Welcome Ask The Experts March 24-27, 2007 New Orleans, la incorporating Patient Risk into Decisions Regarding the Optimal Reperfusion Strategy for st elevation mi duane S


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  • Welcome

  • Ask The Experts

  • March 24-27, 2007

  • New Orleans, LA


Incorporating Patient Risk into Decisions Regarding the Optimal Reperfusion Strategy for ST Elevation MI Duane S. Pinto, MD Assistant Professor of Medicine Harvard Medical School Director, Cardiology Fellowship Training Program Beth Israel Deaconess Medical Center Boston, MA



PAMI



GUSTO IIb



PCI vs Fibrinolysis for STEMI: Short Term Clinical Outcomes



Importance of Rapid Time to Treatment With Fibrinolysis in STEMI



NRMI 2: Primary PCI Door-to-Balloon Time vs. Mortality





Time from Symptom Onset to Treatment Predicts One-year Mortality with PCI



PCI-Related Time Delay vs Mortality Benefit in 22 Randomized Studies of PCI vs Fibrinolytic Therapy



PCI-Related Time Delay vs Mortality Benefit in 21 Randomized Studies of PCI vs Fibrinolytic Therapy



PCAT-2 Analysis

  • Patient level data included in analysis of 22 trials (n=6,763)

  • PPCI was associated with a



Advantage of PCI Compared With Fibrinolysis Decreases as PCI-Related Delay Increases



PCI Related Delay (DB-DN) Where PCI and Fibrinolytic Mortality Are Equal (Min) Stratified by Patient Characteristics



Meta-analysis of Transfer for PCI vs. Fibrinolysis



DANAMI-2: Primary Results





Maybe Our Systems Are Not Completely Optimized in the US!



DANAMI vs US AMI: Are We As Quick in the US?



Times in Randomized Trials vs. the “Real World”



PCI-Related Time Delay vs Mortality Benefit in 22 Randomized Studies of PCI vs Fibrinolytic Therapy



Prehospital Delay & Timing of Reperfusion Strategy Equivalence





One Size Does Not Fit All!



Summary

  • Simple rules:

    • DB<90 min
    • DB-DN <60 min
    • DN <30 min
    • Transfer all for PCI, etc
  • are not enough to determine the optimal reperfusion strategy for all patients in all situations



Summary

  • The clinician must integrate:

    • Prehospital Delay
    • Anticipated STEMI Risk (age, anterior, inferior, shock)
    • Anticipated Risk for ICH
    • Anticipated Transfer time/PCI related delay


Summary

  • Fibrinolysis is not unreasonable when

    • PCI associated with unacceptable delay (Class I)
    • Short time from symptom onset (<1 hr) (Class I)
  • Primary PCI is superior to Fibrinolysis in several clinical situations, particularly if:

    • Competent personnel involved
    • DB times are <90 Min, PCI related Delay Acceptable
    • High Risk for Bleeding or Complication from MI
    • Late Presentation


Summary

  • The benefits and limitations of Primary PCI should be considered when developing regionalized transfer and community based PCI systems

  • Continued work is needed to develop pharmacologic strategies to rapidly, effectively, and safely open closed arteries thereby extending the benefit of PCI to a larger group of patients



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  • Thank You!

  • Please make sure to hand in your evaluation and pick up a ClinicalTrialResults.org flash drive




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