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.

Implementation of the STEMIESC Guidelines

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 <2-3 h from onset chestpain & transp. > 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)

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

Trombolyse PCIPrehospitalt EKG

Reperfusion Options for STEMI PatientsStep One: Assess Time and Risk.

Time Since Symptom

Onset

Time Required for Transport to

a Skilled PCI Lab

Risk of STEMI Risk of Fibrinolysis

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.

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.

Evolution of PCI for STEMI

Antman. Circulation 2001;103:2310.

Balloon Antiplatelet Rx

Stent DES

GP IIb/IIIa inhibitor

ASAClopidogrel AngioJet

Thrombus Removal and

Distal Embolization

Protection Devices

Embolization Protection Device

Platelet

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

Reperfusion strategyRecommendation 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

Prognostic PCIRecommendation IA

• PCI within 24 hrs after sucessful thrombolysis– Randomised trials; effect on combined

endpoints – No effect on mortality– Discussed…..

Rescue PCIRecommendation IB-IIC

• Cardiac shock <75 y & <18 h after development of shock (IB)

• Unsuccessful thrombolysis after 45-60 min (ECG & clinical eval) (IIC)

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??

”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%

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??

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%

• 3.9 mill• 88/km2

• GNP 2300 US$/year (2005)

Bosnia and Herzegovina

Interventional cardiology in BiH

• PCI centres 5• PCI-mil. 770.000

• Independent interv.cardiologists 11• Anual MI admissions 7200• Anual STEMIs 3100

Invasive procedures in Bosnia and Herzegovina

Coronography PCI

2007. 3676 616

2008. 3167 784

2009. 3569 1018

Implementation of the STEMIESC 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

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 STEMIESC Guidelines in Bosnia and Herzegovina

Implementation of the STEMIESC Guidelines in Bosnia and Herzegovina

STEMI – Do we need more PCI-centers?

”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

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

B.M.44 mSTEMI ant.