Aderenza alle Linee Guida internazionali nei pazienti con Sindrome Coronarica Acuta

Antonio Manari

Key points:

• 1‐ Linee Guida STEMI e NSTEMI• 2‐ Razionale delle indicazioni  delle Linee Guida• 3‐ Risultati nella pratica clinica (aspetti logistici)

Hospital Link Between Overall Guidelines Adherence and Mortality

Peterson et al, JAMA 2006;295:1863-1912

Every 10% ↑ in guidelines adherence →10% ↓ in mortality (OR=0.90, 95% CI: 0.84-0.97)

ESC Up-dated Guidelines STEMI 2008

Reperfusion strategy

Recommended Logistics

• Pre-hospital triage/care:● EMS

• unique telephone number• tele-consultationAmbulance• 12-ECG recorder/defibrillator• staff able to provide basic and advanced life support

• Networks:● implementation of a network of hospitals with different levels of

technology connected by an efficient ambulance service using the same protocol

• Targets:● < 10 min ECG recording/ transmission● < 120 min to first balloon inflation

ESC Guidelines STEMI 2008

Pre - Hospital ECG: NCDR (National Cardiovascular Database Registry) ACTION

EMS7,098 patients STEMI

pre - hospital ECG

1,941 (27.4%) 5,157 (72.6%)

pPCI92.1 % 86.3 %

DTB(p<0.0001)61 min 75 min

Mortality(p=0.06)6.7% 9.5%

Diercks et al, JACC 2009

Yes No

Bypassing the ER impacts outcomes in STEMI

5,13,8

12

8,37,9 8,4

16,4

13

0

5

10

15

20

All Reperfusion Rx

All Reperfusion Rx

Direct CCU

via ER

5 days 1 year

P=0.03

P=0.04

P=0.02

P=0.006

Steg et al. Heart 2006;92:1378-83

Recommended Logistics

• Pre-hospital triage/care:● EMS

• unique telephone number• tele-consultationAmbulance• 12-ECG recorder/defibrillator• staff able to provide basic and advanced life support

• Networks:● implementation of a network of hospitals with different levels of

technology connected by an efficient ambulance service using the same protocol

• Targets:● < 10 min ECG recording/ transmission● < 120 min to first balloon inflation

ESC Guidelines STEMI 2008

H= hub cardiochirurgico h= sede di emodinamica diagnostico/interventisticas= spoke: Unità Terapia Intensiva Cardiologica

h

hss

Hss H s

ss

s

sh h h

hH HH

s

s

ss

ssh H h

h hs

s

hh

h

s s s

s

s

ss

Organizzazione della rete cardiologica e cardiochirurgica Regionale

Delibera regionale 1267, del 22 luglio 2002

RIDEFINIZIONE DEI PERCORSI DI TEMPESTIVO ACCESSO AI

SERVIZI, DIAGNOSI E CURA PER PAZIENTI CON INFARTO MIOCARDICO ACUTO

Agenzia Sanitaria Regionale Em-Rom.Commissione Cardiologica-Cardiochirurgica

PRIMARER

Documento approvato dalla Commissione il 27 gennaio 2003

Progetto presentato ai Direttori Generali e Sanitari il 18 marzo 2003

Clinical Impact of an Inter-hospital Transfer Strategy in pts. with STE-MI treated with Primary PCI

The Emilia-Romagna STEMI network

Manari A et al. Eur Heart J 2008;29:1834

On-site p-PCITransfer p-PCI

9.2%

7.4%

HR: 0.8295% CI: 0.62 – 1.08; P=0.16

Months

1-Ye

ar

Car

diac

Mor

talit

y (%

)

Door-to-Balloon according to the number of key strategies used

Time Saved

E. H. Bradley, N Engl J. Med 13, 2006;335

Recommended Logistics

• Pre-hospital triage/care:● EMS

• unique telephone number• tele-consultationAmbulance• 12-ECG recorder/defibrillator• staff able to provide basic and advanced life support

• Networks:● implementation of a network of hospitals with different levels of

technology connected by an efficient ambulance service using the same protocol

• Targets:● < 10 min ECG recording/ transmission● < 120 min to first balloon inflation

ESC Guidelines STEMI 2008

Total, n=63,478ECG ≤ 10 min, n=22,081ECG > 10 min, n=41,397

Death Postadmission MI Death or MI

Diercks, et al. Am J. Cardiol. 2006

%

ECG & Clinical Outcome

In a perfect world …..

