Diagnostic et Prise Prise en Charge des en Charge des Diagnostic et Echecs De Thrombolyse De Thrombolyse Echecs Antoine Sarkis, MD Jeudi 24 Novembre 2005
Diagnostic et Prise Prise en Charge des en Charge des Diagnostic et Echecs De Thrombolyse De Thrombolyse Echecs � Modalit Modalité és s de de traitement traitement de de l l’ ’infarctus infarctus aigu aigu du du � myocarde (AMI) (AMI) myocarde � Thrombolyse Thrombolyse � � Vari Varié ét té és s d d’ ’angioplastie angioplastie (PCI) (PCI) dans dans AMI AMI � � Crit Critè ères res d d’é ’échec chec de thrombolyse de thrombolyse � � Angioplastie Angioplastie apr aprè ès s é échec de thrombolyse chec de thrombolyse �
r-PTCA d-PTCA t - P T C A f-PTCA p-PTCA a-PTCA PCI in AMI
é t é s Vari é t é s de PTCA in AMI de PTCA in AMI Vari � Primary Primary (P (P- -PTCA) PTCA) � � Transfer Transfer (T (T- -PTCA) PTCA) � –– after reduced dose Facilitated PCI –– � Facilitated PCI after reduced dose lytics lytics alone, alone, � or with IIb/IIIa IIb/IIIa inhibitors inhibitors (F (F- -PTCA) PTCA) or with � PCI early after PCI early after thrombolytic thrombolytic therapy therapy � � Routine Routine- -immediately after immediately after- - (Adjunctive) (Adjunctive) (A (A- -PTCA) PTCA) � – in pts with persistent occlusion or reduced � Rescue Rescue – in pts with persistent occlusion or reduced � flow in the infarct artery (R (R- -PTCA) PTCA) flow in the infarct artery — hours to days later � Delayed Delayed — hours to days later (D (D- -PTCA) PTCA) �
P- -PTCA=Primary PTCA PTCA=Primary PTCA P PCI v/s v/s Thrombolysis in STEMI : Thrombolysis in STEMI : PCI « A quantitative review of 23 randomized trials A quantitative review of 23 randomized trials » » « Short- -term Results term Results Short 25,00% 21% Thrombolysis 20,00% PCI 14,50% 15,00% 9,30% 10,00% 8,20% 7% 6,80% 6% 5,00% 2,50% 2% 1% Keeley et al. 0,00% Lancet 2003;361:13-20 Death re-MI Stroke Combined Ischemia
P- -PTCA=Primary PTCA PTCA=Primary PTCA P PCI v/s v/s Thrombolysis in STEMI : Thrombolysis in STEMI : PCI Long- -term Results term Results Long 39% 40,00% 35,00% 30,00% 25,00% 22% 19% Thrombolysis 20,00% PCI 15,00% 12,80% 12% 10% 9,60% 10,00% 4,80% 5,00% 0,00% Death re-MI Combined Ischemia Keeley et al. Lancet 2003;361:13-20
Transfer PCI Transfer PCI The DANAMI- -2 Trial 2 Trial The DANAMI Danish Trial in Acute Myocardial Infarction- -2 2 Danish Trial in Acute Myocardial Infarction Danish Trial in Acute Myocardial Infarction-2 Dr. Henning Rud Rud Andersen Andersen Dr. Henning Dr. Henning Rud Andersen for the DANAMI- -2 investigators 2 investigators for the DANAMI for the DANAMI-2 investigators NEJM 2003, 349:733-742
DANAMI- -2: Primary Results 2: Primary Results DANAMI Non-Transfer Sites Transfer Sites Combined Non-Transfer Sites Combined Transfer Sites P=0.048 P=0.048 P=0.0003 P=0.002 P=0.0003 P=0.002 16% 16% 16% 16% 16% 16% 14% 14% 14% 14% RRR RRR RRR RRR 12% 12% 40% 40% Death / MI / Stroke (%) Death / MI / Stroke (%) 45% 45% RRR RRR 12% 12% 12% 12% 12% 12% 45% 45% 9% 9% 8% 8% 8% 8% 8% 8% 8% 8% 7% 7% 4% 4% 4% 4% 4% 4% 0% 0% 0% 0% 0% 0% Lytic Primary PCI Lytic Primary PCI Lytic Primary PCI Lytic Primary PCI Primary PCI Lytic Lytic Primary PCI
Captim trial: trial: Captim Outcomes in patients randomized within first two Outcomes in patients randomized within first two hours of symptom onset hours of symptom onset End point Prehospital lysis Primary PCI p End point Prehospital lysis Primary PCI p <2 hours (%) <2 hours (%) <2 hours (%) <2 hours (%) 30- -day death, reinfarction, or day death, reinfarction, or 7.4 6.6 0.855 30 7.4 6.6 0.855 stroke stroke 30- -day death day death 2.2 5.7 0.058 30 2.2 5.7 0.058 30- -day reinfarction day reinfarction 4.0 1.4 0.141 30 4.0 1.4 0.141 30- -day stroke day stroke 1.3 0.0 0.249 30 1.3 0.0 0.249 Cardiogenic shock (between 1.3 5.3 0.032 Cardiogenic shock (between 1.3 5.3 0.032 randomization and discharge) randomization and discharge) Cardiogenic shock (between 0.0 3.6 0.007 Cardiogenic shock (between 0.0 3.6 0.007 randomization and admission) randomization and admission) Steg et al, Circulation 2003,108:2851
