ST YKSELMEL MYOKARD NFARKTSNDE KORONER TROMBSLE MCADELE
Do.Dr.Erturul Okuyan
28 yanda, Bayan Hasta
Akut nferior MI tansyla ve 4 saatlik ar yaknmasyla bavurdu
Youn sigara iicisi Hiperlipidemisi mevcut Aile yks poziHf
PPKG srasnda distal embolizasyon %15 orannda gzlenebilmektedir ve ileme bal komplikasyonlarn sk bir nedenidir.
Distal embolizasyon oluanlarda 5 yllk mortalite %44 iken olumayanlarda %9dur
Distal embolizasyondan birincil olarak sorumlu trombs
younluudur
Burzotta F et al. Eur Heart J 2009;30:2193-2203
DSTAL EMBOL
Mekanik olarak mikrovaskler yata Ikayarak miyokardn devam eden iskemik nekrozuna yol aar.
Lokal olarak in-situ platelet adhezyonunu ve trombosisi uyararak doku perfzyonunun bozulmasna ve no-reow fenomenine yol aabilir.
Mikrovaskler spazm ve lokal enamatuar sreci uyararak daha fazla miyokard nekrozuna sebep olabilir
Mikrovaskler obstrksiyon
SubopHmal reperfzyon Artm enfarkt alan Azalm ventrikl fonksiyonu 5-yllk mortalitede 5 kat arI
Akut reperfzyon parametreleri
Thrombolysis in myocardial infarcHon(TIMI) ow
Myocardial Blush Grade(MBG) lem sonras EKG de ST segment rezolsyonu
LER TETKKLER -Myocardial contrast echo -Cardiovascular MRI(Gadolinium)
STENT TROMBOZU
Angiographic Stent Thrombosis A[er RouHne Use of Drug-EluHng Stents in ST-Segment ElevaHon Myocardial InfarcHon: The Importance of Thrombus Burden
Georgios Sianos, MD, PhD, , Michail I. Papafaklis, MD, Joost Daemen, MD, Soa Vaina, MD, Carlos A. van Mieghem, MD, Ron T. van Domburg, PhD, Lampros K. Michalis, MD, MRCP, Patrick W. Serruys, MD, PhD, FACC
Show more doi:10.1016/j.jacc.2007.04.059 Journal of the American College of Cardiology
Fazla trombs yk olan damarlarda primer PCI sonras stent trombozu oranlar anlaml olarak artmaktadr( 8.2% vs 1.3% p
TIMI TROMBS SINIFLAMASI
TIMI TROMBS 0
TROMBS YOK
TIMI TROMBS 1
TROMBS OLMA HTMAL VAR
TIMI TROMBS 2
TROMBS VAR EN BYK UZUNLUU DAMAR APININ 1/2 FAKAT 2
TIMI TROMBS 5
TOTAL TIKALI
Glimm et al. Circulation 2001;21:2550
Primer PCIda Koroner trombsn distal embolizasyonunu nleme
stratejileri 1-Trombs rezolsyonu iin Farmakolojik yaklamlar
2-AdjuncHve mekanik cihazlar(Trombs aspiarasyonu ve Embolik proteksiyon cihazlar)
Abciximab Eftifibatide Tirofiban
Reseptr affinitesi Hzl affinite Yava ayrlm Yarmasz inhibisyon
Yava affinite Hzl ayrlm Yarmal inhibisyon
Yava affinite Hzl ayrlm Yarmal inhibisyon
Etkinliin balangc 10-26 dakika 90-150 dakika 90-150 dakika
Vcttan atlm 12-24 saat 2-4 saat 2-4 saat
Atlm yolu Plasma proteazlar
Bbrek Bbrek(%30-60) Karacier (%40-70)
Dier -3 integrin (vitronectin), MAC-1 reseptr inhibisyonu
Gp2b/3a RESEPTR ANTAGONSTLER
Study GPI PopulaXon Access Site IC IV ICE, 2010 E[ibaHde ACS
(26%STEMI) Femoral IC bolus/18-h IV inf. IV bolus/18-h IV inf.
CICERO, 2010 Abciximab STEMI - IC bolus a[er thrombectomy
IV bolus a[er thrombectomy
Iverson et al ,2011 Abciximab STEMI - IC bolus/12-h IV inf. IV bolus/12-h IV inf.
Dominguez et al, 2009
Abciximab
STEMI Femoral
IC bolus a[er thrombectomy/12-h IV inf.
IV bolus a[er thrombectomy/12-h IV inf.
Wu et al, 2008 Tiroban ACS (63%STEMI)
- IC bolus/36-h IV inf. IV bolus/36-h IV inf.
Thiele et al, 2008 Abciximab STEMI - IC bolus /12-h IV inf. IV bolus/12-h IV inf.
Yang et al, 2007 Tiroban STEMI - IC bolus/36-h IV inf. IV bolus/36-h IV inf.
Bellandi et al, 2004 Abciximab
STEMI
Femoral
IC bolus/12-h IV inf. IV bolus/12-h IV inf.
