Fibrinolysis or Primary PCI:
Does “One Size Fits All” for Acute
Myocardial Infarction Patients?
Luiz Alberto Mattos
Instituto Dante Pazzanese de Cardiologia
Sao Paulo, Brazil
Reperfusion for Acute Myocardial Infarction
Primary PCI is the “Gold-Standard” Treatment
Circulation, November 14 Th, 2006
TIMI-3
Flow
100%
Gradient of Benefit: Primary PCI vs. Lytics
30 day Mortality – Summary from RCT’s
75%
50%
47% vs STK
38% vs Lytic
(>70-<80 yrs)
30% vs TNK
25%
24% vs
Transfer
0
Time Delay for
Primary PCI
< 90 minutes
> 90 minutes
Reperfusion Therapy Evolution
July 1999 / December 2005 – GRACE Registry
JAMA 2007;297:1894
Reperfusion in Latin America
Reperfusion for Acute MI (STEMI)
Geographical Variances of Therapeutics
Global Registry of Acute Coronary Events (GRACE)
Predictors of “No Reperfusion” Strategy
94 Hospitals in 14 Countries
Variable
Odds Ratio
p
Age >75
yrs
2.28 (1,35-3,87)
<0,001
No More
Pain
3.23 (2,13-4,89)
<0,001
Diabetics
1.46 (1,11-1,94)
0,001
Heart
Failure
2.92 (1,84-4,67)
<0,001
Previous
CABG
2.28 (1,35-3,87)
<0,001
Eagle KA, Lancet, February 2, 2002
Myocardial Reperfusion Strategies
Primary PCI versus Fibrinolysis
Variable
Accessibility
Delay for
reperfusion
Limitation
Benefit
Restricted
Broad
Higher for arriving
Reduced to arriving
Reduced to obtain
Higher to obtain
Failure of
No-flow still is a
Rescue PCI
Reperfusion challenging scenario
Future Directions for Primary PCI
Which Will Be The Next Steps?
MI ST Segment
Elevation
Logistics Improvements
 Reducing PCI Delay
 Transferring
 Acute MI Units
 Facilitated PCI
 Pre-Hospital Lytics
Quality of Reperfusion
 Antiplatelets Agents
 Clopidogrel
 Rheolytic (Aspiration)
 Adenosine
During
 DES Usage
Pre
3-Challenging Priorities for
Primary Coronary Intervention
1. Optimizing Logistical Intake – MI Hubs
 Multidisciplinary Approach Protocols
2. Speed Up Admittance and Transfer
 Better Quality-of-Care Process
D2B Alliance is a vehicle to disseminate
knowledge and promote improvement
www.d2balliance.org
More than 1,000 hospitals
joined the effort
The Use of Strategies Changed
in D2B Alliance Hospitals
Recommended Strategy*
Baseline
Follow-up
EM activation
Single call
Cath team < 30 min
Prompt data feedback
Activate from PH ECG
D2B Team
52%
31%
81%
61%
33%
64%
60%
37%
89%
79%
41%
85%
* All differences are significant P< 0.001
Several Key
Strategies Were Identified
Harvard
Medical
School
How to Optimize Reperfusion in Acute MI
Problem
Solution
Longer Delay for Presentation
Large Midia
Education
(symptom onset to presentation)
Delay for Transportation
(reception and guiding)
Delay for Treatment
(either lytics or PCI)
Logistical
Protocols
In-Hospital
Quality of
Care
3-Challenging Priorities for
Primary Coronary Intervention
1. Optimizing Logistical Intake – MI Hubs
 Multidisciplinary Approach Protocols
 Brazilian Scenario – Primary PCI
2. Speed Up Admittance and Transfer
 Better Quality-of-Care Process
SBHCI – Brazilian Society
of Interventional Cardiology
1) 33 years in Brazil, from diagnostic
to
interventional
cardiology
(1975-2008) – www.sbhci.org.br
2) Gather nearly 1,000 interventional
cardiologists spread in 26 of 27
federative states
3) Strongly committed to board
certification, medical education and
quality of care in clinical practice
4) Open elections each 2-year period
200 million people
70.000 PCI’s year =
0,3/1,000
<30% DES Usage
5) Annual Scientific Meeting since
1976, that receive up to 1,000 health
professionals
Brazilian SAMU Emergency 192 System
www.datasus.gov.br
SAMU (Serviço de Atendimento Móvel de Urgência)
 Reintrodução no SUS Brasileiro – Abril de 2004
 Disque 192 – Atendimento em até 12 minutos
 452 ambulâncias UTI já entregues
 Sistema de Gestão Pública Mista
 146 cidades atendidas = >100 milhões de pessoas
 32 centrais telefônicas com médicos 24 horas
 Investimento inicial de 297 milhões de reais
(150 milhões de dólares americanos)
Reperfusion for Acute MI
