Cardiologia Intervencionista_tratamento Na Fase Aguda

totalCOR 2009

REUNI ÃO HEMODIN ÂMICA REUNIÃO HEMODINÂMICA E CARDIO INTERVENCIONISTA Prof. Dr. EXPEDITO E. RIBEIRO LIVRE-DOCENTE CARDIOLOGIA- FM USP SUPERVISOR SERVIÇO DE HEMODINÂMICA INCOR-HCFMUSP DIRETOR SERVIÇO HEMODINÂMICA HOSP TOTALCOR

PARTE 1 1.QUEM TEM TELHADO DE VIDRO NÃO JOGA PEDRA NO VIZINHO. - O TRATAMENTO CLÍNICO É SOBERANO!

van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530

van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530

van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530

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

Khot, U. N. et al. Circulation 2004;109:2086-2091

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

Khot, U. N. et al. Circulation 2004;109:2086-2091

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

Khot, U. N. et al. Circulation 2004;109:2086-2091

A Randomized Comparison of Radial-Artery and SaphenousVein Coronary Bypass Grafts Nimesh 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 Med Volume 351;22:2302-2309 November 25, 2004

Study Overview • The radial artery was first used as a coronary bypass graft in 1971, but there have been conflicting reports about its patency as compared with that of saphenous-vein grafts • In this study, radial-artery grafts had a higher patency rate at one year than control saphenous-vein grafts • The advantage was particularly evident when the radial artery was grafted to coronary vessels with high-grade lesions • This study supports the use of the radial artery as a coronary bypass conduit in vessels with high-grade stenosis

Clinical Characteristics of All Patients and Those Who Underwent Follow-up Angiography

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Operative Data on All Patients and Those Who Underwent Postoperative Angiography

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Angiographic End Points

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Angiographic End Points

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Clinical Outcomes among the 561 Patients

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Conclusions • Radial-artery grafts are associated with a lower rate of graft occlusion at one year than are saphenous-vein grafts • Because the patency of radial-artery grafts depends on the severity of nativevessel stenosis, such grafts should preferentially be used for target vessels with high-grade lesions

Five-year patency of three subgroups of conduits 96%

88% 82%

Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799

Comparative patencies of different in situ and free arterial conduits at 5 years

RA=RADIAL

Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799

PARTE 2 2. ATUALIZAÇÃO DO TRATAMENTO IAM

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO

URGÊNCIA

PRIMÁRIA

RO pós FIBRINOLÍTICO com sucesso

Sem FIBRINOLÍTICO Prévio

ATC IAM

ELETIVA PAC estável Trat. lesão residual

FACILITAD A

SALVAMENTO “RESCUE” falha do FIBRINOLÍTICO

Volume 278(23)

17 December 1997

pp 2093-2098

Comparison of Primary Coronary Angioplasty and Intravenous Thrombolytic Therapy for Acute Myocardial Infarction: 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 MD From the Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich (Dr Weaver); National Health and Medical Research Council Clinical 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); Unicor Hospital, Sao Paulo, Brazil (Dr Ribeiro); Spokane Heart Research Foundation, Spokane, Wash (Dr DeWood); and Ospedale Santa Croce, Cuneo, Italy (Dr Ribichini

ESTUDO PCAT MORTALITY

%

20

11 Trials (1989-96) Thrombolysis

Lytics

PTCA PTCA

15

(N) Time (min)

1377

1348

172

219

10

5 p < 0.04 0 0

2

4

6 m

ESTUDO PCAT DEATH + MI

%

20

Thrombolysis PTCA

15

10

5 p < 0.0001 0 0

2

4

6 m

LIÇÕES LIÇÕES JÁ JÁ APRENDIDAS APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE

NRMI NRMI 1-4: 1-4: Impact Impact of of Door Door to to Balloon Balloon Time Time on on In-hospital In-hospital Mortality Mortality 29,222 STEMI pts treated with PCI within 6 hrs of presentation at 395 hospitals from 1999 to 2002 8

In-hospital Mortality Rate (%)

