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PRIMARY ANGIOPLASTY DR. RAJAT GANDHI, INTERVENTIONAL CARDIOLOGIST ,
BANKERS HEART INSTITUTE , VADODRA .
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RISK FACTORS FOR CAD HYPERTENSION DIABETES MELLUTUS SMOKING OBESITY
LACK OF EXERCISE DYSLIPIDAEMIA
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CORONARY ARTERY DISEASE
NON- ST ELEVATION MI AND UNSTABLE ANGINA ST -ELEVATIONMI STABLE ANGINA
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CORONARY ARTERY DISEASE
STABLE ANGINA - Chest discomfort precipitated by physical exertion releived by rest or nitrates . UNSTABLE ANGINA -occurs at rest, last for more than 20 min, severe pain . NSTEMI – evidence of myocardial necrosis with high cardiac enzymes . STEMI - Complete occlusion of one coronary artery .
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SYMPTOMS OF ACS -sudden onset of retrosternal CHEST PAIN.
-lasting for more then 30 min . -associated with nausea,vomiting, shortness of breath
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APPROACH TO THE PATIENT WITH ST – ELEVATION MI
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TIME
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GENERAL TREATMENT MEASURES
ASPIRIN MG CLOPIDOGREL /PRASUGREL/TICAGRELOR. STATIN (ATORVA -80MG,ROSUVA – 40 MG) NITRATES(IF HAEMODYNAMICALLY STABLE) OXYGEN
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TIMI RISK SCORE FOR STEMI
AGE >75 YRS SBP<100MMHG HEART RATE >100/MIN LBBB H/O DM/HTN AWMI TIME TO TREATMENT >4HRS
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FIBRINOLYTICS Streptokinase MU in 30 – 60 min , allergic reactions, marked fibrinogen depletion , 50 % -90min patency rate , Tenectplase – mg bolus , no allergic reaction , 75 % - 90 min patency rate , minimal fibrinogen depletion. Reteplase –10 u two bolus , 30 min apart , moderate fibrinogen depletion ,75% - 90 min patency rate . Alteplase – up to 100 mg in 90 min , mild fibrinogen depletion , 75% - 90 min patency rate .
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ACTION OF FIBRINOLYTICS
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CONTRAINDICATIONS FOR FIBROLYTIC USE IN STEMI
ABSOLUTE – PRIOR ICH , CEREBERAL VASCULAR AV MALFORMATIONS , ISCHEMIC STROKE WITHIN 3 MONTHS , SUSPECTED AORTIC DISSECTION , BLEEDING DISORDERS , INTRACRANIAL NEOPLASMS . RELATIVE – SBP >180 , DBP > 110MMHG, PREGNANCY , RECENT INTERNAL BLEEDING , RECENT MAJOR SURGERY, ISCHEMIC STROKE MORE THAN 3 MONTHS .
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COMPLICATIONS OF FIBRINOLYTICS
FATAL INTRACRANIAL HAEMORRAGE . INADEQUATE MYOCARDIAL REPERFUSION CARDIOGENIC SHOCK . MYOCARDIAL RUPTURE . ANTIBODY RESISTANCE TO STREPTOKINASE .
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ACC 2013 GUIDELINES FOR FIBRINOLYTIC THERAPY IN ACS PATIENTS .
IIa IIb III A In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed Within 120 min. I IIa IIb III In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12 to 24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability. I IIa IIb III B Fibrinolytic therapy should not be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR. Harm
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CORONARY ANGIOPLASTY PRIMARY ANGIOPLASTY – EMERGENCY PERCUTANEOUS CORONARY INTERVENTION (PCI) IN PATIENTS WITH ACUTE ST ELEVATION MYOCARDIAL INFARCTION PRESENTED WITHIN 12 HOURS OF ONSET OF SYMPTOMS . RESCUE ANGIOPLASTY – PCI IN PATIENTS WITH FAILED THROMBOLYSIS . FACILITATED ANGIOPLASTY –PCI IN PATIENTS WITH STEMI WHO ARE PRETREATED WITH GP IIBIIIA INHIBITORS OR FIBRINOLYTICS .