DTB = 1st Door to BalloonDTN = 1st Door to Needle for Lytics

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

STEMI – Timing of Reperfusion

Widimsky et. al E Heart J, 2009

Variables 2004(year)

2005(year)

2006(first semester)

Emilia-Romagna Region p-PCI:

On-site p-PCI, (n) 879 985 580

Transfer p-PCI, (n) 281 359 212

Network door-to-balloon time:

On-site p-PCI, (min), (median 25th-75th)

73 (50-102) 69 (43-100) 74 (47-115)

Transfer p-PCI, (min), (median 25th-75th)

114 (90-146) 111 (90-150) 107 (81-140)

Manari A et al . Eur Heart J, 2008

Variables 2004(year)

2005(year)

2006(first semester)

Emilia-Romagna Region p-PCI:

On-site p-PCI, (n) 879 985 580

Transfer p-PCI, (n) 281 359 212

Non-transferred STEMI patients admitted to non-PCI centres (%)

26.0 19.5 15.5

Age, (yrs), mean ± SD 77 ± 13 78 ± 13 81 ± 12

Charlson index, mean ± SD 1.4 ± 1.7 1.6 ± 1.7 1.7 ± 1.8

Mortality, (%) 25.5 32.2 31.2

Fox KAA et al. JAMA 2007;297:1892-1900

In-Hospital and 6-Month Outcomes in Patients With STEMI or LBBB

Changes in 30-day mortality over 15 years3 nationwide surveys of STEMI in France

30-day Mortality According to use of Reperfusion Therapy

RRR: 44%, 44%, 46% for no reperfusion, thrombolysis and PPCI, respectively

Registries and RCTs enroll different populations with different outcomes

example of STEMI outcomes in RCT participants, RCT-eligible and RCT-ineligible pts within GRACE

3,63,0

7,1

4,8

11,4

7,7

0

4

8

12

In-hospital mortality Post-discharge mortality

Mor

talit

y ra

te (%

)

RCT participants: 11.3%

RCT-eligible patients: 55.1%

RCT-ineligible patients: 33.6%

Steg et al. Arch Int Med 2007;167:68-73

P=0.001

P=0.001

N=8469

Are We Performing Interventional Procedures in the Right Patients

26.632.2

53.563.264.1

75.5

Tricoci et al, AHA 2005 Abstract

“…Establishing networks of reperfusion at regional and national level…is a key issue.”

NSTEMI Inter-hospital networks?

UTICCorreggio

UTICC Monti

Montecchio

14 Km

50 Km

13 Km32 Km

UTICLab. Emo Cardio Chir

18 Km

UTICGuastalla

Scandiano

Provincia di Reggio Emilia (582.000 abitanti)

DISTRIBUZIONE DEI PRESIDI OSPEDALIERINELLA PROVINCIA DI MANTOVA

PS,UTIC,Emodinamica h24, CaCh

PS,UTIC

PS, degenza

Ospedali riabilitativi

Estensione: 2300 KmqPopolazione: 370000 abitanti

La rete di Massa-CarraraP.S. I° LIVELLO

P.S. I° LIVELLO

U.T.I.C. II° LIVELLO

U.T.I.C. II° LIVELLO

IFC CNROsp. “G. Pasquinucci”

Telemedicina + Cath LabIII° LIVELLO

0,05,0

10,015,020,025,030,035,040,045,050,0

Rischio basso Rischio Intermedio Rischio alto

23,5

36,839,7

%

RegistroReggio Emilia – Mantova - Massa

Tipologia dei pazienti avviati alla coronarografia

Ritardo Ricovero-Angiografia

0102030405060708090

100

Rischio basso Rischio Intermedio Rischio elevato

56,867,2

84,4

ore

RegistroReggio Emilia – Mantova - Massa

88,278,6

128,3

47,556,4

66,6

0,0

20,0

40,0

60,0

80,0

100,0

120,0

140,0

Rischio basso Rischio Intermedio Rischio elevato

ore

Spoke Hub

RegistroReggio Emilia – Mantova - Massa

Ritardo Ricovero-Angiografia

Conclusioni • I risultati osservati nella pratica clinica

indicano che oltre il 50% dei pazienti con SCA non è trattato secondo i parametri organizzativi delle L. G.

• Ciò non ostante, i dati di registri sulle SCA indicano una prognosi “buona/accettabile”

• Le Linee Guida individuano comportamenti “virtuosi” analizzando dati di studi randomizzati e controllati;

Conclusioni

ACC/AHA STEMI reperfusion guidelines