1. Treatmant patients with acute myocardial infarcton in Bosnia and Herzegovina BH Heart Centre Tuzla Terzić I, Čaluk J, Delić A, Osmanović E, Porović E, Avdić S.

2. Implementation of the STEMI ESC Guidelines

3. ACC/AHA & ESC guidelines ESC STEMI – guidelines Primary PCI(Pre)hospital Thrombolyse Rescue PCI Onset of chestpain <12 h & transp.< 90 min to PCI rTPA if 45 – 60 min to PCI-senter No effect of thrombolyse after 45-60min: Contraindication to thrombolysis <50% ST-resolution, ongoing chestpain, arrythmias, hemodynamic unstable Patients <75 with cardiac shock early after MI (12- 36t) <75 year & cardiac shock On and off – symptoms for a longer period (EKG)

4. Myokardnekrose Starts 30-45min after occlusion After 90min is 40-50% necrotised After 6h the necrosis is often complete Collaterals modify Occlusion is often sub-total or fluctuating AHA Textbook of Advanced Cardiac Life Support, 1999

5. Trombolyse PCIPrehospitalt EKG

6. Reperfusion Options for STEMI Patients Step One: Assess Time and Risk. Time Since Symptom Onset Time Required for Transport to a Skilled PCI Lab Risk of STEMI Risk of Fibrinolysis

7. 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 Reperfusion Options for STEMI Patients Step 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.

8. 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 Reperfusion Options for STEMI Patients Step 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.

9. Evolution of PCI for STEMI Antman. Circulation 2001;103:2310. BalloonAntiplatelet Rx StentDES GP IIb/IIIa inhibitor ASA Clopidogrel AngioJet Thrombus Removal and Distal Embolization Protection Devices Embolization Protection Device Platelet

10. The essence in todays PCI - ”Guidelines” (2005). STEMI should be evaluated with respect to reperfusion therapy immediately Establish good networks –Preshospital services –Local hospitals –PCI-centra Implement details in guidelines at all levels in the treatment chain

11. Reperfusion strategy Recommendation IA…. Primary PCI –All when < 90 –120 (?) min. to balloon –All with contraindicasion to thrombolysis –Probably most patients with long chest pain history (> 3 – 6 - 12 t??) Thrombolyse to the others; –preferably prehospital and within 3 h from onset of symptoms

12. Prognostic PCI Recommendation IA PCI within 24 hrs after sucessful thrombolysis –Randomised trials; effect on combined endpoints –No effect on mortality –Discussed…..

13. Rescue PCI Recommendation IB-IIC Cardiac shock <75 y & <18 h after development of shock (IB) Unsuccessful thrombolysis after 45-60 min (ECG & clinical eval) (IIC)

14. Combined strategy, recomm IIB Pretreatment with thrombolysis or Gp-IIb- IIIa-inhibitor before PCI in high-risk? –Insufficient documentation (Garcia, SIAM..) –ASSENT IV; higher mortality with combined treatment (6%)versus primary PCI(3,8%), but positiv for some groups and some weekness in the study –STREAM??

15. ”Facilitated PCI” (thrombolysis before PCI) ASSENT-4 trial, Lancet 2006; 367:569-78. PCI: 3,8% Tenecteplase + PCI: 6,0% 30d mort. But, pts with prehospital thrombolysis; ~2%

16. Pretreatment before primary PCI MONA (morphine, Oxyg, Nitro, ASA 300) Heparin bolus;5-10.000 iv.(70IE/kg iv. ) Clopidogrel 600mg pr. os Evt. Thrombolyse befor transportation (facilitated PCI) when high risk??

19. TREATMENT MI IN EUROPE Anual incidence of hospital admissions 900-3120 on mil. STEMI amdissions 440-1420 on mil. P-PCI 20-920 on mil. P-PCI 5-92% TL – thrombolysis 0-55% Single p-PCI centre 0.3-7.4 mil In hospital mortality 4,2-13,5% P-PCI mortality 2,7-8 % TL mortality 3,5-14%

20. 3.9 mill 88/km 2 GNP 2300 US$/year (2005) Bosnia and Herzegovina

21. Interventional cardiology in BiH PCI centres 5 PCI-mil. 770.000 Independent interv.cardiologists 11 Anual MI admissions 7200 Anual STEMIs 3100

22. Invasive procedures in Bosnia and Herzegovina Coronography PCI 2007. 3676 616 2008. 3167 784 2009. 3569 1018

23. Implementation of the STEMI ESC Guidelines in Bosnia and Herzegovina 2009. 8 interventional cardiologists, 4 PCI centres PCI totaly 1018 PCI – per centre 254 PCI – per operator 127 Primary PCI –NA les then 10% Radial – brachial access (%)1 Abciximab (%)4 IABP(%)1 Respirator(%)1

24. Challenges: –Geography –Distances –Number of invasive centers –24 hours on call – costs –Transportation –Revascularisation mode; PCI? Thrombolysis? –Prehospital ECG-systems –Responsibility for patients Implementation of the STEMI ESC Guidelines in Bosnia and Herzegovina

25. STEMI – Do we need more PCI-centers?

27. ”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 New PCI – centers

29. M.R.38 y.m. STEMI inf.

34. B.M.44 m STEMI ant.