LIPSIA-STEMI 2010 Abciximab
STEMI
- IC bolus/12-h IV inf IV bolus/12-h IV inf
EASY-MI, 2010 Abciximab STEMI Transradial IC bolus/12-h IV inf IV bolus/12-h IV inf
Galache Osuna et al,2006
Abciximab ACS (41%STEMI)
Radial or femoral IC bolus/12-h IV inf IV bolus/12-h IV inf
RANDOMIZED STUDIES 1590 paXents
Friedland S et al. Am J Cardiol 2011;108:1244-1251
What is The Reason to Prefer Local Coronary Infusion of IIb/IIIa
Inhibitors ??
Her bir trombosit yzeyinde 60 000 to 80 000 GP IIb/IIIa receptr bulunmaktadr. Tedavi, bu reseptrlerin en az %80ini bloke etmeyi amalamaktadr.
IC GP IIbIIIa receptor inhibitor uygulanmas ile daha fazla lokal konsantrasyon salanmakta ve platelet GP IIb/IIIa receptor occupancy artmaktadr.
Ayrca yksek lokal konsantrasyonlar, trombs disagregasyonu salayabilmektedir.
Abciximab, yksek lokal konsantrasyonlarda potent anH-enamatuar etki gsterir. Bu etki i.v. Uygulamada gsterilememiHr.
IC uygulama ile , post-PCI i.v. Uygulama gereksinimi ortadan kalkabilir ve bylece sistemik ila konsantrasyonlar minimize edilerek kanama olaylar azalabilir.
Abciximab bolus uygulamas, total dozun 75% ine karlk gelir.. Pharmacological data , single bolus (0.25 mg/kg) abciximab ile >80% of platelet aggregaHon inhibisyonu salanabildii ve bu etkinin saatlerce srdn gstermiHr.
Domiguez A et al. Atherosclerosis 2009;206:523-27
ICE CICERO Iversen Dominquez-Rodriquez Wu Thiele Yang EASY-AMI Overall (I-squared=20.1%,p=0.270)
1.07 (0.89-1.28) 1.03 (0.97-1.10) 1.10(0.96-1.24) 1.29 (0.96-1.76) 1.22 (1.01-1.48) 0.98(0.86-1.12) 1.27(0.98-1.64) 1.15 (0.96-1.37) 1.08 (1.02-1.15)
8.66 34.90 17.43 3.27 7.96 14.25 4.60 8.92 100.0
IC better IV better
Study RR (95% CI)
% Weight
0 0.5 1 1.5 2
GPIIb/IIIa IC versus IV TIMI 3 FLOW AFTER PCI
Friedland S et al. Am J Cardiol 2011;108:1244-1251
CICERO Iversen Wu Thiele Overall (I-squared=0.0%,p=0.552)
0.87 (0.36-2.12) 0.40(0.17-0.95) 0.33 (0.01-7.86) 0.20(0.01-4.10) 0.54 (0.30-0.96)
32.91 54.08 4.91 8.11 100.0
IC better IV better
Study RR (95% CI)
% Weight
0 0.5 1 1.5 2
GPIIb/IIIa IC versus IV SHORT-TERM TVR
Friedland S et al. Am J Cardiol 2011;108:1244-1251
CICERO Iversen Wu Thiele Yang Bellandi Overall( I-squared=0.0%,p=0.777)
0.69 (0.22-2.16) 0.20 (0.04-0.93) 0.49(0.05-5.27) 0.67(0.11-3.98) 0.19 (0.01-3.71) 1.05(0.07-15.70) 0.45 (0.23-0.90)
28.34 37.42 8.05 11.97 10.33 3.90 100.0
IC better IV better
Study RR (95% CI)
% Weight
0 0.5 1 1.5 2
GPIIb/IIIa IC versus IV 30 DAY MORTALITY
Friedland S et al. Am J Cardiol 2011;108:1244-1251
CICERO Iversen Dominguez-Rodriquez Wu Thiele Yang Overall( I-squared=0.0%,p=0.562)
1.11 (0.68-1.81) 0.69 (0.41-1.17) 0.67(0.12-3.65) 0.76(0.31-1.91) 0.80(0.22-2.87) 2.17(0.63-7.51) 0.92(0.68-0.1.24)
35.69 38.01 3.91 11.82 6.51 4.05 100.0
IC better IV better
Study RR (95% CI)
% Weight
0 0.5 1 1.5 2
GPIIb/IIIa IC versus IV SHORT-TERM BLEDNG EVENTS
Friedland S et al. Am J Cardiol 2011;108:1244-1251
Intracoronary Versus Intravenous Administration of Abciximab in Patients With ST-Segment Elevation
Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention With Thrombus
Aspiration
The Comparison of Intracoronary Versus Intravenous Abciximab Administration During Emergency Reperfusion of ST- Segment
Elevation Myocardial Infarction (CICERO) trial
ENZYMATIC INFARCT SIZE
Intracoronary (n=126)
Intravenous (n=122)
p
Peak CK, U/L 1214 1746 0.008
Peak CK-MB, U/L 154 232 0.003
Peak cTnT, g/L 3.03 4.36 0.008
Gu Y L et al. Circulation 2010;122:2709-2717
30 % Smaller in the IC group
Clinical Outcome at 30 Days
Intracoronary (n=271), n(%)
Intravenous (n=263)
p
Mortality 5 (1.8) 7 (2.7) 0.524
Cardiac mortality 4 (1.5) 6 (2.3) 0.492
TVR 9 (3.3) 10 (3.8) 0.764
ReinfarcXon 3 (1.1) 4 (1.5) 0.721
In-stent thrombosis 1 (0.4) 3 (1.1) 0.366
MACEs 15 (5.5) 16 (6.1) 0.786
Gu Y L et al. Circulation 2010;122:2709-2717
