I International Symposium on Prevention of Cardiovascular Diseases Kraków Prevention of Heart Failure after AMI MAŁOPOLSKA STUDY A 2256-Patients Registry in Krakow Prewencja niewydolności krążenia po zawale – Program Małopolski Prof. dr hab. Jacek S Dubiel Dr med. Dariusz Dudek Dr hab. med. Krzysztof Żmudka Dr med. Mieczysław Pasowicz Prof. dr hab.. Wiesława Tracz Dr med. Łukasz Rzeszutko

I International Symposium on Prevention of Cardiovascular Diseases Kraków The Krakow Experience Primary PCI I II I 1999 year invasive reperfusion for 2 mlns Primary PCI + GpIIb/IIIatransfer delay <90min 2004 year 700 primary PCI / 1 mln

I International Symposium on Prevention of Cardiovascular Diseases Kraków Primary PCI - ESC PCI, march2005 REMARKS 1)Prolonged symptom to treatment times are associated with impaired myocardial perfusion independent of epicardial flow 2)PRIMARY PCI - Data based on: a.high volume centers b.experienced operators c.short response time (delay) RESULTS DO NOT NECESSARILY APPLY IN OTHER SETTINGS 3)DELAY in initiating Primary PCI > 2-3h => recommendation for fibrynolitic agents (2nd or 3rd generation)

I International Symposium on Prevention of Cardiovascular Diseases Kraków p. tatrzański 65,3 tys. p. nowotarski 179,9 tys. p. limanowski 120,2 tys. Nowy Sącz + p. nowosądecki 279,4 tys. p. gorlicki 106,4 tys. p. suski 81,5 tys. p. wadowicki 153,4 tys. p. oświęcimski 153,1 tys. p. chrzanowski 128,7 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys. p. brzeski 89,7 tys. Kraków + p. krakowski 998,8 tys. p. myślenicki 114,9 tys. 86 km 60 – 120min Tarnów + p. tarnowski 310,5 tys. 85 km min 98 km 100 – 150min 125 km 120 – 180min

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI - ESC PCI, march2005 Facilitated PCI is defined as planned intervention within 12hrs after onset of chest pain or symptoms, soon after clot dissolving medication to bridge the delay between first medical contact and primary PCI term not uniformly used 1. Thrombolysis facilitated primary PCI 2. Gp IIb/IIIa inhibitor facilitated primary PCI

I International Symposium on Prevention of Cardiovascular Diseases Kraków Cathlab Acute MI < 12 hrs in the region of 3.4 mln inhabitants transfer delay < 30min (Ia) Thrombectomy and PCI and abciximab Tele ECG transfer delay < 90min (Ib) abciximab PCI transfer delay > 90min (II) abciximab + ½ lyitcs & transfer for PCI II Ib 150 km Ia

I International Symposium on Prevention of Cardiovascular Diseases Kraków p. nowotarski 179,9 tys. p. limanowski 120,2 tys. Nowy Sącz + p. nowosądecki 279,4 tys. p. gorlicki 106,4 tys. p. suski 81,5 tys. p. wadowicki 153,4 tys. p. oświęcimski 153,1 tys. p. chrzanowski 128,7 tys. p. olkuski 114,7 tys. p. miechowski 51,5 tys. p. proszowicki 43,6 tys. p. dąbrowski 58,6 tys. p. brzeski 89,7 tys. p. tatrzański 65,3 tys. p. myślenicki 114,9 tys. Tarnów + p. tarnowski 310,5 tys. Kraków + p. krakowski 998,8 tys. p. wielicki 102,5 tys. p. bocheński 99,7 tys.

