Treatmant patients with acute myocardial infarcton in Bosnia and Herzegovina

1. Treatmant patients with acute myocardial infarcton in Bosnia and Herzegovina BH Heart Centre Tuzla Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.

2. Implementation of the STEMIESC Guidelines

3. ESC STEMI – guidelines ACC/AHA & ESC guidelines

4. Myokardnekrose • Starts 30-45min after occlusion • After 90min is 40-50% necrotised • After 6h the necrosis is often complete • Collaterals modify • Occlusion is often sub-total or fluctuating AHA Textbook of Advanced Cardiac Life Support, 1999

5. Prehospitalt EKG PCI Trombolyse

6. Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk. Risk of Fibrinolysis Time Since Symptom Onset Risk of STEMI Time Required for Transport to a Skilled PCI Lab

7. Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. • Fibrinolysis generally preferred • Early presentation ( ≤ 3 hours from symptom onset and delay to invasive strategy) • Invasive strategy not an option •  Cath lab occupied or not available •  Vascular access difficulties No access to skilled PCI lab • Delay to invasive strategy •  Prolonged transport Door-to-balloon more than 90 minutes •  > 1 hour vs fibrinolysis (fibrin-specific agent) now

8. Reperfusion Options for STEMI PatientsStep 2: Select Reperfusion Treatment. If presentation is < 3 hours and there is no delay to an invasive strategy, there is no preference for either strategy. • Invasive strategy generally preferred • Skilled PCI lab available with surgical backup Door-to-balloon < 90 minutes • High Risk from STEMI Cardiogenic shock, Killip class ≥ 3 • Contraindications to fibrinolysis, including increased risk of bleeding and ICH • Late presentation > 3 hours from symptom onset • Diagnosis of STEMI is in doubt

9. Evolution of PCI for STEMI AngioJet ASA Clopidogrel Platelet GP IIb/IIIa inhibitor Embolization Protection Device Thrombus Removal and Distal Embolization Protection Devices Balloon Antiplatelet Rx Stent DES Antman. Circulation 2001;103:2310.

10. The essence in todays PCI -”Guidelines” (2005). • STEMI should be evaluated with respect to reperfusion therapy immediately • Establish good networks • Preshospital services • Local hospitals • PCI-centra • Implement details in guidelines at all levels in the treatment chain

11. Reperfusion strategyRecommendation IA…. • PrimaryPCI • All when < 90 –120 (?) min. to balloon • All with contraindicasion to thrombolysis • Probably most patients with long chest pain history (> 3 – 6 - 12 t??) • Thrombolyse to the others; • preferably prehospital and within 3 h from onset of symptoms

12. Prognostic PCIRecommendation IA • PCI within 24 hrs after sucessful thrombolysis • Randomised trials; effect on combined endpoints • No effect on mortality • Discussed…..

13. Rescue PCIRecommendation IB-IIC • Cardiac shock <75 y & <18 h after development of shock (IB) • Unsuccessful thrombolysis after 45-60 min (ECG & clinical eval) (IIC)

14. Combined strategy, recomm IIB • Pretreatment with thrombolysis or Gp-IIb-IIIa-inhibitor before PCI in high-risk? • Insufficient documentation (Garcia, SIAM..) • ASSENT IV; higher mortality with combined treatment (6%)versus primaryPCI(3,8%), but positiv for some groups and some weekness in the study • STREAM??

15. ”Facilitated PCI” (thrombolysis before PCI) PCI: 3,8% Tenecteplase + PCI: 6,0% 30d mort. But, pts with prehospital thrombolysis; ~2% ASSENT-4 trial, Lancet 2006; 367:569-78.

16. Pretreatment before primary PCI • MONA (morphine, Oxyg, Nitro, ASA 300) • Heparin bolus;5-10.000 iv.(70IE/kg iv. ) • Clopidogrel 600mg pr. os • Evt. Thrombolyse befor transportation (facilitated PCI) when high risk??

19. TREATMENT MI IN EUROPE • Anual incidence of hospital admissions 900-3120 on mil. • STEMI amdissions 440-1420 on mil. • P-PCI 20-920 on mil. • P-PCI 5-92% • TL – thrombolysis 0-55% • Single p-PCI centre 0.3-7.4 mil • In hospital mortality 4,2-13,5% • P-PCI mortality 2,7-8 % • TL mortality 3,5-14%

20. Bosnia and Herzegovina • 3.9 mill • 88/km2 • GNP 2300 US$/year (2005)

21. Interventional cardiology in BiH • PCI centres 5 • PCI-mil. 770.000 • Independent interv.cardiologists 11 • Anual MI admissions 7200 • Anual STEMIs 3100

22. Invasive procedures in Bosnia and Herzegovina Coronography PCI 3676 616 3167 784 3569 1018

23. Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina • 2009. • 8interventional cardiologists, • 4 PCI centres • PCI totaly 1018 • PCI – per centre 254 • PCI – per operator 127 • Primary PCI –NA les then 10% • Radial – brachial access (%) 1 • Abciximab (%) 4 • IABP (%) 1 • Respirator (%) 1

24. Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina Challenges: • Geography • Distances • Number of invasive centers • 24 hours on call – costs • Transportation • Revascularisation mode; PCI? Thrombolysis? • Prehospital ECG-systems • Responsibility for patients

25. Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina STEMI – Do we need more PCI-centers?

27. New PCI – centers ”Proposal” • Centervolume > 600 PCI (1500-2000 angiograms) • Cheaf > 500 PCI (historical experience) • On-call operator >300 PCI (historical experience) • Yearly operatorvolum >100 PCI • 24 hours service • On duty – how often? 4 – 5 – 6 ?? • On call clinical cardiology service • Defined geographical regions

29. M.R.38 y.m.STEMI inf.

34. B.M.44 mSTEMI ant.