Intracoronary Compared with Intravenous Bolus Abciximab Application
During Primary Percutaneous Coronary Intervention
The Abciximab Intracoronary versus intravenously Drug
Application in ST-Elevation Myocardial Infarction (AIDA STEMI) trial
Holger Thiele, MD; Jochen Whrle, MD; Rainer Hambrecht, MD; Harald Rittger, MD; Ralf Birkemeyer, MD;
Bernward Lauer, MD; Petra Neuhaus, PhD; Oana Brosteanu, PhD; Peter Sick, MD; Marcus Wiemer, MD; Sebastian Kerber, MD; Ingo Eitel, MD; Klaus Kleinertz, MD; Gerhard Schuler, MD
on behalf of the AIDA STEMI Investigators
ST-Segment-Resolution
Early ST-Segment Resolution (%)
IV A
bciximab
IC A
bciximab
Freq
uenc
y
p=0.37
Conclusions
This randomized, multi-center, large-scale trial involving more than 2000 STEMI patients undergoing primary PCI showed that IC abciximab bolus administration is safe.
The IC bolus administration of abciximab does not add a benefit in comparison to the standard IV bolus with respect to the combined primary study endpoint consisting of death, reinfarction, or new congestive heart failure within 90 days.
The IC route might be related to reduced rates of new congestive heart failure.
IC bolus doses of GPIIb/IIIa inhibitors
Bolus Dose Infusion dose
Abciximab 0.25mg/kg 0.125g/kg/min
E[ibaHde 180 g/kg 2g/kg/min
Tiroban 10 g/kg 0.15g/kg/min
Friedland S et al. Am J Cardiol 2011;108:1244-1251
Guiding catheters without side holes must be prefer to administer i.c. GPIIb/IIIa inhibitors
MORE BENEFIT FROM IC GpIIb/IIIa
High thrombus burden; aspiraHon thrombectomy (-)
Symptom duraHon is long (>4 hour)
High risk paHents (type B2/C lesions, dissecHon,no-reow)
TROMBEKTOM LE BRLKTE YAPILIRSA ?
ATTEMPT VER TABANI
Burzotta F et al. Eur Heart J 2009;30:2193-2203
INFUSE AMI TRIAL
INFUSE AMI TRIAL: Intracoronary bolus dose of abciximab delivered with a dedicated infusion catheter (Clear-Way) versus no bolus with or without thrombus aspiraHon in paHents treated with bivalirudin
INFUSE-AMI is tesHng the hypothesis that the intracoronary administraHon of an abciximab bolus with or without thrombus aspiraHon before stent implantaHon compared to no infusion with or without thrombus aspiraHon reduces infarct size among paHents undergoing primary PCI for anterior STEMI who are treated with bivalirudin.
Date of download: 12/8/2014 Copyright 2014 American Medical Association. All rights reserved.
From: Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction: The INFUSE-AMI Randomized TrialJAMA. 2012;307(17):1817-1826. doi:10.1001/jama.2012.421
More than 1 reason for study exclusion were present in some patients who were not eligible for randomization. Cardiac magnetic resonance imaging (cMRI) at 30 days was not performed in 70 enrolled patients for the following reasons: patient refusal or withdrawn consent for cMRI (n=27); patient inability to complete the cMRI (most commonly for claustrophobia) (n=15); death before the 30-day cMRI (n=13); too ill (n=4); patient forgot (n=4); contrast contraindication (n=2); other (n=5). In addition, despite being performed, the cMRI study was not evaluable for the primary end point of infarct size in 29 patients because of technical issues in image acquisition, including incorrect image sequencing, inadequate inversion recovery time, excessive breathing artifact, and missing slices. CABG denotes coronary artery bypass graft; GPI, glycoprotein IIb/IIIa inhibitor; IC, intracoronary; LAD, left anterior descending coronary artery; PCI, percutaneous coronary intervention; and TIMI, Thrombolysis in Myocardial Infarction.
Figure Legend:
INFUSE AMI -SONU
In paHents with large anterior STEMI presenHng early a[er symptom onset and undergoing primary PCI with bivalirudin anHcoagulaHon, infarct size at 30 days was signicantly reduced by bolus intracoronary abciximab delivered to the infarct lesion site but not by manual aspiraHon thrombectomy.