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ACC 2013 GUIDELINES FOR PRIMARY PCI IN STEMI.
IIa IIb III A Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration. I IIa IIb III B Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC. I IIa IIb III B Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset.
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ACC GUIDELINES 2013 FOR PRIMARY PCI in STEMI
IIa IIb III B Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset. I IIa IIb III B PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable Harm
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Antiplatelet Therapy to Support Primary PCI for STEMI
IIa IIb III B A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. Options include: Clopidogrel 600 mg; or Prasugrel 60 mg; or Ticagrelor 180 mg
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Antiplatelet Therapy to Support Primary PCI for STEMI
IIa IIb III B Aspirin 150 to 300 mg should be given before primary PCI. I IIa IIb III A After PCI, aspirin should be continued indefinitely.
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Antiplatelet Therapy to Support Primary PCI for STEMI
IIa IIb III B P2Y12 inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (BMS or DES) during primary PCI using the following maintenance doses: Clopidogrel 75 mg daily; or Prasugrel 10 mg daily; or Ticagrelor 90 mg twice a day* *The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.
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Antiplatelet Therapy to Support Primary PCI for STEMI
IIa IIb III B Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic attack. Harm
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New Inhibitors of the platelet the ADP P2Y12 receptor
Receptor Binding Prodrug (requires hepatic activation) Onset of Action Half life Clopidogrel Irreversible Yes Slow Long Prasugrel Irreversible (stronger) More rapid Ticagrelor Reversible (stronger) No Rapid Short
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PLATO: ticagrelor vs clopidogrel in ACS (n=18624)
Wallentin L et al. N Engl J Med 2009 Reduced risk of CV events with no increase in bleeding risk
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NEWER ANTIPLATELETS PRASUGREL – risk of stent thrombosis is half compared to clopidogrel , side effects ; high risk of bleeding in patients with weight <60 kg and age > 75 . TICAGRELOR - reversible platelet inhibitor , safely given in patient with no restriction in age and weight .
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Use of Stents in Patients With STEMI
Reperfusion at a PCI-Capable Hospital Use of Stents in Patients With STEMI
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Use of Stents in Patients With STEMI
IIa IIb III A Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI. I IIa IIb III BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year. I IIa IIb III B DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents. Harm *Balloon angioplasty without stent placement may be used in selected patients.
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PRIMARY ANGIOPLASTY Arrival After balloon Balloon Open artery Closed
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PRIMARY ANGIOPASTY
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PCI IN STEMI PATIENTS
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DES vs BMS for primary PCI: meta-analysis of RCTs (n=2786)
HR: 0.80 ( ) HR: 0.38 ( ) Kastrati A et al. Eur Heart J 2007;28:
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BARE METAL STENT BMS currently used in 10% to 20 % patients .
Large size vessel > 4.0 mm in diameter . Restenosis is higher in small size vessel ,long lesions and patients with diabetes . Used in patients where dual antiplatelets cannot be given for longer time .
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DRUG ELUTING STENTS Made up of cobalt chromium .
Coated with durable polymer and drug. Polymer helps sustained release of drug over 30 days. Drugs like sirolimus, paclitaxel, everolimus. Theses drugs are immunosuppressive and antiproliferative which prevent intimal hyperplasia .
