Thrombolysis in Era of PCI Dr. Vinod Sharma National Heart Institute (All India Heart Foundation) New Delhi
STEMI represents the critical phase of Acute Coronary Syndrome ST Elevation MI
Clinical manifestation of CAD is DYNAMIC in nature ……
Atherosclerosis n Continuous but not a linear process n Disease with alternate phase of stability & instability
Culprit is vulnerability ……
Link between CV risk factors, endothelial dysfunction, inflammation & ACS CV RISK FACTORS Smoking Diabetes Hypertension Shear stress Oxidative stress Infection ? ENDOTHELIAL DYSFUNCTION ↓ Nitric Oxide, PGI 2, TGF ↓ Andrenomedullin, CNP ↑ Endothelin – 1, PDGF, ACE INFLAMMATION NFk. B ↑ Adhesion molecules (ICAM, VCAM) ↑ Chemotactic proteins (MCP – 1) ↑ Interleukins, C-reactive protein ↑ Apoptosis, tissue factor PLATELET AGGREGATION, FIBRIN PRODUCTION, PLAQUE GROWTH ACUTE CORONARY SYNDROMES
Acute Coronary Syndrome a “PANCORONITIS” ? Local manifestation of systemic disease
Evidence of multiple “vulnerable” plaques in acute coronary syndrome
Plaque Rupture – Clinical Manifestation People who died due to ACS, harbour both thrombosed & non thrombosed ruptured plaques in their coronary arteries. Goldstein JA et al: NEJM 2000 Additional plaques are frequently found adjacent to the culprit lesions in patients undergoing PTCA. Schoenhager Petal: 2003
Additional Unstable Plaques Beyond the Culprit Lesion 27 patients with ACS. Angio + 3 vessel IVUS
Time is essence ……
1. Time is Myocardium 2. Infarct Size is Outcome Mortality Reduction (%) 100 D 80 60 C 40 20 B A Extent of Myocardial Salvage 0 0 4 12 8 16 20 Time From Symptom Onset to Reperfusion Therapy, h Critical Time-dependent Period Goal: Myocardial Salvage 24 Time-independent Period Goal: Open Infarct-Related Artery Gersh BJ, et al. JAMA. 2005; 293: 979.
Reduction in Long Term Mortality Every 30 -minute delay from onset of symptoms to reperfusion. 1 year mortality is increased by 8% De Luca et al, Circulation 2004
Red Vs White Thrombus ……
NSTEMI Platelet rich Thrombus Anti-platelet drugs STEMI Fibrin rich Thrombus Thrombolysis / PCI
Myocardial perfusion, not the epicardial perfusion is the final determinants……
Illustration of the traditional concept of microcirculatory impairment in the setting of no flow in the proximal LAD compared with preserved flow in the left circumflex coronary artery, as typically seen in acute anterior ST-segment elevation myocardial infarction (upper left panel). Lerman A et al. Eur Heart J 2007; 28: 788 -797
“Despite the proven success of restoration of epicardial coronary blood flow in a reasonably timely fashion, reperfusion on the myocardial level is not accomplished in ~50% of patients with STEMI and is of negative prognostic implication” Lerman et al; European Heart Journal 2007
ECG suggestive of failure of myocardial perfusion
Correlation of TIMI flow grade to mortality
Prognostic merit of two surrogates of myocardial perfusion, readily available during clinical practice
AMI Therapy : A stunning Evolution !! “Brave New world” Best of Angioplasty Techniques Multifacelated Approach + Adjunctive Medication Angioplasty Thrombolysis CCU Bed Rest Dark-Ages
Absolute mortality rate remains same For last 15 years 5. 5% in young and 19. 7% in elderly
Reperfusion is the key to save myocardium and life…. Aim is to open the blocked I. R. A. and Re-establish the coronary blood flow A. Rapid B. Early C. Complete D. Sustained
PTCA vs. Fibrinolysis: Short Term Clinical Outcomes (23 RCTs) N = 7739 PTCA P<0. 0001 Fibrinolysis P<0. 0001 Frequency (%) P=0. 0002 P=0. 0003 P<0. 0001 P=0. 032 P=0. 0004 Death, no SHOCK data Re. MI Rec. Isch Stroke P<0. 0001 Hem. Stroke Major Bleed Death MI CVA Keeley E. et al. , Lancet 2003; 361: 13 -20.
Lytic Vs. PCI in Acute MI Patients Fibrinolysis 100% Availability Primary Angioplasty 0% 5% availability 2% Reocclusion 0. 1% Stroke <50% Treated 50% 60% TIMI 3 5% Reocclusion 1% Stroke 50% 25% Late occlusion 0% 100% >95% TIMI 3
Selection of Reperfusion Strategy in STEMI Time since the onset of symptoms Risk of Mortality from STEMI Availability of skilled PCI Laboratory Time required for Transport Any contraindication to thrombolysis including bleeding, ICH Patient preference ACC/AHA STEMI Guidelines 2013
Selection of Reperfusion Strategy for STEMI ACC / AHA Update 2013 on STEMI “Regardless of mode of reperfusion, the overarching concept should be to minimize total ischemic time, which is defined as the time from onset of symptom of STEMI to initiation of reperfusion therapy”.