7 6 5 4

Ptrend < 0.001

3 2 1 0 < 90

> 90 - 120

> 120 - 150

Door to Balloon Time (min)

> 150

TIME TO TREATMENT

meta-analysis meta-analysis of of lytics lytics trials trials

ACC / AHA GUIDELINES

EUROPEAN EUROPEAN HEART HEART JOURNAL JOURNAL 2002 2002 ;; 23:550-7 23:550-7

Relationship Relationship of of Presentation Presentation Delay Delay and and Outcome Outcome for for Primary Primary PCI PCI vs vs Fibrinolysis Fibrinolysis 6-Month Mortality

10% 10%

10% 10% 6,1% 6,1%

5% 5%

14,6% 14,6%

15% 15%

15% 15%

7,3% 7,3%

6,7% 6,7% 5,4% 5,4%

5,1% 5,1%

5% 5%

0% 0%

0% 0%

< 2hr

2-4hr

> 4hr

Sx Onset to Presentation, Primary Angioplasty

< 2hr

2-4hr

> 4hr

Sx Onset to Presentation Fibrinolysis Zijlstra F, Ribeiro E. et al, EHJ, 2002

PCAT PCAT 2: 2: PCI PCI DELAY DELAY AND AND BASELINE-ADJUSTED BASELINE-ADJUSTED RISK RISK OF OF 30-DAY 30-DAY MORTALITY MORTALITY

BOERSMA E, RIBEIRO E et al EHJ 2006;27:779-788

Selection criteria used for study inclusion

Pinto, D. S. et al. Circulation 2006;114:2019-2025

Relationship between PCI-related delay (minutes; x axis) and inhospital mortality (%; y axis) as a continuous function was assessed as a linear regression model

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

Pinto, D. S. et al. Circulation 2006;114:2019-2025

Adjusted analysis illustrating significant heterogeneity in the PCI-related delay (DB-DN time) for which the mortality rates with primary PCI and fibrinolysis were comparable after the study population was stratified by prehospital delay, location of infarct, and age

Pinto, D. S. et al. Circulation 2006;114:2019-2025

PCI – related delay

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE 3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

ACC / AHA GUIDELINES

PHYSICIAN PHYSICIAN VOLUME VOLUME -- OUTCOMES OUTCOMES

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE 3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR

IS PRIMARY PCI FOR SOME AS GOOD AS FOR ALL?

PRIMARY PRIMARY PCI PCI MAKES MAKES THE THE BIGGEST BIGGEST DIFFERENCE DIFFERENCE IN IN THE THE SICKEST SICKEST

BRODIE BR ey al JACC 2006;47:2892006;47:289-95.

CLASSIFICATION AND TREATMENT EFFECT BASED ON LEVEL OF RISK Low Risk

Age (years) < 50

Intermediate Risk

0

Higj Risk

Number of Risk 1 2 3

50 - 59 60 - 69 > 70 Risk Factors • Anterior myocardial infarction • Prior myocardial infarction • Systolic blood pressure < 115 mmHg • Pulse rate > 85/min

4

MORTALITY BY LEVEL OF RISK

30 days death + MI (%)

PTCA TT

24.1

12.7 7.2

13.1

8.0

2.9 Low

Intermediate

Risk group

High

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE 3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR 5. FIBRINOLÍTICOS E TERAPIA ADJUNTA

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE 3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR 5. FIBRINOLÍTICOS E TERAPIA ADJUNTA

6. ATC FACILITADA VS ESTRATÉGIA FARMACOINVASIVA

DiMario , C et al LANCET 2008;371;559-568

CARESS-in-AMI Events Rates, 30 Days

DiMario , C et al LANCET 2008;371;559-568

7 PUBLISHED RANDOMIZED TRIALS 1996 pat PRAGUE, WEST, CARESS-AMI, LEIPZIG 3 MONTHS FU

CAPITAL-AMI, SIAM 3 6 MONTHS FU

GRACIA 1 1 YEAR FU Stone, G. W. Circulation 2008;118:552-566

POOLED ANALYSIS OF THE RESULTS FROM 7 PUBLISHED RANDOMIZED TRIALS IN PAT. TREATED WITH FIBRINOLYTIC COMPARING IMMEDIATE OR EARLY PCI WITH STENTING X DELAYED ISCHEMIA-DRIVEN OR ROUTINE PCI WITH STENTING