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PCI IN NSTEMI PATIENTS
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Trials of Invasive vs Conservative
ACS indicates acute coronary syndromes; CI, confidence interval; MI, myocardial infarction; NSTE, non–ST-segment elevation. Size of data markers is weighted based on the inverse variance. O’Donoghue, M. et al. JAMA 2008;300:71-80
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Days after presentation
NSTEMI: don’t under-estimate it Prognosis: poor NSTEMI Non-MI ACS STEMI Chest Pain ?cause Days after presentation Probability of dying Undertreated
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NSTEMI -etiology and prognosis
Myocyte necrosis – troponin levels Haemodynamic stress – bnp and nt probnp levels Vascular damage – microalbuminurea Inflammation – hsCRP Acclerated athersclerosis HBA1C LEVELS
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CLINICAL INDICATORS OF HIGH RISK IN NSTEMI .
AGE >70 YRS LBBB INCREASED TROPONIN LEVELS . INCRRASED CREATININE ,HBA1C,BNP LEVELS HYPOTENSION HEART FAILURE
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Anticoagulant Therapy to Support Primary PCI
For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended: I IIa IIb III UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered; or I IIa IIb III B Bivalirudin with or without prior treatment with UFH.
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Antiplatelet Therapy to Support Primary PCI for STEMI
It is reasonable to start treatment with an intravenous GP IIb/IIIa receptor antagonist at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving UFH. I IIa IIb III A Abciximab: 0.25 mg/kg IV bolus, then mcg/kg/min (maximum 10 mcg/min); or I IIa IIb III B High-bolus-dose tirofiban: 25 mcg/kg IV bolus, then 0.15 mcg/kg/min; or I IIa IIb III B Double-bolus eptifibatide: 180 mcg/kg IV bolus, then 2 mcg/kg/min; a 2nd 180-mcg/kg bolus is administered 10 min after the 1st bolus.
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CABG in Patients With STEMI
IIa IIb III B Urgent CABG is indicated in patients with STEMI with severe LMCA DISEASE . I IIa IIb III B CABG is recommended in patients with STEMI at time of operative repair of mechanical defects.
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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy I IIa IIb III B Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable* and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy. *Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.
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Transfer of Patients With STEMI to a PCI-Capable Hospital for Coronary Angiography After Fibrinolytic Therapy I IIa IIb III B Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset. I IIa IIb III B Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.
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Importance of Time to Reperfusion
Reinfarction Microvascular Reperfusion Myocardial Salvage
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“Time is Muscle”
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Improvement in LV Ejection Fraction
by Time to Reperfusion 4.8% p=0.03 2.5% Improvement LVEF % (7 mos) -0.2% <3 3-6 >6 Time to Reperfusion (hrs) Brodie ACC 2003
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Myocardial Salvage by Time to Reperfusion with Primary PCI
Myocardial Salvage Index % Time to Reperfusion O’keefe J Nucl Cardiol 1995;2:35
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Time to Reperfusion and Re-infarction
CADILLAC (One Year) Stent PAMI (6 Months) 4.2% p=0.03 3.3% 3.0% 2.6% p=0.003 Re-infarction % 1.5% 1.4% 0% <3 3-6 >6 <2 2-4 4-6 >6 Time to Reperfusion (hrs) Brodie AJC 2001;88:1085 Brodie ACC 2003
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Door-to-Balloon Time and One Year Mortality
Stratified by Time to Presentation CADILLAC Trial p=NS 5.1% 4.8% p=0.12 3.9% DB Time < 1.5 hrs DB Time > 1.5 hrs 1.9% <2 hrs >2 hrs Time To Presentation Brodie ACC 2003
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Door-to-Balloon Time and In-Hospital Mortality NRMI-2 Registry
2.2 2 (n=27,080) 1.8 1.62 1.61 1.6 Adjusted Odds Ratio 1.41 1.4 1.2 1.14 1.15 1 0.8 0.6 <1.0 >3.0 Door-to-Balloon Time (hrs) Cannon JAMA 2000;283:2941
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Death at 3 years – presentation delay
Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)
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Time to Reperfusion and One Year Mortality CADILLAC Trial (n=2002)
4.8 4.4 4.2 p=0.04 (<3 hrs vs >3 hrs) 2.6 2.6 One Year Mortality % <2 2-3 3-4 4-6 6-12 (n=121) (n=438) (n=455) (n=475) (n=513) Time to Reperfusion (hrs) Brodie JAAC 2003
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COMPARISON BETWEEN PRIMARY PCI AND THROMBOLYSIS
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PCI vs Fibrinolysis for STEMI:
Short-Term Clinical Outcomes PCI N=7739 Fibrinolysis P<.0001 Frequency (%) P<.0001 P=.0002 P=.0003 P<.0001 P=.032 Metaanalysis of 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. P=.0004 P<.0001 Death Death, no shock data ReMI Rec. Ischemia Total Stroke Hem. Stroke Major Bleed Death MI CVA Keeley E, et al. Lancet ;361:13-20.
