1. PRIMARY ANGIOPLASTY DR. RAJAT GANDHI, INTERVENTIONAL CARDIOLOGIST ,
BANKERS HEART INSTITUTE , VADODRA .

2. RISK FACTORS FOR CAD HYPERTENSION DIABETES MELLUTUS SMOKING OBESITY
LACK OF EXERCISE
DYSLIPIDAEMIA

3. CORONARY ARTERY DISEASE
NON- ST ELEVATION
MI AND UNSTABLE ANGINA
ST -ELEVATIONMI
STABLE ANGINA

4. 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 .

5. SYMPTOMS OF ACS -sudden onset of retrosternal CHEST PAIN.
-lasting for more then 30 min .
-associated with nausea,vomiting, shortness of breath

6. APPROACH TO THE PATIENT WITH ST – ELEVATION MI

7. TIME

8. GENERAL TREATMENT MEASURES
ASPIRIN MG
CLOPIDOGREL /PRASUGREL/TICAGRELOR.
STATIN (ATORVA -80MG,ROSUVA – 40 MG)
NITRATES(IF HAEMODYNAMICALLY STABLE)
OXYGEN

9. TIMI RISK SCORE FOR STEMI
AGE >75 YRS
SBP<100MMHG
HEART RATE >100/MIN
LBBB
H/O DM/HTN
AWMI
TIME TO TREATMENT >4HRS

10. 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 .

11. ACTION OF FIBRINOLYTICS

12. 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 .

13. COMPLICATIONS OF FIBRINOLYTICS
FATAL INTRACRANIAL HAEMORRAGE .
INADEQUATE MYOCARDIAL REPERFUSION
CARDIOGENIC SHOCK .
MYOCARDIAL RUPTURE .
ANTIBODY RESISTANCE TO STREPTOKINASE .

14. 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

15. 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 .

16. 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.

17. 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

18. 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

19. 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.

20. 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.

21. 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

22. 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

23. 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

24. 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 .

25. Use of Stents in Patients With STEMI
Reperfusion at a PCI-Capable Hospital
Use of Stents in Patients With STEMI

26. 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.

27. PRIMARY ANGIOPLASTY
Arrival
After balloon
Balloon
Open artery
Closed

28. PRIMARY ANGIOPASTY

29. PCI IN STEMI PATIENTS

30. 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:

31. 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 .

32. 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 .

33. PCI IN NSTEMI PATIENTS

34. 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

35. 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

36. NSTEMI -etiology and prognosis
Myocyte necrosis – troponin levels
Haemodynamic stress – bnp and nt probnp levels
Vascular damage – microalbuminurea
Inflammation – hsCRP
Acclerated athersclerosis HBA1C LEVELS

37. CLINICAL INDICATORS OF HIGH RISK IN NSTEMI .
AGE >70 YRS
LBBB
INCREASED TROPONIN LEVELS .
INCRRASED CREATININE ,HBA1C,BNP LEVELS
HYPOTENSION
HEART FAILURE

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. Importance of Time to Reperfusion
Reinfarction
Microvascular Reperfusion
Myocardial Salvage

44. “Time is Muscle”

45. 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

46. Myocardial Salvage by Time to Reperfusion with Primary PCI
Myocardial Salvage Index %
Time to Reperfusion
O’keefe J Nucl Cardiol 1995;2:35

47. 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

48. 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

49. 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

50. Death at 3 years – presentation delay
Maeng,M et al. Am J Cardiol 2010;105:1528 –1534)

51. 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

52. COMPARISON BETWEEN PRIMARY PCI AND THROMBOLYSIS

53. 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.

54. 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

55. 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

56. 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

57. 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.

58. Systematic reviews

59. Individual studies – Gusto II B

60. 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

61. 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 .

62. THANK YOU