cardiologia intervencionista_tratamento na fase aguda
TRANSCRIPT
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Prof. Dr. EXPEDITO E. RIBEIROLIVRE-DOCENTE CARDIOLOGIA- FM USP
SUPERVISOR SERVIO DE HEMODINMICA INCOR-HCFMUSPDIRETOR SERVIO HEMODINMICA HOSP TOTALCOR
REUNIO HEMODINMICAE CARDIOINTERVENCIONISTA
REUNIREUNIO HEMODINO HEMODINMICAMICAE CARDIOE CARDIOINTERVENCIONISTAINTERVENCIONISTA
totalCOR2009totalCOR2009
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van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
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van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
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van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
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Khot, U. N. et al. Circulation 2004;109:2086-2091
Rates of occlusion, severe disease (>=70% stenosis), and patency according to graft typeand anastomosis site
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Khot, U. N. et al. Circulation 2004;109:2086-2091
Rates of occlusion, severe disease (>=70% stenosis), and patency according tograft type and anastomosis site
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Khot, U. N. et al. Circulation 2004;109:2086-2091
Rates of occlusion, severe disease (>=70% stenosis), and patencyaccording to graft type and anastomosis site
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A Randomized Comparison ofRadial-Artery and Saphenous-
Vein Coronary Bypass GraftsNimesh D. Desai, M.D., Eric A. Cohen, M.D., C. David Naylor, M.D., D.Phil.,
Stephen E. Fremes, M.D. and the Radial Artery Patency Study Investigators
N Engl J MedVolume 351;22:2302-2309
November 25, 2004
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Clinical Characteristics of All Patients and Those
Who Underwent Follow-up Angiography
Desai, N. et al. N Engl J Med 2004;351:2302-2309
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Operative Data on All Patients and Those WhoUnderwent Postoperative Angiography
Desai, N. et al. N Engl J Med 2004;351:2302-2309
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Angiographic End Points
Desai, N. et al. N Engl J Med 2004;351:2302-2309
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Angiographic End Points
Desai, N. et al. N Engl J Med 2004;351:2302-2309
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Clinical Outcomes among the 561 Patients
Desai, N. et al. N Engl J Med 2004;351:2302-2309
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ConclusionsConclusions Radial-artery grafts are associated with
a lower rate of graft occlusion at oneyear than are saphenous-vein grafts Because the patency of radial-artery
grafts depends on the severity of native-vessel stenosis, such grafts shouldpreferentially be used for target vesselswith high-grade lesions
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Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799
Five-year patency of threesubgroups of conduits
82%88%96%
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Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799
Comparative patencies of different in situ and freearterial conduits at 5 years
RA=RADIAL
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO
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RO pRO pssFIBRINOLFIBRINOL TICOTICOcom sucessocom sucesso
URGURGNCIANCIA PRIMPRIMRIARIA
ELETIVAELETIVA SALVAMENTSALVAMENTOO
SemSemFIBRINOLFIBRINOL TICOTICO
PrPrviovio
PAC estPAC est velvelTrat. lesTrat. lesooresidualresidual
RESCUERESCUEfalha dofalha do
FIBRINOLFIBRINOL TICOTICO
ATCATCIAMIAM