Peut- -on encore am on encore amé éliorer les r liorer les ré ésultats sultats Peut de l’ ’angioplastie coronaire ? angioplastie coronaire ? de l F- -PTCA=Facilitated PCI PTCA=Facilitated PCI F � PCI could be facilitated with : PCI could be facilitated with : � � Thrombolysis (PACT, BRAVE, ASSENT 4, Thrombolysis (PACT, BRAVE, ASSENT 4, � … ) FINESSE … ) FINESSE � GIIb/IIIa GIIb/IIIa inhibitors (ADMIRAL, ON inhibitors (ADMIRAL, ON- -TIME, TIME, � … ) TIGER- -PA, BRIDGING PA, BRIDGING … ) TIGER
Anti GP IIb IIb- -IIIa IIIa F F- -PTCA PTCA Anti GP � ADMIRAL ADMIRAL � � 300 300 pts pts 59 % � P=0,01 � Abciximab Abciximab + stent vs stent + stent vs stent alone alone � � Combined Combined end end- -point point ( (mortality mortality, , � reinfarction, revascularisation) , revascularisation) reinfarction lower in in abciximab abciximab group group at at 30 30 lower days: (6 vs 14.6%), : (6 vs 14.6%), and and at at six six days months (7.4 vs 15.9%) (7.4 vs 15.9%) months 53 % P=0,02 � TIMI 3 TIMI 3 flow flow before before angiogram angiogram : : � 16.8 vs 5.4% 16.8 vs 5.4% NEJM 2001; 341:1895-1903
Thrombolysis F- -PTCA PTCA Thrombolysis F Large AMI < 6hrs Large AMI < 6hrs Planned PCI Planned PCI Cath lab delay of 1- -3 hr 3 hr Cath lab delay of 1 Randomize Randomize ASA ASA ASA ASA UFH (bolus) UFH (bolus) n = 2,000 UFH (bolus) UFH (bolus) n = 2,000 n = 2,000 n = 2,000 TNK No lytic TNK No lytic Cath lab lab Cath Angiography / PCI Angiography / PCI Angiography / PCI Angiography / PCI (immediate) (immediate) (immediate) (immediate) Stent / clopidogrel (optional) Stent / clopidogrel (optional) Stent / clopidogrel (optional) Stent / clopidogrel (optional) Heparin as routinely used Heparin as routinely used Heparin as routinely used Heparin as routinely used NO GP IIb/IIIa inhibitors GP IIb/IIIa inhibitors GP IIb/IIIa inhibitors at NO GP IIb/IIIa inhibitors at investigators discretion investigators discretion
ASSENT 4 ASSENT 4 Pharmaco- -Mechanical Reperfusion Mechanical Reperfusion Pharmaco The study was prematurely stopped because of a significant increase of death in the TNK group. ase of death in the TNK group. � The study was prematurely stopped because of a significant incre � Outcome TNK+PCI PCI alone p Outcome TNK+PCI PCI alone p (n=828) (n=838) (n=828) (n=838) Number (%) of deaths 50 (6.0) 32 (3.8) 0.04 Number (%) of deaths 50 (6.0) 32 (3.8) 0.04 ASSENT- -4: 30 4: 30- -day mortality results day mortality results ASSENT van de Werf F. European Society of Cardiology Congress 2005; September 4-7, 2005; Stockholm, Sweden.
AMI : ESC recommendations recommendations AMI : ESC � PTCA PTCA is is the the preferred preferred therapy therapy if : if : � � Artery Artery can can be be opened opened in in less less than than 90 minutes 90 minutes after after � first medical first medical contact contact � Contra Contra- -indications to indications to thrombolytic thrombolytic therapy therapy � � Cardiogenic Cardiogenic shock shock � � Thrombolytic Thrombolytic therapy therapy in all in all other other cases cases �
Questions raised raised by by thrombolytic thrombolytic therapy therapy: : Questions The Gray Areas Gray Areas The � Major Major difficulties difficulties in in clinical clinical practice to practice to assess assess � the success success of of thrombolytic thrombolytic therapy therapy based based on on the clinical and and ECG data ECG data clinical � What What should should be be done done if a if a coronary coronary angiogram angiogram � is performed performed immediately immediately after after thrombolytic thrombolytic is therapy ? ? therapy
Angiographie de routine et angioplastie aprè ès s Angiographie de routine et angioplastie apr Thrombolyse (Adjunctive Adjunctive PTCA) PTCA) Thrombolyse (
Adjunctive PTCA PTCA after after Adjunctive Thrombolytic Therapy Therapy Thrombolytic ’ s � 3 trials 3 trials performed performed in in the the 80 80 ’ s � � Topol Topol et et al al (TAMI I), N (TAMI I), N Engl Engl J J Med Med 1987, 371; 581 1987, 371; 581- -8 8 � � Simoons Simoons et al et al Lancet Lancet 1988, 1; 197 1988, 1; 197- -203 203 � � TIMI IIA TIMI IIA study study, Circulation 1990; 81, 1457 , Circulation 1990; 81, 1457- -1476 1476 � � Routine Routine immediate immediate angiography angiography and and PTCA PTCA did did � not improve not improve clinical clinical outcomes outcomes and and was was associated associated with increased increased bleeding bleeding and and a trend a trend towards towards with increased mortality mortality increased
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