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Mreža urgentne PCI u tretmanu bolesnika sa akutnim infarktom miokarda u Bosni i Hercegovini

Mreža urgentne PCI u tretmanu bolesnika sa akutnim infarktom miokarda u Bosni i Hercegovini. BH Centar za srce Tuzla Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S. Akutni MI. Ucinak savremene terapije na mortalitet. Defibrillation Hemodynamic Monitoring b -Blockers.

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Mreža urgentne PCI u tretmanu bolesnika sa akutnim infarktom miokarda u Bosni i Hercegovini

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  1. Mreža urgentne PCI u tretmanu bolesnika sa akutnim infarktommiokarda u Bosni i Hercegovini BH Centarzasrce Tuzla Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.

  2. Akutni MI Ucinak savremene terapije na mortalitet Defibrillation Hemodynamic Monitoring b-Blockers Aspirin Thrombolysis PTCA Adapted from Antman, Braunwald In:Braunwald ed. Heart Disease p 1184.

  3. ECS smjernice

  4. Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Hospital fibrinolysis: Door-to-Needle within 30 min. Not PCI capable Call 1-2-4 Call fast • EMS on-scene • Encourage 12-lead ECGs. • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min. Inter-Hospital Transfer Onset of symptoms of STEMI 1-2-4 EMS Dispatch EMS Triage Plan PCI capable GOALS 5 min. 8 min. EMS Transport Patient EMS Prehospital fibrinolysis EMS-to-needle within 30 min. EMS transport EMS-to-balloon within 90 min. Patient self-transport Hospital door-to-balloon within 90 min. Dispatch 1 min. Golden Hour = first 60 min. Total ischemic time: within 120 min.

  5. Correct STEMI diagnosis in >90% only by phone conversation and sometimes faxing No need for advanced ECG transmission “Telelink” Lifenet

  6. PATIENT WITH CHEST DISCOMFORT • - Recognition • - ASA, nitroglycerin • - Immediate “124” phone call • 2. PREHOSPITAlL EMERGENCY UNIT • 12-lead ECG within 10 minutes • Phone “cath lab alert” 3. EMERGENCY TRANSPORT WITH “BYPASSING” -Non-PCI hospital -ER, CCU of PCI hospital “STEMI-FAST TRACK” SYSTEM 4. PRIMARY PCI CENTER -Primary PCI -CICU support

  7. 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

  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. 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

  10. Primary PCI for STEMI: General Considerations • Patient with STEMI (including posterior MI) or MI with new or presumably new LBBB • PCI of infarct artery within 12 hours of symptom onset • Balloon inflation within 90 minutes of presentation • Skilled personnel available (individual performs > 75 procedures per year) • Appropriate lab environment (lab performs > 200 PCIs/year of which at least 36 are primary PCI for STEMI) • Cardiac surgical backup available

  11. Comb endpt of death, non-fatal reinfarction, and stroke Non-fatal reinfarction Short-term death (4-6 weeks) Odds ratios (95% CI) Keeley, Boura & Grines. Lancet. 2003;361:13-20.

  12. Tromboliticka terapija • Do 12 sati odpocetkasimptoma – svi koji odbijajuinvazivne procedure • Pacijentibezarterijskogpristupa • Logistickiproblemi(tehnickiproblemi u katlabu,vremenskiproblemi I sl)

  13. Prednosti primarne PCI • Smanjuje mortalitet • Duzinu hospitalizacije • Brzi oporavak • Manje ponovnih hospitalizacija

  14. Ciljevi primarne PCI • Primarna PCI >70% STEMI pacijenata • Primarna PCI > 600/milionstanovnika • Postojeci PCI centri – 24/7 princip –tretiratisve STEMI primarnom PCI

  15. Primarna PCI NSTEMI • Rekurentna – refraktorna progresivna angina • Sa progresivnim ST EKG promjenama • Sercana insuficijencija • Aritmija – vitalno ugrozavajuca • Hemodinamska nestabilnost

  16. Minimalno iskustvooperateraicentra za primarnu PCI • Individualni 75 elektivnih PCI godisnje 15 primarnih PCI PCI centar 200 PCI god. 50 primarnih PCI

  17. PRIMARY PCI FOR STEMI HAS LOWER MORTALITY IN HIGH VOLUME CENTERS ! High volumeLow volume p (>400 PCI/year)(<400 PCI/year) 6.75%8.54% 0.028 Spaulding C, et al. Eur Heart J 2006;27:1054-65.