FACILITADFACILITADAA
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Volume 278(23) 17 December 1997 pp 2093-2098
Comparison of Primary Coronary Angioplasty andIntravenous Thrombolytic Therapy for Acute MyocardialInfarction: A Quantitative Review
[Review]Weaver, W. Douglas MD; Simes, R. John MD; Betriu, Amadeo
MD; Grines, Cindy L. MD; Zijlstra, Felix MD; Garcia, Eulogio MD;Grinfeld, Lilliana MD; Gibbons, Raymond J. MD; Ribeiro, Expedito
E. MD; DeWood, Marcus A. MD; Ribichini, Flavio MDFrom the Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich (Dr Weaver); National Health and Medical Research CouncilClinical Trials Centre, Sydney, Australia (Dr Simes); Hospital Clinico y Provincial, Barcelona, Spain (Dr Betriu); William Beaumont Hospital,Royal Oak, Mich (Dr Grines); Ziekenhuis De Weezenlanden, Zwolle, the Netherlands (Dr Zijlstra); Hospital General Gregorio Maranon, Madrid,Spain (Dr Garcia); Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Dr Grinfeld); Mayo Clinic, Rochester, Minn (Dr Gibbons); UnicorHospital, Sao Paulo, Brazil (Dr Ribeiro); Spokane Heart Research Foundation, Spokane, Wash (Dr DeWood); and Ospedale Santa Croce,Cuneo, Italy (Dr Ribichini
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00 22 44 66
2020
1515
1010
00
%%
55
m
ESTUDO PCATESTUDO PCATMORTALITYMORTALITY
p < 0.04p < 0.04
Thrombolysis
PTCA
11 Trials (198911 Trials (1989 --96)96)
LyticsLytics PTCAPTCA(N)(N) 13771377 13481348
Time (min)Time (min) 172172 219219
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LIES J APRENDIDASLIES J APRENDIDAS1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO
2. REPERFUSO TEMPO DEPENDENTE
NRMI 1 4 I f DNRMI 1 4 I t f D t
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NRMI 1-4: Impact of Door toBalloon
Time on In-hospital Mortality
NRMI 1-4: Impact of Door toBalloon
Time on In-hospital Mortality29,222 STEMI pts treated with PCI within 6 hrs of29,222 STEMI pts treated with PCI within 6 hrs ofpresentation at 395 hospitals from 1999 to 2002presentation at 395 hospitals from 1999 to 2002
< 900
> 90 - 120 > 120 - 150 > 150
Door to Balloon Time (min)
I n - h o s p i t a
l
M o r t a
l i t y R a t e
( % )
1
23
45
678
P trend < 0.001
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TIME TO TREATMENTmeta-analysis of lytics trials
TIME TO TREATMENTmeta-analysis of lytics trials
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ACC / AHA GUIDELINESACC / AHA GUIDELINES
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EUROPEAN HEART JOURNAL 2002
; 23:550-7
EUROPEAN HEART JOURNAL 2002
; 23:550-7
Relationship of Presentation DelayRelationship of Presentation Delay
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Relationship of Presentation Delayand Outcome for Primary PCI vs
Fibrinolysis
Relationship of Presentation Delayand Outcome for Primary PCI vs
Fibrinolysis
5,1%6,1%
6,7%
0%
5%
10%
15%
< 2hr 2-4hr > 4hr
5,1%6,1%
6,7%
0%
5%
10%
15%
< 2hr 2-4hr > 4hrSx Onset to Presentation,
Primary Angioplasty
Zijlstra F, Ribeiro E.Zijlstra F, Ribeiro E.et al EHJ 2002
6 - M o n
t h M o r t a
l i t y
5,4%
7,3%
14,6%
0%
5%
10%
15%
< 2hr 2-4hr > 4hr
5,4%
7,3%
14,6%
0%
5%
10%
15%
< 2hr 2-4hr > 4hrSx Onset to Presentation
Fibrinolysis
PCAT 2: PCI DELAY AND BASELINE ADJUSTEDPCAT 2: PCI DELAY AND BASELINE-ADJUSTED
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PCAT 2: PCI DELAY AND BASELINE-ADJUSTEDRISK OF 30-DAY MORTALITY
PCAT 2: PCI DELAY AND BASELINE ADJUSTEDRISK OF 30-DAY MORTALITY
BOERSMA E, RIBEIRO E et al EHJ 2006;27:779-788
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Pinto, D. S. et al. Circulation 2006;114:2019-2025
Selection criteria used for study
