolytic Eligible Acute ST Elevation MI 100 85 TIMI Flow 0 = no flow 1 = poor flow 2 = intermed 3 = brisk flow 90 minute Patency 57 TIMI 3 Flow 35 No Residual Stenosis 30 Long Term Patent Artery

  30. Thrombolytic Eligible Acute ST Elevation MI 100 85 90 minute Patency No Reperfusion 57 TIMI 3 Flow 35 Residual Stenosis No Residual Stenosis 30 Late Reocclusion Long Term Patent Artery

  31. Residual Stenosis in Infarct Artery at 90 minutes after Thrombolysis Am J Cardiol 2000;85:1409-1413

  32. Thrombolytic Therapy Limitations • Benefits not clear cut in some subsets • CABG • Cardiogenic Shock • Elderly > 75

  33. Thrombolytic Therapy Limitations • Less effective in some “high risk” subsets • Anterior Wall MI Lundergan et al; GUSTO I Angiographic Investigators; JACC 1998; 32: 648

  34. What does the data tell us ?

  35. Weaver et al. JAMA 1997

  36. Primary angioplasty Thrombolysis Meta analysis of 23 trials Short Term Outcome 15.0% 14.0% 0.0002 < 0.0001 10.0% 9.0% 8.0% 7.0% 7.0% 5.0% 3.0% 2.0% 1.0% 1.0% 0.1% 0.0% Death Re-MI Stroke ICH Any event Keeley, Lancet 2003;361:13

  37. Lessons Learnt from PTCA vs Thrombolytic Trials • Improved MORTALITY • Higher initial reperfusion rates • Lower recurrence of ischemia • Less intracranial bleeding • TIMI 3 flow better but not ideal • Early recurrent ischemia 10-15% • Restenosis/Reocclusion at 6 months up to 50%

  38. What predicts good or bad outcomes after primary PCI ? • Time

  39. 15 10 5 0 -5 0 20 40 60 80 100 23 trials of PCI versus thrombolysis (n=7419) Mean time delay 39.5 mins (SD 22.1, range 7-104) 0.94% decrease in mortality benefit for every 10 min delay, p=0.006 No evidence of benefit if delay >62mins Absolute difference in 4-6 week mortality (%) PCI-related time delay (mins) Circles reflect trial sample size Blue line: weighted meta-regression Nallamothu & Bates, Am J Cardiol 2003;92:824

  40. 2.5 2 1.5 1 0.5 0 0-60 61-90 91-120 121-150 151-180 >180 Door to balloon time (min) Time to angioplasty in 27080 patients with acute myocardial infarction Multivariate adjusted odds of in-hospital mortality (95% CI) * * * p<0.001 Cannon, JAMA 2000;283:2941 Median door to balloon time 116 mins

  41. ACC/AHA Guidelines Smith et al. Circulation 2005

  42. What predicts good or bad outcomes after primary PCI ? • Operator experience

  43. ACC/AHA Guidelines Smith et al. Circulation 2005

  44. Aga Khan University Hospital Experience

  45. Results – Baseline Characteristics Jafary, et al. J Invasive Cardiol 2007; 19:417-423

  46. Results – Angiographic & Procedural Characteristics Jafary, et al. J Invasive Cardiol 2007; 19:417-423

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