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TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO

TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica) Nazario Carrabba Cardiologia 1 - Dipartimento del Cuore e dei Vasi, Azienda Ospedaliera - Universitaria di Careggi, Firenze Firenze, 15 Marzo 2008 EDUCATORIO del FULIGNO.

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TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO

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  1. TRATTAMENTO in RETE INTEROSPEDALIERA di un INFARTO MIOCARDICO ACUTO ST ELEVATO (Dalle Linee Guida alla Realtà Clinica) Nazario Carrabba Cardiologia 1 - Dipartimento del Cuore e dei Vasi, Azienda Ospedaliera - Universitaria di Careggi, Firenze Firenze, 15 Marzo 2008 EDUCATORIO del FULIGNO “Difendiamo il cuore” Campagna Educazionale Regionale ANMCO Toscana

  2. Primary PTCA vs Thrombolysis for AMI: Review of 23 Randomized Trials. Long- term Outcome % PTCA n= 3872 Pz p< 0.0001 Thrombolysis n= 3867 Pz p< 0.0001 p= 0.0019 p= 0.0053 p< 0.0001 Death Death, Non Fatal MI or Stroke Death excluding Shock Non Fatal MI Recurrent Ischemia Keeley EC, Lancet 2003; 361: 13-20

  3. The Transfer for Primary Angioplasty:The Evidences • According to ESC guidelines (and AHA/ACC guidelines too) when primary angioplasty is available in a “timely fashion” and procedure can be performed by an “experienced” operator in a “large volume centre”, primary PCI should be considered the preferred reperfusion strategy • However, which is the best modality of reperfusion treatment for patients admitted to community hospitals without invasive facilities is less clear

  4. The Importance of Time to Transfer The time delay for transferring patients to PCI centers could reduce or even nullify the potential benefit of reperfusion Gersh, B. J. et al. JAMA 2005;293:979-986

  5. ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction—Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) Writing Committee Members: Elliott M. Antman, MD, FACC, FAHA, Chair; Daniel T. Anbe, MD, FACC, FAHA; Paul Wayne Armstrong, MD, FACC, FAHA; Eric R. Bates, MD, FACC, FAHA; Lee A. Green, MD, MPH; Mary Hand, MSPH, RN, FAHA; Judith S. Hochman, MD, FACC, FAHA; Harlan M. Krumholz, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Gervasio A. Lamas, MD, FACC; Charles J. Mullany, MB, MS, FACC; Joseph P. Ornato, MD, FACC, FAHA; David L. Pearle, MD, FACC, FAHA; Michael A. Sloan, MD, FACC; Sidney C. Smith, Jr, MD, FACC, FAHA (Circulation. 2004;110:588-636.)

  6. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction Class I.If immediately available, primaryPCI should be performed in patients with STEMI (including trueposterior MI) or MI with new or presumably new LBBB who canundergo PCI of the infarct artery within 12 hours of symptomonset, if performed in a timely fashion (balloon inflation within90 minutes of presentation) by persons skilled in the procedure(individuals who perform more than 75 PCI procedures per year).The procedure should be supported by experienced personnel inan appropriate laboratory environment (performs more than 200PCI procedures per year, of which at least 36 are primary PCIfor STEMI, and has cardiac surgery capability). (Level of Evidence:A) (Circulation. 2004;110:588-636.)

  7. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction Strictperformance criteria must be mandated for primary PCI programsso that long door-to-balloon times and performance by low-volumeor poor-outcome operators/laboratories do not occur. Interventionalcardiologists and centers should strive for outcomes to include: (1) door-to-balloon timesless than 90 minutes; (2) TIMI 2/3 flow rates obtained in more than 90% of patients; (3) emergencyCABG rate less than 2%; (4) actual performance of PCI in >85% of patientsbrought to the lab; (5) risk-adjusted in-hospitalmortality rate less than 7% in patients without cardiogenicshock.