In patients undergoing primary PCI treated with UFH, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-
bolus eptifibatide, or high-bolus dose tirofiban), whether or not patients were pretreated with clopidogrel. (For GP IIb/IIIa inhibitor administration in patients not pretreated with clopidogrel, Level of Evidence: A; for GP IIb/IIIa inhibitor administration in patients pretreated with clopidogrel, Level of Evidence: C)
STEMI IV Antiplatelet Therapy: Recommendations
I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
In patients undergoing primary PCI with abciximab, it may be reasonable to administer intracoronary abciximab.(Level of Evidence: B)
These agents might provide more benefit in selective use, such as in patients with large anterior MI and/or large thrombus burden (TIMI thrombus grade >3)
Levine et al. J Am Coll Cardiol 2011;58:917-24
Primer PKG'de adjuvant mekanik yntemler (Manuel - Mekanik Aspirasyon, Distal-
Proksimal Proteksiyon): Kime, nasl?
Primer PKG'de adjuvant mekanik yntemler ne salyor??
Trombs younluunu azaltarak; -Distal embolizasyonu azaltyor, -Direkt stentlemeyi salyor, - Vazokonstriksyonu azaltyor, -Damar apnn daha iyi belirlenmesini salayp
malappozisyon gelimesini engelliyor, -Gerek aterosklerotik darln gzkmesini salayarak
bu darln medikal tedavi ile stabilize olup olamayacan gsterebiliyor
De Luca G et al. Int J of Cardiol BASKIDA
PPKG SIRASINDA KULLANILAN ADJUVANT MEKANK YNTEMLER
Manuel Aspirasyon Mekanik Aspirasyon Distal-Proksimal Proteksiyon
Distal embolizasyon zaman
Napadono ,2005
ASPRASYON CHAZLARI MANUEL MEKANK
EXPORT ANGIOJET
DIVER CE X-SIZER
PRONTO THROMCAT
QUICKCAT RINSPIRATOR
THROMBUSTER
RESCUE
TVAC
PROTEKSYON CHAZLARI DSTAL
FLTRE BALON TIKAYICI
Angioguard Guardwire
Filterwire TriActive Cardioshield (Emboshield)
Theron
Spider RX MoMa
Interceptor Arteria
PROKSMAL PROKSS
KERBEROS RINSPIRATOR
PARODI
De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE REMEDIA VAMPIRE TAPAS TOPLAM(%95 CI)
0.19(0.01-4.08) 0.33 (0.01-8.11) 0.35(0.01-8.93) 0.64 (0.15-2.72) 0.94 (0.18-4.77) 1.00(0.19-5.22) 0.97(0.06-15.66) 0.52(0.25-1.08) 0.58 (0.34-0.98)
6.59 4.01 3.78 12.55 8.02 7.51 2.69 54.82 100.0
Manual trombektomi iyi
alma RR (95% CI)
%
0.1 0.5 1 2 5 10
De Luca G et al. Eur Heart J 2008;29:3002-3010
P=0.04
Kontrol iyi
MANUEL ASPRASYON-30 GN LM
DEAR MI De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE VAMPIRE TAPAS TOPLAM(%95 CI)
2.28(0.91-5.71) 1.73 (0.61-4.88) 2.03(1.00-4.11) 5.49(0.59-50.79) 1.93 (0.70-5.32) 1.42(0.73-3.60) 1.70(0.94-3.05) 1.29(0.92-1.82) 1.59 (1.26-2.00)
5.49 4.79 9.60 0.73 4.95 8.33 15.20 50.91 100.0
Manual trombektomi iyi
alma RR (95% CI)
%
0.1 0.5 1 2 5 10
De Luca G et al. Eur Heart J 2008;29:3002-3010
P
DEAR MI De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE VAMPIRE TAPAS TOPLAM(%95 CI)
9.48(4.11-21.85) 3.85 (1.22-12.14) 5.91(3.08-11.35) 2.27(0.73-7.07) 1.63 (0.92-2.90) 2.33(1.21-4.48) 3.32(2.07-5.33) 1.77(1.36-2.29) 2.44(2.04-2.92)
2.54 2.06 4.84 2.58 11.86 7.68 12.55 55.99 100.0
Manual trombektomi iyi
alma RR (95% CI)
%
0.1 0.5 1 2 5 10
De Luca G et al. Eur Heart J 2008;29:3002-3010
P
Trombektomi ve Emboli Koruma Cihazlarnn AM deki Rol: Randomize almalarn Metaanalizi Bavry et al. Eur Heart J 2008
30 randomize alma: n=6415 13 manuel aspirasyon %47 5 mekanik aspirasyon %38 12 emboli koruma cihaz %15
%
Manuel Aspirasyon
6
3
0
Adjuvant cihaz Sadece PKG P=0.05
P=0.018
Proteksiyon cihaz
2.7
ST YKSELMEL M 30 ALIMA 6 AY MORTALTE
4.4
Mekanik Aspirasyon
2.8 5.3
3.1 3.4
P=0.69
Bavry A A et al. Eur Heart J 2008;29:2989-3001
11 alma ,n=2686, izlem median 1 yl, PSN total mortalite
PKG yaplan STEMI hastalarnda trombektomi (zellikle manuel trombektomi) klinik sonular olumlu etkiler, GpIIbIIIa inh ek yarar salayabilir.
