Chiến lược tái thông mạch vành hiện nay cho NMCT cấp ST chênh lên

15th National Congress of Cardiology
Hanoi, Vietnam, October 9-11, 2016

Contemporary Strategies for
Percutaneous Reperfusion in STEMI
2016
Gregory W. Barsness, MD, FACC, FAHA, FSCAI
Consultant, Mayo Clinic Departments of Cardiovascular Diseases and Radiology
Director, Mayo Clinic CICU
©2014 MFMER | Slide-1


Ischemic Heart Disease in Vietnam
Growing and Costly Problem
In 2011:
38% of Deaths related to CV Disease
23% of Deaths from Stroke
15% of Death attributable to Coronary Disease
By 2017:
20% prevalence of CV Disease and HTN

WHO Report 2011
Data from 2016 Pacific Cross Vietnam (Blue Cross Vietnam)
©2014 MFMER | Slide-2


All-Cause Long-Term Mortality in ACS
4606 AMI Pts Undergoing Angiography
70

Mortality (%)

60

NSTEMI

50
40
30

STEMI

20
10
0
0

1

2

3

4
Years

5

6

7

8

Chan, et al. Circ 2009;119
©2014 MFMER | Slide-3


6-Month Mortality Following ACS
GRACE
(n=43,810)

Fox, et al. BMJ 2006
©2014 MFMER | Slide-4


Guideline Adherence and Outcome
In-hosp mortality (%)

7
6

5.95

6.33
5.16

5
4
3

5.07

4.97

Adjusted
Unadjusted

4.63

4.16

4.17

Every 10%  in guidelines adherence

2

11%  in mortality

1
0
<=25%

25-50%
50-75%
>=75%
Hospital composite quality quartiles

Peterson, et al. ACC 2004
©2014 MFMER | Slide-5

Hospital Performance and Outcome
Mean Life Expectancy After AMI
119,735 AMI Patients in Cooperative Cardiovascular Project (1994-97)

>1 Year Longer Life Expectancy!

Bucholz, et al. NEJM 2016;375 (14)
©2014 MFMER | Slide-6


STEMI Management Algorithm

Www.

www.cardiosource.org
©2014 MFMER | Slide-10


35-Day Mortality Reduction with Thrombolysis
58,600 Patients in 9 Randomized Trials
30

Mortality (%)

P<0.00001
18%
reduction

Lytic
Thrombosis
Placebo
Placebo

23.6

18.7

20

16.9
13.4

13.2

11.5

10

NNT

15.2
13.8

10.6

9.6

7.5

8.4

50

20

27

111

33

Total

BBB

Ant MI

Inf MI

Other
ST
ST -

0

ST 
¯

FTT: Lancet, 1994
©2014 MFMER | Slide-11


Primary PCI vs. Fibrinolysis
Meta-analysis of 23 RCTs of 7739 pts
NNT = 50

NNT = 17

4-6 week outcomes

25

21

PCI

20

Lysis

15
%

10

13
7

9

5

7

7

6

2.2

1

2

0

Death

Re-MI

Rec
Isch

Total
stroke

0

8
5

1

Hem
stroke

Major
bleed

Death
MI
Stroke

Keeley and Grines. Lancet 2003
©2014 MFMER | Slide-17


Time to Reperfusion
Effectiveness of Thrombolysis and PPCI
PCI

Thrombolysis
Benefit

Benefit

< 2 Hours
> 2 Hours

Lysis or PPCI
PPCI
Risk

Risk
Time

Time

Consider Pharmaco-Invasive Approach

©2014 MFMER | Slide-18


“The Problem of Time”
80

1st

60

Greatest benefit in

40

Minimal additional
benefit after 3 hours

hr

20

1-yr Mortality (%)

Abs. Survival Benefit (per 1000
patients)

12

10

8

Each 30 min delay in
PPCI = 7.5% relative
increase in 1 year
mortality

6

4

2

0

0
3

6

9

12

15

Ischemic
Time (h)

Circulation 2004;109:1223
JAMA 2005;293:979-86

18

21

25

60

120

180

240

300

360

Ischemic
Time (Min)