  18. Transfer pacijenata sa AMI • 12 kanalni EKG • Defibrilator • Kisik,priborzaintubaciju I evasist.ventilaciju • Medikamenti:aspirin,klopidogrel,heparin,nitroliglicerin,betabloker,morfij

  19. Treatment Delayed is Treatment Denied Cath Lab Symptom Recognition Call to Medical System PreHospital ED Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy

  20. Katlab organizacija • Medicinski tehnicar 24/7 – priprema materijal I pacijenta • Invazivni kardiolog – on call -30 minuta • Medicinski – Rtg tehnicar – on call

  21. Financijski aspekti • Fiksnanaknadapo PCI proceduriza PCI centre(odvlastiilifondazdravstvenogosiguranja) • Extra naknadazatim (zarad u nocnimsatimaivikendom) • Drugaopcija – povecatibrojosobljazakontinuiranirad 24/7 porotirajucemprincipu

  22. Politicki aspekti • Nacionalni Program primarne PCI • Koordinacija nacionalnog udruzenja kardiologa, ministrastva zdravlja,zdravstvenog osiguranja –hitna pomoc,non PCI I PCI centri • Nacionalni registar – sa evidencijom mortaliteta,kompliikacija ,kontrolom kvaliteta

  23. NO CALL TO THE PRIMARY PCI CENTER- STEMI PATIENT STAYS IN NON-PCI HOSPITAL ! Hospital mortality in Ljubljana Thrombolysis 1996-97 16.3% Primary PCI 2000-5 6.2%

  24. Inicijativa za formiranje regionalne mreze primarne PCI u BiH • Inicijalnafaza • PCI centri u BH kojimoguobezbjediti 24/7servis • Pokrivatiregioneudaljenosti do 100 km ili 90 min transportazaprimarnu PCI • Pacijentiizostalihregionakoji se jave u <3h odpocetkasimptoma- trombolitickath

  25. Regionalna mreza PCI • EMS – hitna pomoc • Non PCI bolnice • PCI centri

  26. Mreza primarne PCI u BiH - nastavak • >3h -12h od pocetka simptoma – transfer u PCI centar – primarni transport • Nakon neuspjele trombolize – hitni transfer u PCI centar – rescue PCI • Nakon uspjele trombolize transport u PCI centar unutar 24 h – sekundarni transport • Nakon 24-48 h transport u lokalne non PCI bonice- tercijarni transport

  27. Mreza primarne PCI u BiH • Preostali interventni PCI centri koji nisu u stanju obezbjediti 24/7 servis – u incijalnoj fazi ne ulaze u mrezu • Kao low volume centri rade elektivne procedure • Nakon edukacije kadrova i obezbjedjenja kontinuiranog servisa ravnopravno ulaze u mrezu

  28. Mreza primarne PCI u BiH • Nacionalni program za primarnu PCI – koordiniran od strane Ministarstve zdravlja • Nacionalni registar primarne PCI • Koordinirajuce tijelo regionalnih mreza kao I centralno koordinirajuce tijelo na drzavnom nivou . • Rok 2 godine za formiranje mreze na cijeloj teritoriji BiH – preko 70%STEMI primarnom PCI I 2000 infarkta godisnje

  29. STRUKTURA DATABASIS • DEMOGRAFSKI PODACI • ISTORIJA BOLESTI • relevantnu za koronarnu bolest: uključuje podatke kao što su raniji infarkt,AP, ranije intervencije i postupke kao što su PCI i CABG • FAKTORI RIZIKA: • relevantni za koronarnu bolest (hipertenzija, hiperlipidemija, pušenje, šećernu bolest...)

  30. STRUKTURA DATABASIS • UČINJENE PRETRAGE • PCI SEKCIJA • fokusira se na revaskularizaciju • MEDIKACIJA • prije – u toku PCI • ISHOD • podaci o neposrednom ishodu nakon PCI • LIJEKOVI NA OTPUSTU I FOLLOW-UP

  31. 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

  32. D.M. 46 y m.STEMI inf.

  33. G.M.42y.m.STEMI,ant.

  34. G.M.63y f.STEMI inf S-P CABG

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