STEMI de Trombektominin Klinik Etkisi :ATTEMPT
Metaanaliz: de Luca et al.
30 gnlk Mortalite
Manuel aspirasyon cihazlar ile mortalitede bir azalma,
Mekanik aspirasyon cihazlar ile mortalitede bir art saptanrken,
Emboli proteksiyon cihazlar ile mortalitede bir fark saptanmamtr
SONU PPKG'de adjuvant mekanik yntemler
Trombektominin PPKG sonularna etkisi: Metaanaliz Mongeon FP, CirculaHon Cardiovascular IntervenHons 2010 21 alma, 4299 hasta (16 alma 3365 hasta manuel trombektomi)
Sonu: Trombektomi reperfzyonu olumlu etkiliyor ama 1 aylk klinik sonulara etkisiz
Thrombus Aspiration during Primary Percutaneous Coronary Intervention
TAPAS Trial
Tone Svilaas, M.D., Pieter J. Vlaar, M.Sc., Iwan C. van der Horst, M.D., Ph.D., Gilles F.H. Diercks, M.D., Ph.D., Bart J.G.L. de Smet, M.D., Ph.D., Ad F.M. van den Heuvel, M.D., Ph.D., Rutger L. Anthonio, M.D., Ph.D., Gillian A. Jessurun, M.D., Ph.D., Eng-Shiong Tan, M.D., Albert J.H. Suurmeijer, M.D., Ph.D., and Felix Zijlstra, M.D., Ph.D.
N Engl J Med 358(6):557-567 February 7, 2008
TAPAS TRIAL
Manuel Aspirasyon N=1071, tek merkez, randomize,6F Export Aspirasyon+ direkt stent vs stent MBG 0-1 %17,1 vs %26.3 ,P
STEMI de trombs aspirasyonu bazal klinik ve anjiyograk zelliklerden bamsz olarak konvansiyonel PKG ye gre daha iyi reperfzyon ve klinik sonu salar.
One year follow up
All cause mortality: 38% reduction
Cardiac death: 46% reduction
Cardiac death/MI: 43% reduction Vlaar et al. Lancet 2008;371:1915-20..
PIHRATE: PPKG de Trombs Aspirasyonu +Direkt Stent
Dudek et al. Am Heart J 2010;160:966-72
EXPIRA
Erken sonu:
2 yllk sonular:
Sardella G. American Heart AssociaXon 2009 ScienXc Sessions; November 14, 2009; Orlando, FL.
Hangi hastada yararl? Kime yapalm? Erken gelen vs ge gelen?
Thrombus AspiraXon in ST- ElevaXon myocardial infarcXon
in Scandinavia (TASTE trial)
Ole Frbert, MD, PhD - on behalf of the TASTE invesHgators Departement of Cardiology rebro University Hospital
Sweden
Main results at 30 days
TASTE ALIMASI
TASTE (Thrombus aspiraHon during ST-segment elevaHon myocardial infarcHon) almas, STEMIde trombs aspirasyonu ile ilgili en nemli almadr .
TASTE almasna 7244 hasta alnm, 3621i trombs aspirasyonu koluna, 3623 kontrol grubuna randomize edilmiHr.
TASTE and previous studies
0 1000 2000 3000 4000 5000 6000 7000 8000
Liistro
DEAR-MI
EXPIRA
PIHRATE
X AMINE ST
MUSTELA
Kalto[
Chevalier
PREPARE
VAMPIRE
INFUSE-AMI
AIMI
JETSTENT
TAPAS
TASTE
Number of paXents
TASTE
TASTE -30. GN SONULAR
30. gn sonunda lm oranlar asndan 2 grup arasnda fark yok.
All-cause mortality at 30 days
HR 0.94 (0.72 - 1.22), P=0.63
Per protocol analysis based on
actual treatment:
HR 0.88 (0.66 - 1.17), P=0.38
ReinfarcXon at 30 days
HR 0.61 (0.34 - 1.07), P=0.09
Per protocol analysis based on
actual treatment:
HR 0.67 (0.36 - 1.20), P=0.19
TASTE-1.YIL SONULARI
Lagerqvist B1, Frbert O, Olivecrona GK, Gudnason T, Maeng M, Alstrm P, Andersson J, Calais F, Carlsson J, Collste O, Gtberg M, Hrdhammar P, Ioanes D, Kallryd A, Linder R, Lundin A, Odenstedt J, Omerovic E, Puskar V, Tdt T, Zelleroth E, stlund O, James SK. Outcomes 1 year a[er thrombus aspiraHon for myocardial infarcHon. N Engl J Med. 2014 Sep 18;371(12):1111-20. doi: 10.1056/NEJMoa1405707.
TASTE- 1. YIL
Bir yllk takipte primer sonlanm olan tm nedenli lmler aspirasyon yaplanlarda %5.3, yaplmayanlarda %5.6 olarak bulunuyor (p=0.57). Miyokart infarktsyle tekrar hastaneye yaI ve stent trombozu da iki grupta benzer kyor.
