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Background

A Pharmaco-invasive Reperfusion Strategy with Immediate Percutaneous Coronary Intervention is Safe and Effective in ST-Elevation Myocardial Infarction Patients with Expected Delays Due to Long Distance Transfer.

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  1. A Pharmaco-invasive Reperfusion Strategy with Immediate Percutaneous Coronary Intervention is Safe and Effective in ST-Elevation Myocardial Infarction Patients with Expected Delays Due to Long Distance Transfer David M. Larson, Chris Solie,Scott Sharkey,Sue Duval, Steven Mulder, Joan Krikava, Timothy Dirks, Peter Stokman, James Madison,Barbara Unger, James Harris, Robert Westin, Debra Nyquist, Timothy Henry

  2. Background • Primary PCI is the preferred reperfusion strategy for STEMI patients if it can be done in a timely manner • Only 25% of hospitals in the US are capable of Primary PCI • 82% of STEMI patients transferred from non-PCI hospitals for Primary PCI have Door to Balloon times > 120 minutes (ACC/NCDR) Chakrabarti, JACC 2008

  3. Reperfusion Options for Patients with Expected Delays • Full-dose fibrinolytic, admission to non-PCI hospital with ischemia guided transfer for rescue PCI • Full-dose fibrinolytic, routine transfer to PCI hospital with aggressive rescue PCI • Primary PCI (no matter how long it takes) • Full or reduced dose fibrinolytic with transfer for immediate PCI (Pharmaco-invasive strategy) • Any of the above depending on the PCI facility and Cardiologist on call

  4. Current Guidelines for STEMI Patients With Expected Delays to PCI

  5. Unresolved Issues • Timing of PCI following fibrinolysis • Optimal pharmacologic regimen

  6. Study Objective • Assess the safety and efficacy of a pharmaco-invasive approach utilizing half dose fibrinolytic, Clopidogrel (600mg), UFH and ASA combined with transfer for immediate PCI in patients transferred from rural hospitals located long distances from a PCI center

  7. Methods • Prospective registry data from the “Level 1 MI” program of the Minneapolis Heart Institute at Abbott Northwestern Hospital (ANW) • Included all STEMI patients from 4/03 to 12/08, presenting directly to the PCI hospital (ANW) or transferred from 30 community hospitals • No exclusions for age, cardiac arrest or cardiogenic shock

  8. Primary PCI protocol (Zone 1 < 60 miles) Aspirin 324mg Clopidogrel 600mg UFH 60/kg load, 12/kg/hr infusion Metoprolol 25mg PO Ph-Inv PCI protocol (Zone 2: 60-210 miles) Aspirin 324mg PO Clopidogrel 600mg PO UFH 60/kg load, 12/kg/hr infusion Metoprolol 25mg PO ½ dose Fibrinolytic Ph-Inv PPCI

  9. Total STEMI N=2,262 PCI Hosp N=496 Zone 1 Hosp N=1,031 Zone 2 Hosp N=735 PPCI N=496 PPCI N=1,005 Ph-Inv N=26 PPCI N=155 Ph-Inv N=580 PPCI N=1,501 Ph-Inv N=606

  10. Baseline characteristics

  11. Clinical characteristics

  12. Results

  13. ICH in Pharmaco-invasive patients • 3 Intracranial hemorrhage (0.5%) • 74 yr old male – survived • 82 yr old female – survived • 57 yr old male – survived

  14. Kaplan-Meier Survival PPCI Ph-Inv

  15. Pre-PCI Patency P<0.001 Ph-Inv PPCI

  16. Summary • Pharmacologic Regimen: ½ dose Fibrinolytic, Clopidogrel 600mg, UFH, ASA combined with transfer for immediate PCI • All patients included unless contraindication to fibrinolytic • Cardiogenic shock – 8% • Elderly – 24% ≥ 75yrs • Timing: Median D2B time – 123 minutes • Safety: No differences in major bleeding or stroke • Efficacy: • Increased pre-PCI patency • Mortality similar to non-transfer PPCI patients • Reduced re-ischemia compared to non-transfer PPCI patients

  17. Conclusion A pharmaco-invasive approach utilizing a reduced dose fibrinolytic combined with immediate transfer for PCI is a safe and effective reperfusion strategy for STEMI patients with expected delays due to long distances to a PCI center

  18. Thank you

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