1. Warong Lapanun MD.
Bhumibol Adulyadej Hospital
6/2/2011

2. Mr PM: 54-y-o presenting at a non-PCI
hospital
• 12.00 Myalgia and fatigue
Epigastric fullness for 2 hrs
• 12.30 : Rx Diclofinac IM
• 12 .45 : VF arrest CPR ,DF x 5
• 13.00 : ECG Ac STEMI inferior
wall+ RVMI BP 90/40 mmHg
•Nearest cath lab 40 min away

4.  Transfer for primary PCI
 Lysis on Site
 Lysis with immediate transfer to cath lab
 Which type of Lytic Rx will be selected?

6. %
20
n = 29,222
15
Mortality
p < 0.01
10
7.4
5.7
5 4.2
3.0
0
< 90 91-120 121-150 > 150
Door-to-Balloon Time (minutes)
McNamara et al. JACC. 2006;47:2180-6.

7. 192, 509 pts at 645 NRMI hospitals
Pinto et al. Circulation. 2006;114:2019-2025

8. • 43801 pts STEMI PPCI •D2B  Mortality( P<0.001)
• ACC registry 2005-2006 • 30 min = 3.0%
• In hospital Mortality • 60 min = 3.5%
• Median D2B 83 min. • 90 min = 4.3%
• Overall MR 4.6% • 120 min = 5.6%
• 180 min = 8.4%
Rathor SS,et al. BMJ2009:338;1807

9. Rathor SS,et al. BMJ2009:338;1807

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

12. Fribrinolytic Characteristic
SK r-tPA TNK
TIMI flow gr 3 ~30% ~50% ~60%
Boden et al. JACC 2007,50;10. 923

13. Risk Factors Risk Score ICH(%)
 Age > 75 yr 0-1 0.69
 Black race 2 1.02
3 1.63
 Female
4 2.49
 Hx of stroke >5 4.11
 SBP > 160 mmHg
 Wt <65(w),<80(m)
 INR>4
 Use of rt-PA

14. CAPTIM: 5 Year Survival
Prehospital Thrombolysis vs Primary PCI
Prehosp lysis
<2 hrs
Survival of Proability
PPCI
PPCI
>2 hrs
Prehosp lysis
Bonnefoy, E. et al. Eur Heart J 2009 30:1598-1606

15. %
Historical Points 40
Age > 75 3 35.9
65-74 2 35
DM or HT or 1 30
Angina 26.8
Exam. 23.4 25
SBP<100 3 20
HR >100 2 16.1
Killip II-IV 2 15
12.4
Wt < 67kg 1 10
7.3
Presentation
4.4 5
Ant. STE or LBBB 1 1.6 2.2
0.8
Time to Rx > 4 hr 1 0
0 1 2 3 4 5 6 7 8 >8
Points
Antman et al Circulation 2000;102:2031-7

16. ST Resolution
Benjamin M. Scirica JACC 2010;55;1403-1415

17.  Primary PCI
 Rescue PCI
 Facilitated PCI
 Pharmaco-invasive

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

20. 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

24. Verheugt, NEJM 2009; 360, 26: 2779-2781

26. Pharmacoinvasive
Facilitated PCI
No Class III

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

30. ESC GUIDELINES
European Heart Journal (2008) 29, 2909–2945

31. ESC PCI
Guidelines 2O10

33. Mr PM: 54-y-o presenting at a non-PCI
hospital
• 12.00 Myalgia and fatigue
Epigastric fullness for 2 hrs
• 12.30 : Rx Diclofinac IM
• 12 .45 : VF arrest CPR ,DF x 5
• 13.00 : ECG Ac STEMI inferior
wall+ RVMI BP 90/40 mmHg
•Nearest cath lab 30 min away

34.  Transfer for PPCI
 14.30 Lab
 100% Prox. RCA
 Clot aspiration
 14.50 Balloon
 Stent 4.0x20 mm
 Final TIMI III flow

36.  Oxygen,NTG, Morphine
 ASA / Clopidrogrel /Prasugrel/Ticangrelor
 Heparin/ LMWH/ Fonda
 GP IIb IIIa antagonist
 Lab
 Echo
 IABP
 CAG / PCI : Early or Late

38. Benjamin M. Scirica JACC 2010;55;1403-1415

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

40. Thygesen et al,Circulation November 27, 2007

41. Benjamin M. Scirica JACC 2010;55;1403-1415

43. Equally
Effective
Goncalves PA, et al. Eu Heart J 2005;26:865

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

47. NSTE-ACS
63%

48.  Plaque rupture: 80%
 Plaque erosion/spasm
 CASPAR study : 448 ACS
pts
 ~ 25% of ACS: no culprit lesion
 ~ 50% of no culprit
IC Ach spasm
 CCBs / nitrates : may benefit
 Endothelial function
Ong P, et al. JACC 2008; 52:523
CASPAR: Coronary Artery Spasm in Patients With ACS

49.  OCT  Thin-Capped fibroatheromatous ( TCFA)
 Positive remodeling
 Plaque rupture : Rest-onset, Exertion-trigger
Plaque shoulder
Lipid core
Lipid core
Thin-capped Thick-capped
OCT: Optical Coherence Tomography
Tanaka A. et al. Circulation 2008;118;2368

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

51. Antman. Circulation 2001;103:2310-4

57. 57

59. Inf.
epigastric
artery

60. 89-y-o lady with severe Lt. RAS and TVD

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