©2014 MFMER | Slide-19


Absolute Risk Difference PCI vs Lytic (%)

Survival Benefits of Primary PCI and Time
15

10

>60 minute
Delay results in
no survival
benefit for
primary PCI

5

0

-5

20

40

60

80

100

DTB-DTN time (min)
AJC 2003;92:824
©2014 MFMER | Slide-21


Pharmaco-Invasive Strategy for STEMI
Importance of Medications and Timing
Pharmaco-Invasive
Lysis
+ clopidogrel
Transfer to CCU
Urgent/routine elective
Angio/PCI 3-24 hours
(Class IIa)
©2014 MFMER | Slide-28


1-Year Mortality in STREAM
Pharmaco-Invasive vs PPCI (n=1892)

Inclusion:

Symptoms <3 hours
PPCI > 1 hour

2 mm STE
PreHospital lytic eligible

Sinnaeve et al. Circulation 2014;130:1139.
©2014 MFMER | Slide-31


Pharmaco-Invasive vs PPCI Strategy
1216 Patients in Regional STEMI System (2009-11)
8
PharmacoInvasive
PPCI

6
%

4

All p=NS

2

0

Death/MI/CVA

Death

PPCI mean D2B=95 min

Stroke

Maj. Bleeding

PI mean D2N=31 min
Rashid, et al. JACC Card Int 2016;9:2014
©2014 MFMER | Slide-32


Reperfusion Strategy
No

Lytic
Eligible?

Transfer for
Primary PCI

Anticipated
Time from
FMC to PCI

Acceptable
Bleeding Risk?

Yes

PARAMEDIC
UNIT

23 5

Time of Symptoms
<3 Hours

3-12 Hours

<120
Minutes

Transfer for
Primary PCI

Transfer for
Primary PCI

>120
Minutes

Lytics and
Transfer

?

©2014 MFMER | Slide-34


©2014 MFMER | Slide-36

Access Choice in Stable Syndromes and ACS
Pooled Analysis of All-Cause Death

Ferrante et al. JACC CV Int 2016;9:1419
©2014 MFMER | Slide-42


Recent Trials of Complete Revascularization
in STEMI
Complete vs Culprit-Only

Complete Culprit-Only
Better
Better
Binder et al. Eur Heart J. 2016;37:217-220
©2014 MFMER | Slide-45


Recent Trials of Complete Revascularization
in STEMI
Ad hoc Complete vs Staged Complete
48/44

65/65

46/43

159/152

Binder et al. Eur Heart J. 2016;37:217-220

©2014 MFMER | Slide-46


Ischemia Evaluation in ACS
FFR Remote to Culprit Lesion
• 101 with MV disease
• 75 STEMI + 26 NSTEMI
• Stable hemodynamics
• FFR of remote lesion
during acute phase and
median 27 days later

No significant change
from acute phase to
early follow-up
Ntalianis A: JACC CV Intv 2010
©2014 MFMER | Slide-47


FAMOUS-NSTEMI
FFR- vs Angiography-Guided Management
350 NSTEMI with at least 1 lesion ≥30% stenosis
FFR Disclosure modified treatment choice in 21.6%
Similar MACE with 8% lower revascularization rates
MACE

But lesion deferral in ACS controversial
(Especially of presumed culprit lesion)
DANAMI 3-PRIMULTI trial demonstrated safety and
feasibility of FFR in STEMI patients w/in 2 days

Layland, et al. EHJ 2015;36:100
Hakeem, et al. JACC 2016;68:1181

©2014 MFMER | Slide-48


BMS vs PTCA in AMI
Meta-Analysis of 13 RCT (n=6922)

De Luca et al. Int J Card 2007;119:306
©2014 MFMER | Slide-49


EXAMINATION Trial
2-Year Outcome Xience V (EES) vs Vision (BMS)
PCI within 48 hours (85% PPCI within 12 hr) for STEMI

Sabate et al. JACC CV Int 2014; 7:64
©2014 MFMER | Slide-50


Jolly et al. Lancet 2015

Higuma JACC Card Int 2016;8:2002
©2014 MFMER | Slide-54