Evidencias sobre el Evidencias sobre el tratamiento del IAM en 2010tratamiento del IAM en 2010

Casa del Corazón, 10 de junio de 2010Casa del Corazón, 10 de junio de 2010

Hitos en el manejo del Hitos en el manejo del SCACESTSCACEST

1º1º etapa: etapa: MONITORIZACIONMONITORIZACION - d- desfibrilador externoesfibrilador externo (Lown) (Lown)- “Intensive Cardiac Care Unit” (Julian)- “Intensive Cardiac Care Unit” (Julian)

- monitorizacion ECG ------ desfibrilación- monitorizacion ECG ------ desfibrilación

2º2º etapa: etapa: RECANALIZACIONRECANALIZACION - fibrinolisis- fibrinolisis- angioplastia primaria- angioplastia primaria- coronariografia precoz- coronariografia precoz

Recomendaciones Sociedades CientíficasRecomendaciones Sociedades Científicas

19601960

19801980

20102010

Proteger del riesgo de Proteger del riesgo de muerte repentina por muerte repentina por fibrilación ventricularfibrilación ventricular

Reperfundir el miocardio Reperfundir el miocardio en vías de necrosis en vías de necrosis de forma inmediatade forma inmediata

Mortalidad (35 días)

retraso tto (h) fibrinolisis controlmejor mejor

0-1

1-2

2-3

3-6

6-12

12-24

0.5 1.0 1.5RRR

Boersma et al. Lancet 1996;348:771-75

Meta-análisis: - 22 estudios (>100 pts) - 50.246 pts (1983-93)

Beneficio de la trombolisis en función Beneficio de la trombolisis en función del retraso inicio síntomas - del retraso inicio síntomas -

tratamientotratamiento

0

20

40

60

80

0 3 6 9 12 15 18 21 24

retraso tratamiento (horas)

vidas

sal

vada

s / 1

000

pts

trata

dos

Primary PCI vs Thrombolysis in Primary PCI vs Thrombolysis in STEMI: STEMI:

Meta-analysis (23 RCTs, N=7739)Meta-analysis (23 RCTs, N=7739)

Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.

PCI

Thrombolytictherapy

0

5

10

25

15

20

Freq

uenc

y (%

)

Short-term Outcomes(4-6 weeks)

Death

P=.0002

NonfatalMI

P<.0001

RecurrentIschemia

P<.0001

Hemor-rhagicStroke

P<.0001

MajorBleed

P=.032

Death, Nonfatal

Reinfarction,or Stroke

P<.0001

Copyright ©2009 BMJ Publishing Group Ltd.

Rathore, S. S et al. BMJ 2009;338:b1807

Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals

Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals

Door-to-balloonDoor-to-balloon Hospital mortalityHospital mortality

30 minutes 3.0%60 minutes 3.5%90 minutes 4.3%120 minutes 5.6%150 minutes 7.0%180 minutes 8.4%

p<0.001

Rathore, S. S et al. BMJ 2009;338:b1807

p < 0.001 for trend comparisonTaher T, et al.

J Am Coll Cardiol 2004;44:38–43

CAPTIM: 1 Year MortalityCAPTIM: 1 Year Mortality

Steg P, et al Circulation 2003; 108:2851-6.Steg P, et al Circulation 2003; 108:2851-6.

Pre HospitalLysis

PrimaryPCI

P=0.057 P=0.47

Pre HospitalLysis

PrimaryPCI

Delay < 2 hoursDelay < 2 hours Delay Delay ≥≥ 2 hours 2 hours

2,2%

5,7%

0%

5%5,9%

3,7%

0%

Fibrinolisis vs Angioplastia Fibrinolisis vs Angioplastia Importancia de los retrasos

Nallamothu and Bates, AJC, 2003;92:824-6

Retraso en la ACTP, min

Dife

renc

ias

en

mor

talid

adRi

esgo

Abs

olut

o, %

0 20 40 60 80 100

15

10

5

0

–5

ACTP mejorFibrinolisis mejor

23 estudios (n= 7419)p=0.006

2008

STE

MI E

SC G

UID

ELIN

ES20

08 S

TEM

I ESC

GU

IDEL

INES

Key questionsKey questionsat presentation:at presentation:

- Delay from onset?Delay from onset?

- PCI capability at this time?PCI capability at this time?

- Lysis contraindicated?Lysis contraindicated???

Widinsky P, et al. Eur Heart J 2009

Reperfusion therapy for ST elevation MI Reperfusion therapy for ST elevation MI Spain vs Europe (2004)Spain vs Europe (2004)

Espinosa MA, et al. Rev Esp Cardiol 2009;9:3C-10CEspinosa MA, et al. Rev Esp Cardiol 2009;9:3C-10C

P-PCIP-PCILysisLysisFacilitated PCIFacilitated PCINo ReperfusionNo Reperfusion

25%25%

43%43%

32%32% 33%33%

26%26%

36%36%

5%5%

Reperfusion therapy for ST elevation MI Reperfusion therapy for ST elevation MI in Spain (2008)in Spain (2008)

P-PCI*P-PCI*78737873

TNK**TNK**1230012300

* Data from SHCI 2008 Spanish Registry* Data from SHCI 2008 Spanish Registry** Data provided by** Data provided by Boehringer Ingelheim España, S.A. Boehringer Ingelheim España, S.A.

2008

STE

MI E

SC G

UID

ELIN

ES20

08 S

TEM

I ESC

GU

IDEL

INES

http://www.pcronline.com/stentforlife/