I International Symposium on Prevention of Cardiovascular Diseases Kraków AMI : ST pain onset < 12h transfer time to the cath lab > 90 minutes ½ tPA + full dose Gp IIb/IIIa Facilitated PCI Interhospital transfer for long distance Age < 75 years, no shock, eligible for lytics Transfer to the cath lab Facilitated PCI in Patients with Acute Myocardial Infarction D, Dudek et al., Am J Cardiol, 2003

I International Symposium on Prevention of Cardiovascular Diseases Kraków Jagiellonian University Institute of Cardiology, Krakow, Poland - 2 buildings; 6 cathlabs - 24 interventional cardiologists In 2004, have been performed: 4000 PCIs

I International Symposium on Prevention of Cardiovascular Diseases Kraków June2001 – June2003 AMI ST n=2256II I II I 3.4 millions population

I International Symposium on Prevention of Cardiovascular Diseases Kraków Time delays 357 min. 206 min. = 150 min. = 150 min. Krakow, STEMI registry

I International Symposium on Prevention of Cardiovascular Diseases Kraków Transport complications for patients treated with facilitated PCI in AMI Death0 (0,0%) stroke0 (0,0%) Rhythm disorders VF bradycardia (HR<60/min) ventricular disorders AF 116 (17,4%) 18 (2,7%) 21 (3,1%) 70 (10,5%) 7 (1,1%) Conduction disorders (AV block 2 degree and higher) 15 (2,2%) Hypotonia31 (3,1%)

I International Symposium on Prevention of Cardiovascular Diseases Kraków Primary PCI vs Facilitated PCI TIMI 2-3 ~85%

I International Symposium on Prevention of Cardiovascular Diseases Kraków day MACE PRIMARY PCI vs FACILITATED PCI NS

I International Symposium on Prevention of Cardiovascular Diseases Kraków Kaplan-Meier curves for survival 1 year follow up Zone II Zone I

I International Symposium on Prevention of Cardiovascular Diseases Kraków Bleeding complications PRIMARY PCI vs FACILITATED PCI p= NS p= ICH p= Krakow, STEMI registry

I International Symposium on Prevention of Cardiovascular Diseases Kraków Independent predictors of 6 months left ventricular EF recovery from multivariate analysis for patients treated with facilitated PCI in AMI. VariableCoef.p[95% Conf. Interval] Age Occluded IRA Diabetes mellitus Time from chest pain onset to lysis IRA TIMI flow after PCI const

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI subanalysis - IRA patency and outcome 225 non shock pts with AMI group A: 32 pts with TIMI 0+1group B: 193pts with TIMI 2+3 Angiography post PCI Echocardiography EF baseline and 6 month Clinical 12 month follow up 14%86% Dudek et al EHJ, 2004 abstract

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI - subanalysis LV EF (BP - ellipse) baseline and 6 months follow up p=NS p<0.001 p=NS p=0.012 Dudek et al EHJ, 2004 abstract

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI – 12-month Kaplan-Meier event-free survival curves for death and reinfarction.

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI – pain onset to admission at remote site impact on LV function recovery at 6 month Krakow registry 4,0% 2,9% -4,2% -15% -10% -5% 0% 5% 10% 15% Delta EF at 6m. 0-3 h3-6 h6-12 h

I International Symposium on Prevention of Cardiovascular Diseases Kraków Facilitated PCI is feasible for pts < 75 years with acute MI transfered from remote hospitals (delay 150 minutes) Transport is safe for pts on combined lytic and Gp IIb/IIIa blockers therapy Combined therapy opens infarct related artery (IRA) (TIMI 3+2) in 86 % of pts before PCI ! ! ! The Krakow Experience Interventional Treatment of Acute MI

I International Symposium on Prevention of Cardiovascular Diseases Kraków Patency of IRA before PCI influences: a. myocardial perfusion, b. systolic function recovery, c. long term clinical follow-up The highest benefits related to facilitated PCI were observed in pts with time from pain onset to fibrynolysis < 6 hrs Despite 150 minutes delay because of transporation MACE rates at 12 months follow-up was similar for facilitated and primary PCI The Krakow Experience Interventional Treatment of Acute MI

I International Symposium on Prevention of Cardiovascular Diseases Kraków STEMI - regional specific solutions when long transfer delays Facilitated PCI with GpIIb/IIIa or combination lytic therapy may be an option for the future (FINESSE, CARESS in AMI) 30-40% of STEMI pts population Community hospitals, interventional centers and ambulance service should set up networks for STEMI 60-70% of STEMI pts population a. elderly b. STEMI> 12 hrs c. cardiogenic shock d. ineligible for lysis