inclusion
R l i hi b PCI l d d l ( i i ) d i
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Pinto, D. S. et al. Circulation 2006;114:2019-2025
Relationship between PCI-related delay (minutes; x axis) and in-hospital mortality (%; y axis) as a continuous function was assessed
as a linear regression model
M lti i bl l i ti ti th t t t ff t f
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Pinto, D. S. et al. Circulation 2006;114:2019-2025
Multivariable analysis estimating the treatment effect of reperfusion therapy with PCI or fibrinolysis based on increasing
PCI-related delay
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Pinto, D. S. et al. Circulation 2006;114:2019-2025
Adjusted analysis illustrating significant heterogeneity in the PCI-related delay (DB-DN time) forwhich the mortality rates with primary PCI and fibrinolysis were comparable after the study
population was stratified by prehospital delay, location of infarct, and age
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LILIES JES J APRENDIDASAPRENDIDAS
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO2. REPERFUSO TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DAEXPERINCIA DO SERVIO E DO OPERADOR
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ACC / AHA GUIDELINESACC / AHA GUIDELINES
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PHYSICIAN VOLUME - OUTCOMESPHYSICIAN VOLUME - OUTCOMES
LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO2. REPERFUSO TEMPO DEPENDENTE3. OS RESULTADOS DEPENDEM DA EXPERINCIA DO SERVIO E DO OPERADOR
4. NOS MAIS GRAVES O BENEFCIO MAIOR
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IS PRIMARYPCI FOR SOMEAS GOOD AS
FOR ALL?
PRIMARY PCI MAKES THE BIGGESTPRIMARY PCI MAKES THE BIGGEST
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PRIMARY PCI MAKES THE BIGGEST
DIFFERENCE IN THE SICKEST
PRIMARY PCI MAKES THE BIGGEST
DIFFERENCE IN THE SICKEST
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BRODIE BR ey al JACC 2006;47:289BRODIE BR ey al JACC 2006;47:289--95.95.
CLASSIFICATION AND TREATMENTCLASSIFICATION AND TREATMENT
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CLASSIFICATION AND TREATMENTCLASSIFICATION AND TREATMENT
EFFECT BASED ON LEVEL OF RISKEFFECT BASED ON LEVEL OF RISK
AgeAge(years)(years)< 50< 50
5050 -- 5959
6060 -- 6969
>> 7070
00 11 22 33 44Number of RiskNumber of Risk
Low RiskLow Risk Intermediate RiskIntermediate Risk Higj RiskHigj Risk
Risk FactorsRisk Factors Anterior myocardial infarctionAnterior myocardial infarction Prior myocardial infarctionPrior myocardial infarction Systolic blood pressure < 115 mmHgSystolic blood pressure < 115 mmHg Pulse rate > 85/minPulse rate > 85/min
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3 0 d a y s
d e a t h
+ M I ( % )
3 0 d a y s
d e a
t h
+ M I ( % )
Risk groupRisk group
MORTALITY BY LEVEL OF RISKMORTALITY BY LEVEL OF RISKMORTALITY BY LEVEL OF RISK
LowLow
22..9977..22
IntermediateIntermediate
88.0.0
1212..77
HighHigh
1313..11
2424..11PTCAPTCA
TTTT
LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO2. REPERFUSO TEMPO DEPENDENTE3. OS RESULTADOS DEPENDEM DA EXPERINCIA DO SERVIO E DO OPERADOR
4. NOS MAIS GRAVES O BENEFCIO MAIOR
5. FIBRINOLTICOS E TERAPIA ADJUNTA
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO2. REPERFUSO TEMPO DEPENDENTE3. OS RESULTADOS DEPENDEM DA EXPERINCIA DO SERVIO E DO OPERADOR
4. NOS MAIS GRAVES O BENEFCIO MAIOR
5. FIBRINOLTICOS E TERAPIA ADJUNTA6. ATC FACILITADA VS ESTRATGIA
FARMACOINVASIVA
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DiMario , C et al LANCET 2008;371;559-568
CARESS-in-AMICARESS-in-AMI
