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Riyadh 14th February 2013

Changing Pattern of STEMI and the New European Guidelines Carlo Di Mario, MD, PhD, FACC, FRCP, FESC Consultant Cardiologist Royal Brompton & Harefield Trust, London UK EAPCI Past-President; ESC Councillor Member Executive Committee SfL Programme


FAST-MI Registry

(STEMI patients only)

USIK 1995

1536 STEMI

USIC 2000

1844 STEMI

FAST-MI 2005

FAST-MI 2010

1611 STEMI

1716 STEMI

6707 patients in all 4 surveys N. Danchin | Munich ESC 2012


Current smoking

Obesity

Men

Women

N. Danchin | Munich ESC 2012


ESC STEMI Guidelines 2003

Frans van der Werf


Reperfusion therapy in STEMI patients (changes over time)

Early/Rescue PCI: 9.9% Any PCI after lysis: 15%

24% 60%

58% 84%

N. Danchin | Munich ESC 2012

55% 87%


30-d Mortality

(changes over time)

Evolution

Multivariable-adjusted risk Adjusted for age, sex, BMI, risk factors, previous history, and use and type of reperfusion therapy

N. Danchin | Munich ESC 2012


Evolution of 30-day mortality according to use and type of reperfusion therapy

N. Danchin | Munich ESC 2012


11


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


STEMI 2012 Guidelines: Regional Network is recommended for STEMI patients management


Di Mario, Kristensen, Wijns, Widimsky, Fajadet Eds EuroIntervention 2012, SfL Supplement


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


Di Mario, Kristensen, Wijns, Widimsky, Fajadet Eds EuroIntervention 2012, SfL Supplement


UK STEMI Mortality

Di Mario et al (Eds) EuroIntervention 2012, SfL Suppl.


Di Mario et al (Eds) EuroIntervention 2012, SfL Supplement


New treatment timing goals


Radial access and culprit lesion treatment are recommended in pPCI


Study 2010 ESC-EACTS RIVAL Myocardial Revascularisation Guidelines


Study 2010 ESC-EACTS RIVAL Myocardial Revascularisation Guidelines


EuroIntervention, on-line February 2013


Thrombus aspiration but not liberal use IABP are recommended in pPCI


TAPAS: 1,071 pts with STEMI undergoing primary PCI randomized to manual aspiration (Export) vs. control Aspiration nonused/totally ineffective in ~ 40% pts!

Vlaar, Zijlstra et al. Lancet 2008


Residual Thrombus after 3 Passes

10 Days post-BMS After withdrawal ASA/Clop for GI Bleed

Residual Thrombus after 3 aspirations

Small thrombus prolapse post-stent

Proximal edge dissection


Thrombus residual (as percentage of pre-treatment amount detected with OCT)

Residual Thrombus expressed as Percentage of the initial thrombus Mass

Inefficiency of Drug Delivery and Manual Thrombectomy

ReoPro

Infuse

Abiciximab Infusion Prati et al.

Imola et al.

ExportPost-PCI Magro et al.

From Prati, Imola et al 2010


Aspiration Trials to Decrease Infarct Size Infarct Size (Nuclear) and Thrombectomy 25

Control

Aspiration

100

20

) V L (% e iz ts rc fa In

5

7.5

9

63

58

50

CPK

11

- M B

15

15 10

75

25

P=0.004

P=0.20

0

P=0.46 0

Kaltoft et al (n=225)

Expira (n=175)

TAPAS (n=1071)

Rescue catheter

Export catheter

Export catheter

Kaltoft A et al. JACC 2006;114:40-47

Sardella G et al. JACC 2009;53:309–15

Svilaas T et al. NEJM 2008;358;-557-67


INFUSE-AMI Trial 452 pts with anterior STEMI Anticipated Sx to PCI <5 hrs, TIMI 0-2 flow in prox or mid LAD Primary PCI with bivalirudin anticoagulation Pre-loaded with aspirin and clopidogrel 600 mg or prasugrel 60 mg

R 1:1

Stratified by symptoms to angio <3 vs ≥3 hrs, and prox vs mid LAD occlusion

Manual aspiration

No aspiration

R 1:1

R 1:1

IC Abcx

No Abcx

IC Abcx

No Abcx

Primary endpoint: Infarct size at 30 days (cMRI) 2º endpoints: TIMI flow, blush, ST-resolution, MACE (30d, 1 yr) Stone GW et al. JAMA 2012


INFUSE-AMI: Infarct size at 30 days Median [IQR]

Median [IQR]

17.0%

17.3%

Infarct size, %LV

[9.0, 22.8]

[7.1, 25.5]

P=0.51

Aspiration N=229

No aspiration N=223 Stone GW et al. JAMA 2012


Thrombus aspiration but not liberal use IABP are recommended in pPCI


CRISP AMI Study RIVAL Study 2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


Results

Primary Study Endpoint (30-Day Mortality) 50 Control

Mortality (%)

40

41.3% 39.7%

IABP 30

20 P=0.92 by log-rank test Relative risk 0.96; 95% CI 0.79-1.17; P=0.69 by Chi 2-Test 10

0

0

5

10

15

20

25

30

Time after Randomization (Days) H. Thiele | DE | 2799


Thiele et al N Engl J Med. 2012;367:1287-96.


2010 ESC-EACTS Myocardial Revascularisation Guidelines


2010 ESC-EACTS Myocardial Revascularisation Guidelines


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