Stone, G. W. Circulation 2008;118:552-566

** ST segment resolution <50% & persistent chest pain or hemodynamic instability

Cantor ACC 2008

Primary Endpoint: 30-Day Death, re-MI, CHF, Severe Recurrent Ischemia, Shock 18

% of Patients

16.6

16 14 12

OR=0.537 (0.368, 0.783); p=0.0013 10.6

10 8 6 4 2 0 0 n=496 n=508

Standard (n=496) Pharmacoinvasive (n=508)

5 422 468

10 15 20 Days from Randomization 415 466

415 463

414 461

25

30

414 460

412 457

Components Components of of Primary Primary Endpoint Endpoint

Standard Pharmacoinvasive Strategy P-Value Treatment (n=512) (n=498) Death 3.7 0.94 3.6 Reinfarction 3.3 0.044 6.0 Recurrent Ischemia 0.2 0.019 2.2 Death/MI/Ischemia 6.5 0.004 11.7 New / worsening CHF 5.2 2.9 0.069 Cardiogenic Shock 4.5 0.11 2.6

Safety Safety Endpoints Endpoints -- Bleeding Bleeding Standard Pharmacoinvasive Strategy P-Value Treatment (n=512) (n=498) Intracranial hemorrhage TIMI scale Major Major (non-CABG-related)

GUSTO scale Moderate Severe Severe (non-CABG-related)

Transfusions

1.2

0.2

0.066

4.6 3.2

4.3 2.2

0.88 0.33

2.2 1.4 1.2 5.5

3.5 0.6 0.6 7.1

0.26 0.22 0.34 0.31

LI ÇÕES JJÁ Á APRENDIDAS LIÇÕES APRENDIDAS 1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO 2. REPERFUSÃO É TEMPO DEPENDENTE 3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR 5. FIBRINOLÍTICOS E TERAPIA ADJUNTA

6. ATC FACILITADA VS ESTRATÉGIA FARMACOINVASIVA 7.CONSIDERAÇÕES FINAIS

A modified algorithm for management of patients with STEMI according to time from symptom onset to hospital arrival, institutional interventional capability, and potential for interhospital transfer, emphasizing increasing access to interventional reperfusion therapy

Stone, G. W. Circulation 2008;118:552-566

UMass STEMI %DTB < 90 minutes vs Mortality 3.5

100%

96.00% 90%

91.70%

89.50% 84.60%

80%

3

81.00% 74.20%

72.00%

70%

2.5

61.50%

60%

57.10%

2

50%

50%

43.50%

1.5

40% 30%

1

20% 0.5 10% 0%

0

Q1 05 Q2 05

Q3 05 Q4 05 Q1 06

Q2 06 Q3 06 Q4 06 Q1 07

DTB time < 90 minutes

Q2 07 Q3 07

Mortality data

Courtesy of Greg Volturo, MD

100%

98%

Acute Acute Medications Medications STEMI vs NSTEMI STEMI vs NSTEMI 97% 96% 93%

93%

90% 84% 75%

80%

59%

60%

52%

40%

20%

0% ASA

STEMI

Beta Blockers

NSTEMI

Heparin (LMW+UFH)

GP llb-llla Inhibitors

Clopidogrel

ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)

100%

99%

Discharge Discharge Medications Medications STEMI STEMI vs vs NSTEMI NSTEMI

97%

97%

95%

91%

89%

86% 76%

80%

90%

74%

60%

40%

20%

0% ASA

STEMI

Beta Blockers

NSTEMI

ACE-I or ARB*

Statins

Clopidogrel

* Ideal Patients ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007 STEMI (n=11,854) NSTEMI (n=26,956)