14 September 2018
Yogyakarta Cardiology Update
• Fibrinolysis
• Invasive Strategy
• Pharmaco-Invasive Strategy
ATHEROSCLEROSIS:
from Plaque to ACS
TIME IS
MUSCLE!
Lama Oklusi
Becker LC, Ambrosio G: Myocardial consequences of reperfusion, Prog Cardiovasc Dis 30:23-
49, 1987
Pasien normal dengan Nyeri Dada Revaskularisasi
faktor resiko
Angio
koroner
Eko
Kardio
graf
Fungsi Ventrikel Kiri - Normal Fungsi ventrikel kiri – Fungsi Ventrikel Kiri - Normal
Lemah Gagal jantung
Total In Hospital Mortality Rate
STEMI Patient Based on Reperfusion
iSTEMI West Jakarta + NCC-HK (3 Years)
16.0%
14.8% 14.8%
78 79
14.0% 13.2%
50% 64
12.0%
10.0%
61
Year 1
8.0% 7.4% Year 2
Year 3
6.0% 5.7%
43
4.2%
4.0% 26
2.0%
N=756 N= 624 N=822 N=567 N =484 N=532
0.0%
Reperfusion No Reperfusion
*36 Months Data, From 30 Juni 2014 – 30 juni 2017 in ISTEMI Network (West Jakarta)
Metode reperfusi
Fibrinolisis Angioplast
• Streptokinase
• Alteplase
Mortalitas STEMI
PPCI vs Fibrinolisis
Major Clinicla trial
35.0%
In hospital mortality 30- or 35-day mortality
30.0% 29.0%
25.0%
(739)
20.0%
15.0%
10.0% 8.7%
5.9%
5.0% (92)
(163)
(100
0.0% n=2767 n=1054 n=2545
PPCI Fibrinolysis
No Reperfusion
Primary PCI :
Time to treatment and 1 year mortality
2nd Year
150 min 120 min DTD 101 min
DTN 85 min
3rd Year
150 min 105 min DTD 115 min
DTN 75 min
40% 20.00%
30% 2.3%
0.00%
20%
10%
0%
Harapn Kita RS Sanglah RS Iskak RSUD cengkareng
Timing and logistical factors influence choice of
reperfusion strategy
1. Ibanez B et al. Eur Heart J 2017. https://academic.oup.com/eurheartj/article/4095042. Accessed November 6, 2017; 2. O’Gara PT et al. Circulation 2013;127:e362–e425; 3.
Armstrong PW et al. Circulation 2009;119:1293–1303; 4. Welsh RC et al. Am Heart J 2006;152:1007–1014; 5. Danchin N et al. Circulation 2004;110:1909–1915; 6. Henriques JPS
et al. J Am Coll Cardiol 2003;41:2138–2142
Pharmacoinvasive
strategy
A strategy of initial pharmacologic/lytic reperfusion followed
by timely planned PCI between 3 and 24 hours
Major
Majordriver
driverof
of
reduction
reductionwas
was
recurrent
recurrentischemia
ischemia
62 29 9 100 min
1st Medical
78 min
Sx onset contact Randomize IVRS difference
Rx PPC
61 31 86
n=1892 1 Hour 2 Hours 178 min
F. Van de Werf, ACC 2013
Median
MEDIAN Times
TIMES to Treatment
TO TREATMENT (min)
(min)
1st Medical Randomize IVRS
Sx onset contact
Rx TNK
36% Rescue PCI at 2.2h
62 29 9 100 min
64% non-urgent cath at 17h
1st Medical
Sx onset contact Randomize IVRS
Rx PPCI
61 31 86
=1892 1 Hour 2 Hours 178 min
F. Van de Werf, ACC 2013
TIMI
TIMI FLOW RATESFLOW RATES
P<0.001 P=0.41