10. Mortality Reduction(%)
10
Potential outcomes
E
8 A-B : No benefit
A-C : Benefit
6 D C
B-C : Benefit
E-D : Harm
4
2 B A
0 Hr
1 3 6 12 24
Time to Rx is Critical Opening the artery is 1o Goal ( PCI>lysis)
Gersh BJ et al. JAMA 2005;293:979-986
11. Infarct size Myocardial Edema
Myocardial Salvage Microvascular
obstruction
Francone M, et al.JACC2009;23:2145
18. I IIa IIb III
with PCI capability should be Rx with p-
A PCI within 90 min of FMC .
Modified
without PCI capability who cannot be
B transferred and PCI within 90 min of FMC
Modified should be Rx with Lytic Rx within 30 min,
unless Lytic Rx is contraindicated.
FMC: First Medical Contact
19. STEMI within 12 h after onset of symptoms
At centre without PCI facilities with
>1 high risk features:
1. Cumulative ST-segment elevation of > 15 mm
2. New onset LBBB
3. Previous MI
4. Killip class of 2 or more or
5. LV ejection fraction of 35% or less.
Carlo Di Mario, Lancet 371 February 16, 2008
21. Pts with STEMI within 12 hrs after onset of symptoms
At centers : No PCI capability
Rx with Tenecteplase (TNK)
ST-segment elevation of ≥ 2 mm in two anterior leads or
ST-segment elevation of ≥ 1 mm in two inferior leads and
One high-risk characteristics:
1. Systolic BP < 100 mm Hg,
2. HR > 100 bpm,
3. Killip class II or III,
4. ST- depression of ≥ 2 mm in the anterior leads, or
5. ST- elevation of ≥ 1 mm in V4R indicative of RV
involvement.
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
22. TRANSFER AMI
High Risk STEMI 12 hrs, 1059 Pts
TNK + ASA + Clopidogrel +
Community Heparin or Enoxaparin
Hospital
Randomization
Emergency
Department
Pharmacoinvasive : Standard Strategy:
Urgent PCI Centre Assess chest pain, ST resolution
at 60-90 min after randomization
PCI Centre Failed Reperfusion* Successful Reperfusion
Cath / PCI within 6 hrs Cath and Rescue Elective Cath
regardless of reperfusion PCI GP IIb/IIIa PCI
status Inhibitor > 24 hrs later
* ST segment resolution < 50% & persistent chest pain, or hemodynamic instability
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
23. Kaplan-Meier Curves
Primary Endpoint* at 30 Days Re-infarction at 6 Months
Std Rx
Std Rx
Early PCI
Early PCI
*Primary endpoint was death, reinfarction, recurrent ischemia,
new or worsening heart failure, or cardiogenic shock at 30 days
Cantor WJ et al. N Engl J Med 2009;360:2705-2718
27. ER physician activate the Cath Lab
One call activate the cath lab
Cath lab team ready in 20-30 min
Prompt data feed back
Senior management commitment
Team-based approach
28. PCI-Center
ผู้ป่วยเจ็บหน้ำอก
รอบัตร รอแพทย์ตรวจ
ทำ EKG ใน 10 นำที
แพทย์เวร ER
แพทย์เวร Med
Fellow cardio
ปรึกษำ staff cardio ผ่ำน single
call operator, rtafheart@gmail.com
ตำมเจ้ำหน้ำที่ Cath Lab
Time to Lab
ส่งทำ PCI
29. Fast Track MI
EKG ด่วนแพทย์ดูใน 10 นำที
elevation ตำม staff cardio ทันที
ST
ST elevation ………………. MD.
No
39. Universal Definition of MI
Spontaneous AMI
Secondary AMI
Sudden cardiac death
Post PCI : 3x 99%URL
Post CABG : 5x 99%URL
URL: upper reference limit Thygesen et al,Circulation November 27, 2007
46. Prevalence increased RFs:
▪ Older age,
▪ Predominance of females
▪ high rate of DM
▪ Smoking and obesity
Use of preventive medications
Increasing sensitive Troponin Assay
Robert P, et al. Circulation 2009; 54: 1544
50. Everyone should be on anti-plt and anti-coag
Choose Rx Consevative vs Invasive
Choose antithrombotic regimen
The strategy selected
Bleeding risk of patients
Strategy selected Pt risk stratification
Bleeding vs Ischemic risk Equally
important
61. Assess/document bleeding risk in every pt.
Avoid crossover : UFH and LMWH
Proper dose Wt. and renal function
Use radial access in pts at high risk of
bleeding
Stop anticoag after PCI/ indication?
Selective “downstream” use of GPI
