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Treatment of STEMI: Mechanical Reperfusion Therapy

Treatment of STEMI: Mechanical Reperfusion Therapy. The Best Practice Department of Internal Medicine . Background. Reperfusion Therapy . Total occlusion. Efficacy and Time Frame . PAMI. (Grines et al. N Engl J Med 1993;328:673). PCI vs Fibrinolysis for STEMI: Short Term Clinical Outcomes.

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Treatment of STEMI: Mechanical Reperfusion Therapy

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  1. Treatment of STEMI:Mechanical Reperfusion Therapy The Best Practice Department of Internal Medicine

  2. Background

  3. Reperfusion Therapy Total occlusion Efficacy and Time Frame

  4. PAMI (Grines et al. N Engl J Med 1993;328:673)

  5. PCI vs Fibrinolysis for STEMI:Short Term Clinical Outcomes PCI Fibrinolysis P < 0.0001 Frequency (%) P < 0.0001 P=0.0002 P=0.032 P=0.0003 P < 0.0001 P=0.0004 P < 0.0001 Hem.Stroke Death Death, no SHOCKdata ReMI Rec.Ischemia Total Stroke Major Bleed DeathMICVA N = 7739 Keeley E. et al., Lancet 2003; 361:13-20.

  6. NRMI 2: Primary PCI Door-to-Balloon Time vs. Mortality P=0.01 P=0.0007 P=0.0003 MV Adjusted Odds of Death n = 2,230 6,616 4,461 2,627 5,412 5,734 Door-to-Balloon Time (minutes) Cannon CP, JAMA 2000

  7. PCI-Related Time Delay vs Mortality Benefitin 22 Randomized Studies of PCI vs Fibrinolytic Therapy For every 10 min delay to PCI: 1 % reduction in Mortality Difference Between PCI & Lysis 23 RCTs N= 7419 p=0.006 Nallamothu and Bates, AJC 2003

  8. PCI related Time delayed(Door to balloon – Door to needle) • < 60 min: PCI survival benefit > Fibrinolysis • 60-90 min: PCI benefit in composite end-point of death, re-infarction and stroke • > 120 min : Fibrinolysis is better than PCI

  9. Emergency PCI @ PSU. 118 69 16 NETWORK DIRECT CALL & FAX

  10. SK Door to Needle Our Practice Evaluation & Decision of Reperfusion strategy PCI-related time delayed Door-to-Balloon ER arrival Referral Hospital History, PE ECG, lab ER Physician Staff Cardiologist Consultation Resident Med Balloon Cath-lab activation Cath-lab nurse Logistic Cath –lab arrival

  11. Indicators • Door-to-Balloon Time < 120 min • PCI related time delayed <60-90 min • Mortality Rate

  12. SK Door to Needle =95 min 25 min Our Practice 2550 Evaluation & Decision of Reperfusion strategy PCI-related time delay 120 min Door-to-Balloon 28 min 31 min 29 min 32 min ER arrival Referral Hospital History, PE ECG, lab ER Physician Staff Cardiologist Consultation Resident Med Balloon Cath-lab activation Cath-lab nurse Logistic Cath –lab arrival

  13. 2551 Clinical tracerThe Faster, the better

  14. 120 min Door-to-Balloon 28 min 31 min 29 min 32 min 81 min 23 min 9 min 24 min 25 min Cath-lab activation Balloon Consult Med Cath –lab arrival ER arrival Door to Balloon 120 min -> 81 min (AIM <120 )

  15. Minutes 120 120 81 60 25 18

  16. Door-to-Needle MINUTES 95 63 30

  17. Mortality Rate

  18. Mortality Rate in STEMI with Cardiogenic Shock 80 47 47 42

  19. Mortality Rate in STEMI without Cardiogenic Shock 7% 2% 2% 0 • NEJM 1993 • Lancet 2003

  20. Advantage • The best treatment of STEMI • Referral Hospital • Excellent Center • Hospital stay and Re-admission • Training Center • Patient ‘s benefit

  21. Thank you

  22. Cardiogenic shock 36 27 7

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