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Events Rates, 30 DaysEvents Rates, 30 Days
DiMario , C et al LANCET 2008;371;559-568
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POOLED ANALYSIS OF THE RESULTS FROM 7 PUBLISHEDRANDOMIZED TRIALS IN PAT. TREATED WITH FIBRINOLYTIC
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Stone, G. W. Circulation 2008;118:552-566
COMPARING IMMEDIATE OR EARLY PCI WITH STENTING XDELAYED ISCHEMIA-DRIVEN OR ROUTINE PCI WITH STENTING
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Cantor ACC 2008** ST segment resolution
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00
22446688
10101212141416161818
00 55 1010 1515 2020 2525 3030
10.610.6
16.616.6
Days from RandomizationDays from Randomization
% of Patients% of Patients
Standard (n=496)Standard (n=496)Pharmacoinvasive (n=508)Pharmacoinvasive (n=508)
n=496n=496n=508n=508
422422468468
415415466466
415415463463
414414461461
414414460460
412412457457
CHF, Severe Recurrent Ischemia, ShockCHF, Severe Recurrent Ischemia, Shock
OR=0.537 (0.368, 0.783); p=0.0013
Components of Primary EndpointComponents of Primary Endpoint
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DeathDeathReinfarctionReinfarction
Recurrent IschemiaRecurrent IschemiaDeath/MI/IschemiaDeath/MI/Ischemia
New / worsening CHFNew / worsening CHF
Cardiogenic ShockCardiogenic Shock
StandardStandardTreatmentTreatment
(n=498)(n=498)3.63.66.06.0
2.22.211.711.75.25.2
2.62.6
PharmacoinvasivePharmacoinvasiveStrategyStrategy
(n=512)(n=512)3.73.73.33.3
0.20.26.56.52.92.9
4.54.5
PP--ValueValue
0.940.940.0440.044
0.0190.0190.0040.0040.0690.069
0.110.11
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LIES J APRENDIDASLILIES JES J APRENDIDASAPRENDIDAS
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1. ATC PRIMRIA SUPERIOR A FIBRINOLTICO2. REPERFUSO TEMPO DEPENDENTE3. OS RESULTADOS DEPENDEM DA EXPERINCIA DO SERVIO E DO OPERADOR
4. NOS MAIS GRAVES O BENEFCIO MAIOR
5. FIBRINOLTICOS E TERAPIA ADJUNTA6. ATC FACILITADA VS ESTRATGIAFARMACOINVASIVA
7.CONSIDERAES FINAIS
A modified algorithm for management of patients with STEMI according to time from symptomonset to hospital arrival, institutional interventional capability, and potential for interhospital
transfer, emphasizing increasing access to interventional reperfusion therapy
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Stone, G. W. Circulation 2008;118:552-566
transfer, emphasizing increasing access to interventional reperfusion therapy
minutes vs Mortality
minutes vs Mortalityminutes vs Mortality
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81.00%
43.50%
50%
72.00%
57.10%61.50%
89.50%
74.20%
84.60%
96.00%91.70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 070
0.5
1
1.5
2
2.5
3
3.5
DTB time < 90 minutes Mortality data
Courtesy of Greg Volturo, MD
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Acute MedicationsAcute Medications
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STEMI vs NSTEMISTEMI vs NSTEMI98% 96% 93%75%
84%
97%93% 90%
52%59%
0%
20%
40%
60%
80%
100%
ASA Beta Blockers Heparin(LMW+UFH)
GP llb-lllaInhibitors
Clopidogrel
STEMI NSTEMIACTION/CRUSADE DATA: July 1, 2006 June 30, 2007STEMI (n=11,854) NSTEMI (n=26,956)
Discharge MedicationsDischarge Medications
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sc a ge ed cat o sSTEMI vs NSTEMI
gSTEMI vs NSTEMI99% 97%
89% 91% 90%97% 95%
76%
86%
74%
0%
20%
40%
60%
80%
100%
ASA Beta Blockers ACE-I or ARB* Statins Clopidogrel
STEMI NSTEMI * Ideal PatientsACTION/CRUSADE DATA: July 1, 2006 June 30, 2007STEMI (n=11,854) NSTEMI (n=26,956)
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