Mekanik Trombektomi
AIMI (Ali A et al ,JACC 2006;48:244-252) ReoliHk trombektomi+PKG vs PKG nfarkt alan (12.5 vs 9.8, p0.03) ve mortalite (%4.6 vs 0.8, p
0.02) daha yksek JETSTENT (Migliorini et al, JACC 2010; 56:1298-1306) Stent ncesi RT vs stent
6 ay MACE dk %11.2 vs %19.4, p 0.011 1 yl olaysz sakalm yksek%85 vs %75, p 0.009
Comparison Of Manual AspiraXon With RheolyXc Thrombectomy In Acute Myocardial InfarcXon: The Final 6-
Month Results Of The SMART Primary PCI Trial
Comparison Of Manual AspiraHon With RheolyHc Thrombectomy In Acute Myocardial InfarcHon: The Final 6-Month Results Of The SMART Primary PCI Trial
Guido Parod, Renato ValenH, Angela Migliorini1, Nazario Carrabba1,Akiko Maehara, Ruben Vergara,Benedea Bellandi1, Gary Mintz3, David Antoniucci,
MAT or RT allow only incomplete removal of thrombus in the seng of AMI. RT as compared to MAT is more eecHve in thrombus removal and is associated with a beer myocardial reperfusion.
lemden nce lem Srasnda
TIMI trombs snflamas (0-5) Hava Embolisi -Aspirasyon kateteri kartlrken hava klavuz kateterde haps olabilir
Damar Anatomisi -Tortyoz -Kalsifikasyon -Kk damar
Drag and drop effect
Aspirasyon kateteri klavuz kateterden kana kadar negatif basnta kartlmaldr
Klavuz kateter ile aspirasyon kateteri co-axial olmaldr. Olmaz ise klavuz kateterin ucunda taklarak trombsn dmesine sebep olabilir
Aspirasyon kateteri kartldktan sonra klavuz kateter mutlaka aspire edilmelidir
%10 ASPRASYON BAARISIZ
Belirgin proksimal tortyozite (> 2 kvrm) Kalsifik lezyon Bifrkasyon lezyonu Cx arter
Vink MA et al. J Am Coll Cardiol Intv 2011;4:634-642
PRMER PKG TROMBOASPRASYON
Klavuz tel ile sorumlu lezyon geildikten sonra AKIM TIMI 0-1 TIMI 2-3 IC TROFBAN TROMBOASPRASYON/ANJYOJET TROMBUS YOUNLUU
AZ OK (TIMI TROMBUS
STYM-Primer PKG 2009
Primer PKG srasnda aspirasyon trombektomi yaplmas nerilir
I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
Primer PKG srasnda aspirasyon trombektomi yaplmas nerilir
STYM-Primer PKG 2011
I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III
ESC/EACT 2010 Klavuzu IIA (A)
EXPRA TAPAS Metaanaliz Bavry et al Metaanaliz de Luca et al Meta analiz Bavry et al Burzoa F TAPAS
PPKG Manuel trombektomi
IIa
PPKG manuel trombektomi IIa
YEN ORAL ANT-TROMBOST AJANLAR
Neden yeni anXtrombositer ila?????
.Klopidogrelin akHf metaboliHne dnmesinin yava olmas, geri dnsz balanmas ve etkisinin hastalar arasnda deikenlik gstermesi(geneHk polimorzm) gibi snrllklar var .Klopidogrelle ilikili olarak iskemik olay sklnn ykseldiine iaret eden kantlar artmaktadr.
Hasta Poplasyonu
123 hasta 18 yanda
Ran
dom
izas
yon 180 mg ykleme dozu ile
600 mg ykleme dozu ile
Plasebo (n=11)* * Tm hastalara ASA verildi.
Ykleme dozu Son doz
Tedaviye Devam (6 hafta)
Balang (1. gn)
Sonlanm (10. gn)
ONSET almas
1. Gurbel PA, et al. Circulation 2009;120:2577-85.
Tikagrelor 90 mg, 6 hafta sreyle gnde iki kez (n=52)*
Klopidogrel 75 mg, 6 hafta sreyle gnde bir kez (n=51)* Belgelenmi stabil KAH Devam eden ASA tedavisi
(75-100 mg/gn)
Faz II, ok merkezli, randomize, ift kr, paralel gruplu alma1
Conclusions First study to comprehensively characterize onset and offset of the antiplatelet effect of ticagrelor compared with clopidogrel in stable CAD patients.
3 Major Findings: - Ticagrelor onset is very rapid and markedly greater than high loading dose clopidogrel - Greater inhibitory eect of Hcagrelor is sustained during maintenance - Ticagrelor oset as determined by IPA slope was signicantly faster than clopidogrel
These eects may explain the lower occurrence of the primary endpoint with Hcagrelor therapy as compared to clopidogrel therapy in PLATO whereas numerically less CABG-related bleeding occurred in the Hcagrelor group despite greater platelet inhibiHon.
