cardiologia intervencionista_tratamento na fase aguda

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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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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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Rates of occlusion, severe disease (>=70% stenosis), and patency according tograft type and anastomosis site


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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



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Angiographic End Points



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Angiographic End Points



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Clinical Outcomes among the 561 Patients



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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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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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Multivariable analysis estimating the treatment effect of reperfusion therapy with PCI or fibrinolysis based on increasing

PCI-related delay


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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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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



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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


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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



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5. FIBRINOLTICOS E TERAPIA ADJUNTA


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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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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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