Acuto a presentazione
“sopralivellamento del tratto ST”
STEMI
Linee Guida ESC 2012
Time to Reperfusion and Outcome
100
Mortality reduction (%)
Potential
80 D outcomes
A-B – no benefit
60 B-C – benefit ?
% C A-C – benefit
D-C – harm
40
B A
20
Extent of salvage (% of area at risk)
0
1 3 6 12 12-24
Time to treatment is critical
Opening the IRA PPCI>lysis
www.escardio.org/guidelines
Percoso STEMI pistoia
Cardiologo UTIC
1 accesso
FMC Trasporto monitoraggio diretto
Accessosala
Diagnosi diretto sala
Ecg teletrasmesso
per 1PTCA
Emodinamista reperibile
& staff : infermiere/TRS
Ritardo di sistema
STEMI ENTRO 12 ORE ANNO 2012
N.TOTALE 173
PAZIENTI 0 RESCUE
0 POST-TL
64 26 83
37% 15% 48%
DIRETTA TRASFERITA AMMESSA
AL CL DA SPOKE AD HUB
D2B TOTALE PAZIENTI N. 173
N. PAZIENTI 173 – MEDIANA D2B: 90 MINUTI
350
300
250
200
MINUTI
150
100
50
0
0 20 40 60 80 100 120 140 160 180 200
PAZIENTI
D2B AMMISSIONE DIRETTA 118
N. PAZIENTI 64 – MEDIANA D2B: 84 MINUTI
D2B AMMISSIONE PS PO PISTOIA
N. PAZIENTI 47 – MEDIANA D2B: 90 MINUTI
D2B AMMISSIONE PS PO PESCIA
N. PAZIENTI 45 – MEDIANA D2B: 100 MINUTI
350
300
250
MINUTI
200
150
100
50
0
0 5 10 15 20 25 30 35 40 45 50
PAZIENTI
PCI di trasferimento tra PO
N. PAZIENTI 26 – MEDIANA D2B: 125 MINUTI
350
300
250
200
MINUTI
150
100
50
0
0 5 10 15 20 25 30
PAZIENTI
Motality benefit of primary PCI declines with
“PCI-related time delay”
10 −
Absolute Risk Difference in Death (%)
13 RCTs
N = 5494
P = 0.04
5−
Favors
PCI Mortality equipose:
60 min
0−
After≥75y:
20%½ofdosetheTNKplanned
Ambulance/ER
YE N
S immediate O
angio +
angio >6 to 24 hrs
rescue PCI if Standard primary PCI
PCI/CABG if indicated
indicated
62 29 9 100
min
1st Medical
78 min
Sx onset contact Randomize IVRS difference
Rx PPCI
61 31 86
n=1892 1 Hour 2 Hours 178 min
F. Van de Werf, ACC 2013
MEDIAN TIMES TO TREATMENT (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
n=1892 1 Hour 2 Hours 178 min
F. Van de Werf, ACC 2013
PRIMARY ENDPOINT
TNK vs PPCI
Dth/Shock/CHF/ReMI (%) Relative Risk 0.86, 95%CI (0.68-1.09)
PPCI 14.3%
TNK 12.4%
p=0.24
The 95% CI of the observed incidence in the pharmaco-invasive arm
would exclude a 9% relative excess compared with PPCI
16%
4%
Significant
MD Net Clinical Benefit
10 mg with Prasugrel
80%
Timing of Benefit
(Landmark Analysis)
8
Primary Endpoint (%)
6.9
Clopidogrel Clopidogrel
6 5.6 5.6
4
4.7
Prasugrel Prasugrel
2
HR 0.82 HR 0.80
P=0.01 P=0.003
1
0 0
0 1 2 3 30 60 90 180 270 360 450
Time-related Kaplan–Meier estimates of the time to first occurrence of the primary end point
(incidence of MI, stroke, or vascular death; HR, 0.87; 95% CI, 0.75 to 1.01; P=0.07)