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Local tPA vs Transport for Primary PCI
DANAMI-2: 30 Day Outcomes Local tPA vs Transport for Primary PCI (n=1129) tPA 14.2 p=0.002 PCI (55 minute treatment delay) Incidence % 8.5 8.5 6.5 6.2 p<0.001 1.9 2.0 1.6 Death Re-infarction CVA MACE Anderson NEJM 2003
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Results of trials examining post-procedural complications associated with PCI and thrombolysis
Lancet 2003;361:13–20. N Engl J Med 1999;341:1413–19 N Engl J Med 1993;328:673–9. Eur Heart J 2007;28:679–84
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Comparison of outcomes in ASSENT-4 with those in other trials of TNK in MI patients
End point ASSENT-2 (n=8461) (%) ASSENT-3 (n=2038) (%) ASSENT 3+ (n=821) (%) ASSENT-4 TNK+PCI (n=829) (%) ASSENT-4 PCI alone (n=836) (%) 30-day death 6.2 6.0 3.8 Intracranial hemorrhage 0.93 0.97 Total stroke 1.8 1.7 1.5 Re-MI 4.1 4.2 5.8 5.2 2.7 Major bleed 4.7 2.2 2.8 5.7 4.4
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COMPARISON BETWEEN PRIMARY PCI AND FACILITATED PCI
Mortality Reinfarction Major Bleeding Lytic alone N=2953 IIb/IIIa alone N=1148 Lytic +IIb/IIIa N=399 All (N=4500) 1.43 ( ) ( ) 1.03 ( ) ( ) 3.07 ( ) 1.03 ( ) Facilitated PCI (PCI with additional therapy) with fibrinolytics shows clear increase mortality. Primary PCI vs Facilitated with GPIIb/IIIa shows no difference. 1.38 ( ) 1.71 ( ) 1.51 ( ) 0.1 1 10 0.1 1 10 0.1 1 10 Fac. PCI Better PPCI Better Fac. PCI Better PPCI Better Fac. PCI Better PPCI Better Keeley E, et al. Lancet 2006;367:579.
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Systematic reviews
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Individual studies – Gusto II B
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Days from Randomization
Primary Endpoint: 30-Day Death, re-MI, CHF, Severe Recurrent Ischemia, Shock % of Patients 18 16.6 16 14 OR=0.537 (0.368, 0.783); p=0.0013 12 10.6 10 8 6 4 Standard PCI > 24 hrs (n=496) Invasive < 6 hrs (n=508) 2 5 10 15 20 25 30 Days from Randomization n=496 n=508 422 468 415 466 415 463 414 461 414 460 412 457
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SUMMARY PRIMARY PCI IS BETTER THAN THROMBOLYSIS.
DEFINITE MORTALITY BENEFIT WITH PRIMARY PCI . COMPLICATIONS ARE LESS WITH PRIMARY PCI . PUBLIC AWARENESS IS REQUIRED TO EXPLAIN THE IMPORTANCE OF PRIMARY PCI . RESTORATION OF LV FUNCTION AND SALVAGE OF CARDIAC MUSCLE IS BEST WITH PRIMARY PCI .
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THANK YOU
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