  8. Caso clinico numero 1 Nazario Carrabba, MD

  9. Caratteristiche Cliniche del Paziente • Maschio, 59 anni • Fattori di rischio cardiovascolare: Fumatore, Ipercolesterolemia, Diabete • Riferisce da circa 5 ore dispnea e dolore toracico posteriore • Killip class: 1 Nazario Carrabba, MD

  10. Primo ECG eseguito

  11. Iter Diagnostico-Terapeutico? • Ricovero nell’UTIC più vicina per eseguire fibrinolisi 2. Fibrinolisi in ambulanza (pre-ospedaliera) 3. PCI facilitata (trombolitici/inibitori IIb/IIIa prima del trasferimento per PCI - 2 ambulanze -) 4. Trasferimento diretto in sala di emodinamica per una PCI (2-ambulanze)

  12. Trasferimento per una PCI una scelta appropriata?

  13. Coronaria destra

  14. ECG post-angioplastica primaria

  15. The Florence Reperfusion Experience Spontaneous organization with Spoke centers

  16. AMI-Florence FLORENCE DISTRICT REGISTRYLocation of the Participating Hospitals Florence District 2,205 Kmq 798.000 residents 33 municipalities Careggi Hospital: 2 PCI centers 5 community hospitals Distance range: 5-33 Km N Mugello H 33 km/20 miles Careggi 2 PCI centers OSMA 12 km/7 miles * NSGD 7 km/4 miles SMN 5 km/3 miles Historic area Urban area Figline H 33 km/20 miles Chianti area Mugello area

  17. AMI-Florence Use of Reperfusion Treatment: March 1, 2000 to February 28, 2001 746 reperfusion treatment eligible patients (<12h) No reperfusion treatment n=274 (36.7 %) Reperfusion treatment n=472 (63.3 %) 91.5% with P- PCI (n°432 patients) 1.1% rescue PCI (n°5 patients) 7.4% with thrombolysis (n°35 patients) Buiatti E. Eur Heart J. 2003;24:1195-203

  18. 36.8 34 30 36.7 35 24 NRMI-2 MITRA-MIR FRENCH GRACE AMI-Florence BLITZ <12h <12h <6h <6 <12h <6h oct. 01 94-96 94-98 nov. 95 00-01 99-01 Underuse of Reperfusion Therapy in Registry Studies 60 % 50 40 No Reperfusion 30 20 10 0 Delay (h) Period

  19. AMI-Florence AMI-Florence Registry In-hospital and 6-month Mortality 30 P<.000 25 20 P<.000 % 15 14.9 24.4 10 9.1 5 5.7 0 In hospital 6 months Reperfusion therapy No reperfusion therapy

  20. AMI-Florence Factors Influencing the use of Reperfusion by Multivariate Regression Analysis HR 95% CI 0.97 0.96 - 0.99 0.26 0.11 - 0.65 0.55 0.33 - 0.93 0.91 0.84 - 0.99 0.32 0.21 - 0.50 0.44 0.24 - 0.83 0.59 0.39 - 0.88 7.8 5.1 - 11.8 Age (years) Previous CHF Previous MI Time delay>6 h Non anterior MI Killip >II Non-office hours Hospitals withP-PCI facilities 0 0.5 1 3 6 9 Reduced probability Increased probability

  21. Caso clinico numero 2 Nazario Carrabba, MD

  22. Caratteristiche Cliniche del Paziente • Donna, 62 anni • Fattori di rischio cardiovascolare: Ipertensione arteriosa, ipercolesterolemia, • Riferisce da >12 ore fastidio epigastrico, • Killip class: 3 Nazario Carrabba, MD

  23. Primo ECG eseguito

  24. Iter Diagnostico-Terapeutico? • Ricovero nell’UTIC più vicina per eseguire fibrinolisi 2. Fibrinolisi in ambulanza (pre-ospedaliera) 3. PCI facilitata (trombolitici/inibitori IIb/IIIa prima del trasferimento per PCI - 2 ambulanze -) 4. Trasferimento diretto in sala di emodinamica per una PCI (2-ambulanze)