Tikagrelor 180 mg ykleme dozu
(n=54)
Klopidogrel 600 mg ykleme dozu
(n=50)
1. Gurbel PA, et al. CirculaHon 2009;120:2577-85.
Tikagrelor 30 dakikada %41lik IPA deerine ulamtr.1
Ykleme Dozu Sonras 30. Dakika IPA Oranlar1
%41 IPA
%8 IPA
Tikagrelor 180 mg ykleme dozu
(n=54)
Klopidogrel 600 mg ykleme dozu
(n=50)
1. Gurbel PA, et al. CirculaHon 2009;120:2577-85.
Tikagrelor 2. saatte %88lik IPA deerine ulayor.1
Ykleme Dozu Sonras 2. Saat IPA Oranlar1
%88 IPA
%38 IPA
PLATO almas Tasarm1,2
Primer etkililik sonlanm: Kardiyovaskler lm, M ve inme bileimi
Primer gvenlilik sonlanm: Toplam PLATO majr kanama
N=18,624 AKSli hastalar (UA, NSTEM ya da STEM)
1. James S, et al. Am Heart J 2009;157:599-605. 2. Wallentin L, et al. N Engl J Med 2009;361:1045-57.
Tikagrelor (n=9,333) 180-mg ykleme dozu 90 mg 2x1 + ASA idame dozu
Klopidogrel (n=9,291) 300-mg ykleme dozu 75 mg 1x1 + ASA idame dozu
PLATO almas: zet
PLATO, tikagrelor ile gnmzdeki standart tedavide kullanlan klopidogreli karlatran bir klinik almayd.1,2
Toplam 18,624 AKSli hasta, hastaneye bavurmalarndan ksa bir sre sonra - semptomlarn balamasndan sonraki 24 saat iinde ve genellikle anjiyografi yaplmadan nce - randomize edildi.1,2
PLATO almas klinik uygulamay yanstacak biimde tasarland.1-3 Daha nce klopidogrel kullanlm olan hastalar da almaya alnd. almaya hem invazif tedavi (%72) hem de medikal tedavi (%28) gruplar
dahil edildi.
PKG ncesi 600 mga dek ykleme dozu uygulanabildi. AKSli geni bir hasta grubu alnd (UA, NSTEM ya da STEM).1,2
1. James S, et al. Am Heart J 2009;157:599-605. 2. Wallentin L, et al. N Engl J Med 2009;361:1045-57. 3. 3. Cannon CP, et al. Lancet 2010;375:283-93.
zet
TU-47-27
2-Ekim
-201
3
1. Ayda Bileik Sonlanm Riski
Her iki grupta da ASA kullanld. ARR: Mutlak risk azalmas, RRR: Rlatif risk azalmas
Tikagrelor, 1. aydaki KV lm, M ve inme bileik sonlanmn klopidogrele gre anlaml oranda azaltmtr.1
%5.4 %4.8
1. Wallentin L, et al. N Engl J Med 2009;361:1045-57.
%0.6 ARR
%12 RRR
Tikagrelor (n=9333)
Klopidogrel (n=9291) HR %95 GA P deeri 0.88 0.77-1.00 0.045
TU-47-27
2-Ekim
-201
3
1. Ylda Primer Bileik Sonlanm Noktas
Her iki grupta da ASA kullanld. nme asndan tedavi gruplar arasnda fark yoktur. ARR: Mutlak risk azalmas, RRR: Rlatif risk azalmas; NNT: Tedavi edilmesi gereken hasta says
Tikagrelor ile klopidogrele gre erken dnemde salanan mutlak risk azalmas 1 yllk tedavi sresince devam etmi.1
%11.7
%9.8
1. Wallentin L, et al. N Engl J Med 2009;361:1045-57.
%1.9 ARR
%16 RRR
Tikagrelor (n=9333)
Klopidogrel (n=9291) HR %95 GA P deeri 0.84 0.77-0.92
Tikagrelor, dk doz ASA alanlarda 1. yldaki KV lm klopidogrele gre %29 azaltmtr.1,2
Dk Doz ASA* Alanlarda 1. Ylda KV lm Riski1
Tikagrelor (n=8025)
Klopidogrel (n=8034)
HR %95 GA P deeri 0.71 0.60-0.84
Olay Tikagrelor,%
(n=3752) Klopidogrel, %
(n=3792) p deeri
KV lm, MI ve inme 9.4 10.8 0.07
Total lm, MI ve inme 9.8 11.3 0.05
KV lm, MI, inme, iskemi, TIA, arteriyal thromboz
13.3 15.0 0.03
MI 4.7 5.8 0.03
KV lm 4.5 5.5 0.07
Inme 1.7 1.0 0.02
Tm nedenlere bal lm 5.0 6.1 0.05
PLATO STE-ACS: Primer ve sekonder sonlanm
noktalar [
Klopidogrel iyi Tikagrelor iyi
1.0 2.0 0.5
HR (95% CI)
ACS, akut koroner sendrom; CI, gven aral ; CV, kardiyovaskler; HR, hazard raHo; MI, miyokart enfarkts; STE, ST-segment ykselmesi; TIA, geici iskemik atak. Steg PG, et al. CirculaCon 2010;122:21312141.
