Primary PCI Treatment of choice for Acute MI

1. Primary PCI Treatment of choice for Acute MI

2. Benefits of primary angioplasty Incontrivertible 1993

3. Benefits of primary angioplasty Incontrivertible 1993

4. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

5. ESC Guidelines for the treatment of ST segment elevation

6. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

7. Meta-analysis of 23 randomised trials comparing Primary PTCA to Thrombolysis7739 patients: 4-6 week data P<0.0001 P=0.0002 P=0.0003 P<0.0001 P=0.0004 Grines et al 2003;NEJM361:13-20

8. True mortality benefit of Primary angioplasty 20 lives /1000 78 lives/1000 P<0.001 P<0.001

9. True mortality benefit of Primary angioplasty 20 lives /1000 78 lives/1000 130 lives/ 1000 P<0.001 P<0.001 P<0.001

10. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

11. Does Time Matter?Individual Patient Data-based Meta-analysis of Primary PCI versus Fibrinolysis in Acute Myocardial InfarctionRandomized Trials Eric Boersma, R John Simes, Cindy L Grines, Cynthia M Westerhout On behalf of the Primary Coronary Angioplasty versus Thrombolysis (PCAT)-2 Collaborators

12. 30 day mortality 15 % of Patients 10 5 0 All 0 - 1 >1 - 2 >2 - 3 >3 - 6 >6 - 12 Presentation delay (h)

13. Very Early Thrombolysis - The Golden Hour Absolute 35 day mortality reduction v treatment delay <20% patients N=50246 Fibrinolytic Therapy Trialist’s Collaborative Group, Lancet 1994 343:311 Boersma et al, Lancet 1996 348:771

14. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

15. ASSENT 4 • Mulitcentric randomized trial comparing two strategies in acute myocardial • “Facilitated PCI” : TNK followed by immediate angiography/ angioplasty (1 to 3 hours) versus primary PTCA

16. ASSENT 4 • 4000 pts with large MI • Study stopped after inclusion of 1667

17. ASSENT-4: 30-day mortality results

18. ASSENT-4: In-hospital stroke rates

19. Comparison of outcomes in ASSENT-4 with those in other trials of TNK in MI patients

20. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

21. Total Cumulative Costs During the First Year

22. UK-PACES In-hospital Costs 400 consecutive patients p=0.04 p<0.001 p<0.001

23. Myths in treating acute MI • Primary PCI is no better than thrombolysis • Primary PCI is better but not much better • Thrombolysis just needs to be given early • Thrombolysis followed by PCI is just as good • Facilitated PCI is the preferred option • Too difficult • Too expensive

24. What have we done in the past 13 years? Benefits of primary angioplasty Incontrivertible 1993