  25. Trasferimento per una PCI una scelta appropriata?

  26. Coronaria Destra

  27. Coronaria Sinistra

  28. ECG post-angioplastica primaria

  29. AMI-Florence Study Population 746 Patients Admitted to hospitals with PCI facilities n=351 (47%) Admitted to hospitals without PCI facilities n=395 (53%) On-site P-PCI n=286 (81.5%) Transf. for P-PCI n=146 (37%) Presented ESC-2006

  30. AMI-Florence Kaplan-Meier Survival Curves by Hospital of Admission % 100 91.3% On-site P-PCI 89.7% Transf. P-PCI 75 50 25 Log – rank test p = 0.305 0 0 2 4 6 Time (months) Presented ESC-2006

  31. AMI-Florence Kaplan Meyer survival curves after 3 years: comparison between on-site and after transferal primary PCI. log-rank test: p<0.20 Variables independently associated with the risk of death at 3 years. Paper submitted

  32. Transfer for Primary Angioplasty: Evidences Metanalysis considering five randomized Trials (n=2909) (+ CAPTIM, n=3750) showed a benefit of transfer for primary PCI compared to on-site fibrinolysis in term of combined endpoint (death, reinfarction, stroke) Dalby, M. et al. Circulation 2003;108:1809-1814

  33. BRAVE-2 Trial: Asymptomatic patients with STEMI and symptom onset > 12 h % 13% Final Infarct size 8% Invasive strategy Conservative strategy Schömig, A. et al. JAMA 2005;293:2865-2872

  34. Should patients with STEMI and symptom onset > 12 h be treated with PCI? Schömig, A. et al. JAMA 2005;293:2865-2872

  35. Practical Messages • The policy of transferring STEMI patients with symptom onset <12 h initially admitted to community hospitals to centres which offer primary PCI seem feasible and safe, with the “useful window for transfer of 90 min”. • For patients with STEMI and symptom onset 12 h (8-31% of all patients with STEMI), the transfer from community hospitals to PCI centres could represent a “missed opportunity”. However, more trials are needed to confirm this policy.

  36. CONCLUSIONE Indipendentemente dal tipo di “rete interospedaliera” che si viene a realizzare, deve essere perseguito l’obiettivo di garantire il trattamento riperfusivo più rapido ed efficace al “maggior numero possibile di pazienti”.

  37. AHA Consensus Statement Recommendation to Develop Strategies to Increase the Number of ST-Segment–Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention The American Heart Association’s Acute Myocardial Infarction (AMI) Advisory Working Group Alice K. Jacobs, MD, FAHA, Chair; Elliott M. Antman, MD, FAHA; Gray Ellrodt, MD; David P. Faxon, MD, FAHA; Tammy Gregory; George A. Mensah, MD, FAHA; Peter Moyer, MD; Joseph Ornato, MD, FAHA; Eric D. Peterson, MD, FAHA; Larry Sadwin; Sidney C. Smith, MD, FAHA (Circulation. 2006;113:2152-2163)

  38. Guiding Principles • Patient-centered care as the No. 1 priority • High-quality care that is safe, effective, and timely • Stakeholder consensus on systems infrastructure • Increased operational efficiencies • Appropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality" • Measurable patient outcomes • An evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelines • A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health care • A reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines

  39. Guiding Principles • Patient-centered care as the No. 1 priority • High-quality care that is safe, effective, and timely • Stakeholder consensus on systems infrastructure • Increased operational efficiencies • Appropriate incentives for quality, such as "pay for performance," "pay for value," or "pay for quality" • Measurable patient outcomes • An evaluation mechanism to ensure quality-of-care measures reflect changes in evidence-based research, including consensus-based treatment guidelines • A role for local community hospitals so as to avoid a negative impact that could eliminate critical access to local health care • A reduction in disparities of healthcare delivery, such as those across economic, education, racial/ethnic, or geographic lines

  40. Grazie

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