STE-ACS hastalarnda Ticagrelora bal primer sonlanm noktasnda azalma PLATO genel sonular ile uyumludur
92
PLATO STE-ACS: Primer Birleik sonlanm noktas1
1. Steg PG et al. CirculaHon 2010;122:21312141; 2. WallenHn L et al. N Engl J Med 2009;361:10451057
10.8%
9.4%
STE-ACS BRILINTA (n=3752) Klopidogrel (n=3792)
Randomizasyon sonras aylar
KV
lm
, MI v
eya n
me
(%)
12
10
8
6
4
2
0 0 2 4 6 8 10 12
HR (95% CI) = 0.87 (0.751.01) P=0.07
PLATO almas genel primer sonlanm noktas: HR: 0.84; 95% CI: 0.770.92; P
TRITON-TIMI 38: Hasta alm emas
UA/NSTEMI semptom balangc sonras
72 saat ve TRS 3
STEMI semptom balangcndan 12 saat - 14 gn sonra (Post-
STEMI)
STEMI semptom balangc sonras
12saat
(Primer PKG)
DiyagnosXk Kateterizasyon
Randomizasyon
alma lac Ykleme Dozu
Gnlk dame Tedavisi & Uzun Dnem Takip
* Elik eden tedavi ve cihaz seimi hekim insiyatifinde
Medikal tedavi veya CABG plan
PKG plan
PKG*
Wiviott SD et al. Am Heart J 2006;152:627-635
Randomize etme
TRITON-TIMI 38 almas 12.ay verilerine gre: Majr kanama oranlar klopidogrelden farkszdr
Tm Kohort 10 mg Endike Kohort Grubu
Wilcox R et al. Current Medical Research & Opinion 2014; 1-13
TRITON-TIMI 38:
Primer sonlanm noktasnda %19 azalma
Prasugrel
Klopidogrel
5
10
15
0 0 30 60 90 180 270 360 450
Randomizasyon sonra geen sre (gn)
Sonlan
m nok
tas (%
)
120
1.8 (111) 2.4 (146)
Non-CABG TIMI majr kanamalar
KV lm, MI, nme
p=0.03
p
TRITON-TIMI 38 prasugrel Ykleme Dozu
Wiviott SD et al. Am Heart J 2006;152:627-635
Prasugrel ykleme dozu: Mmkn olduunca erken veya PKG srasnda
AHA/ACC STEMI Klavuzu, 2013
STEMI Kohort (N = 3534)
Prasugrel STEMI hastalarnda 30.gnde KV lm ve tm nedenli lmleri anlaml olarak azaltmr.
Montalescot G. et al. Lancet 2009; 373: 723-31
Hasta (%
)
TRIPLET almas: 60 mg prasugrel ykleme dozu AKS-PKG hastalarnda klopidogrel 600 mg + prasugrel 60 mg ykleme dozu ile
benzer trombosit inhibisyonu salamr
DiodaX, et al. Circ Cardiovasc Interv 2013;6:567-74.
SWAP almas: Klopidogrel idame tedavisinden prasugrele hem yklemeli hem
yklemesiz gei, anXagregan etkinlii arrr.
LD=Ykleme Dozu; MD=dame Dozu; PRU=P2Y12 ReakHvite nitesi *p
The DAPT Study was designed in response to a request from the FDA to evaluate the eect of dual anXplatelet therapy beyond one year in subjects
treated with coronary stents.
DAPT-CONCLUSIONS
Following drug-eluHng stent treatment, conHnuaHon of thienopyridine plus aspirin beyond one year reduces the risk of stent thrombosis and MACCE compared with aspirin alone. RelaHve reducHons of 71% for ST, 29% for MACCE and 53% for M Myocardial infarcHon reduced both in the stent and in other locaHons Treatment benet on ST and MI consistent across drugs, for newer
and older stents, and across subjects with higher or lower risk of events
The benet of extended thienopyridine treatment was tempered by an increase in bleeding events (relaHve increase, 61%). Severe and/or fatal bleeding was uncommon.
ESC Miyokardiyal Revasklarizasyon Klavuzu
ESC Miyokardiyal Revasklarizasyon Klavuzu
2014 AHA/ACC NSTE-ACS Klavuzu
1. 10. 2013 ACCF/AHA Guideline for the Management of ST-ElevaHon Myocardial InfarcHon. CirculaHon 2013;127:00-00. DOI: 10.1161/CIR.0b013e3182742c84
Tikagrelor
Tikagrelor
Tikagrelor ile nerilen idame ASA dozu 81 mgdir.
TU-47-27
2-Ekim
-201
3
EVE GTRLECEK MESAJLAR
Distal embolizasyon primer PCI da sklkla karmza kabilir ve azalm miyokardiyal perfzyon ve kt klinik sonularla ilikilidir.
GPI ile farmakolojik stratejilerin ilem baars zerine olumlu etkileri zellikle yksek riskli hastalarda belirgindir. IC. Kullanm etkinlii arrabilir
Manual aspirasyon cihazlar basit, hzl kullanm olup, 1 yllk klinik sonular olumlu etkileyebilir
EVE GTRLECEK MESAJLAR
Yeni anHtromboHk ajanlar Primer PKG da ilk seenek olmal