Expediting the Triage Process for the Treatment
1. EMS prompt activation of Invasive Cardiology Group
2. “Singe-call” activation of all professionals involved
3. Invasive Cardiology set-up in average of 30 minutes
4. Constant feed-back review of time to treatment and
quality-of-care of the system
5. Central and Respected Managing
6. Multidisciplinary team effort
7. Pre hospital EKG analysis for speed up the process
Percutaneous Coronary Intervention
Brazil State-Owned Health System
Year
2004
2005
2006
2007
2008
Total of
PCI’s
16,484
35,880
41,730
43,210
46,266
Total of
Stents
15,336
(93,0%)
33,739
(94,0%)
39,563
(94,8%)
41,144
(95,25)
44,123
(95,3%)
Mortality
1,0%
1,0%
0,9%
1,1%
1,4%
Total of
Primary PCI
1,901
(11,7%)
5,400
(15,1%)
6,605
(15,8%)
7,551
(17,4%)
7,648
(16,5%)
Mortality
7,9%
6,6%
6,9%
7,4%
6,7%
Total of MI
45,023
48,749
47,024
45,505
51,350
(16,5%/PPCI)
(14,9%/PPCI)
15,1%
15,9%
(excl. AMI)
(4,2%/PPCI)
Mortality
16,4%
(11,1%/ PPCI) (14,1%/PPCI)
16,1%
15,9%
www.datasus.gov.br
3-Challenging Priorities for
Primary Coronary Intervention
1. Optimizing Logistical Intake – MI Hubs
 Multidisciplinary Approach Protocols
2. Speed Up Admittance and Transfer
 Better Quality-of-Care Process
3. Increase Operator Expertise
 Continuous Medical Education
Primary PCI in Brazil
South (RGS) vs. Other States
AIH’s – Year
2005
2006
2007
RS
Brazil
RS
Brazil
RS
Brazil
Total PCI’s
5,656
35,880
6,633
41,730
6,963
43,210
Mortality
1,1%
1,0%
0,8
0,9%
1,0
1,1%
Total Primary
PCI’s
296
(5,2%)
5,400
(15,1%)
637
(9.6%)
6,605
(15,8%)
936
(13,4%)
7,551
(17,4%)
Mortality
11,1%
6,6%
6,1%
6,9%
7,8%
7,4%
All Acute
MI’s
4,422
48,749
4,612
47,024
4,604
45,505
(6,7%-ICP)
Mortality
17,8%
(13,8%-ICP)
16,1%
17,4%
(20,3%-ICP)
15,9%
17,8%
16,1%
Primary PCI in Brazil
Rio de Janeiro vs. Sao Paulo State
AIH’s – Year
2005
2006
2007
RJ
SP
RJ
SP
RJ
SP
Total Acute
MI’s
5,039
13,072
5,389
13,937
5,663
14,241
Mortality
16,2%
16,9%
15,7%
15,9%
16,7%
16,1%
Total
Primary PCI
58
2,272
80
2,371
60
2,544
Mortality
6,9%
6,0%
12,5%
5,6%
20,0%
6,4%
Continuous Update for Primary PCI
Improving Operator Experience
 Logistic and Pharmacological Enforces Update
 Clopidogrel and beyond
 Bivalirudin and IIb/IIIa Inhibitors
 Mechanical and Intra-Procedural Strategies
 Direct Stenting: DES or BMS
 To aspirate or not aspirate all culprit AMI vessels
 Rheolytic strategies
 No/Slow Flow Prophylaxis
Optimizing The Challenge of Reperfusion in AMI
 Increase the Number of MI Diagnosed and Treated
Higher Rate of
TIMI-3 Flow for the
Culprit Vessel
Primary Percutaneous
Coronary Intervention
Reduce Time to Balloon
Optimize MI
Primary Care Units
Immediate MI Confirmation
Selection for Transferring and Rescue
Aspirin, Clopidogrel and Heparin
(?) Facilitate Reperfusion (r-tpa & tnk)
Increase MI Diagnose and Reperfusion
Broad Spectrum
of Treatment
Fibrinolysis
Estratégias de Reperfusão no IAM ST Supra
STEMI <12 hrs of Symptom Onset
Primary Care Facility
On-Site Invasive Cardiology
Transfer Feasible
Yes
No
No
Pain
Duration
<2 hrs
Lytic
Failure
Primary PCI
Pain
Duration
>2 hrs
Rescue
PCI
Success
PCI
<24-72 hrs
Myocardial Reperfusion and Delay for Lytic
30-day Mortality
FTT (meta-analysis 9 RCT’s; n= 58,600): Fibrinolytics
Lifes
Saved/1000
p<0,01
p<0,01
p<0,01
p<0,01
39
30
27
21
p=NS
7
Lancet 1994
343:311
Selecting the Best Reperfusion Strategy
Fibrinolysis and Primary PCI
 Fibrinolysis is not unreasonable when:
 PCI associated with unacceptable delay (Class I)
 Short time from symptom onset (<2 hr) (Class I) with anticipated
door-to-balloon >2 hours
 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
Selecting the Best Reperfusion Strategy
Fibrinolysis and Primary PCI
“ One Size, Definitely,
Does Not Fit for All AMI’s…
Logistics Sinergy is the way”
The “Patient Size” Will Always Be #...
Joint Efforts Are Mandatory !!
Rio de Janeiro,
March 7 Th 2008
www.sbhci.org.br
Reperfusão no Infarto do Miocárdio
Selecionando A Melhor Estratégia