Five doors representing five different levels of decision making
Selection of Reperfusion Strategy in STEMI Time since onset is important consideration Although the efficacy of both fibrinolytic therapy & primary PCI diminishes with passage of time, • ALKK – STUDY GROUP: AHJ 1999 • D-LUCA et al: Circulation 2004 The ability of PCI to produce a patent IRA is much less time dependent Brodie R: JACC 1998
Time vs In-hospital Mortality - DTB Time: NRMI– 3/4 N = 29, 222 P <. 001 Mc. Namara RL, JACC, 2006
NRMI 4278 transfer patients Thrombolysis (IH) can be given 30 -60 mins after presentation - 60 min (lysis-PPCI) = 90120 mins door> 80% lost incremental benefit Nallamothu BK, Bates E R, Herrin J, et al. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the US. National Registry of Myocardial Infarction 3/4 Analysis. Circulation 2005; 111: 761 -767
Superiority of 1° PCI Over Lysis Lost After a DB − DN Delay of 114 Minutes Fibrino-lysis Better 2. 0 O dds of Deat h 1. 5 1. 25 1. 0 0. 8 PCI Better 0. 5 60 75 90 105 114 120 135 150 165 180 PCI Related Delay (DB − DN) (min) Pinto DS, et al. Circulation. 2006; 114: 2019 -25.
Indian scenario Pain to door time: South India: 10. 8 hours (Indian Heart J 2004; 56: 210– 4) North India: 5. 2 hours (Indian Heart J 2003; 55: 349– 53) Door to drug time: 1 hour Low rate of inhospital thrombolysis mainly due to late arrival. Reasons for not receiving in-hospital thrombolysis 30 days mortality among 1320 pts 16. 9%
95. 8% of patients treated after 90 minutes Door to balloon Door to door
Availability of PCI facility Availability of a skilled PCI Lab with the capacity to provide expert, prompt, 24 x 7 intervention > 50% of patients with STEMI present to a Non PCI capable centre (Water RE: JACC 2004) Less than optimal outcome expected in a low volume centre with less experienced operators.
Availability of PCI facility • Experience & volume of primary PCI cases at PCI Lab play role in choice of therapy. • Mortality benefit with PCI only in high volume centre, whereas no difference in low volume centres.
Availability of PCI facility Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours (n=1702) J Am Coll Cardiol 2003; 41: 2138 -2142 • Patients (47%) who presented during off hours (1800 to 0800 hrs) had a higher rate of PCI failure & 30 days mortality compared to these who presented during normal duty hours.
Availability of PCI facility High failure rate with out-of-hours PCI even in high volume centre In 1702 cases – referral centre for 11 hospitals – 48% presented between 1800 hrs and 0800 hrs – PCI failure rate 6. 9% vs. 3. 8% p<0. 01 – 30 d mortality 4. 2% vs. 1. 9% p< 0. 01 Zwolle Group JACC 2003; 41: 2138
Selection of Reperfusion Strategy in STEMI Majority of the hospitals are not PCI enabled. most of PCI enabled hospitals do not have inhouse interventional Cardiologists & paramedics to carry out interventional procedures round the clock. Availability of transport, long transportation time, traffic congestion & weather condition affects access to the PCI enabled centre.
Time Delay to Treatment and Mortality in Primary Angioplasty for Acute Myocardial Infarction Every Minute of Delay Counts • Every minute of delay in primary angioplasty for STEMI affects 1 -year mortality, characteristics. even after adjustment for baseline Therefore, all efforts should be made to shorten the total ischemic time, not only for thrombolytic therapy but also for primary angioplasty. Circulation 2004
Accounts / Billing section From where, I get 2. 0 lacs at this time in night !!! Your patient needs PPCI. Deposit Rs. 2. 0 lacs immediately for PCI
Time to Treatment for Lytics (Mc. Namara, RL 2007 AJC 100: 1227)
Benefit of Thrombolytic Therapy is Greatest in Patients Treated Within Few Hours of Symptom Onset 50, 246 AMI patients randomized to lytic vs control Boersma E et al. Lancet 1996; 348
Benefits of Early Administration of Thrombolytics n = 1, 922 USIC. Circulation 2004; 110: 1909 -1915
American national registry on MI NRMI-2: Primary angioplasty versus thrombolysis 10. 0% Primary angioplasty (n=4939) Alteplase (n=24705) 5. 0% 5. 2% 5. 4% 2. 5% 2. 9% P<0. 0001 1. 6% 0. 7% 0. 0% Death Presentation to alteplase 42 min Presentation to balloon 111 min Re-MI Stroke Tiefenbrunn, JACC 1998; 31: 1240
USIC 2000, French Registry Data Hospital administered ‘lysis as good as PCI Pre hospital lysis EURO-PCR Paris 2003
French USIC 2000 survey: real world No Pre-hosp reperfusion TT Patients Age (year) Time to admission (h) 1 year death 71 2. 8 155 (12%) 60 2. 4 Hosp TT 322 (25%) 61 2. 2 Primary PCI 425 (33%) 61 2. 1 14. 7% 3. 2% 9. 0% 7. 9% 386 (30%) USIC. Circulation 2004; 110: 1909 -1915
Evolution of thrombolytics (International Journal of Bio-Science and Bio-Technology, March 2011; 3(1): 1 -17)
Ease of Use; Favorable Pharmacokinetics; bri. Highest Reperfusion rates; Agent most used in Clinical Trials Mehta, Textbook of STEMI Interventions
Ideal Thrombolytic Agent Long half-life; reduced clearance. Single-bolus administration High fibrin specificity/decreased bleeding Rapid and consistent achievement of TIMI grade 3 flow No effect on blood pressure No antigenicity No re-occlusion Great resistance to PAI-1 Compatible with other intravenous agents
What are advantages of TNK-t. PA (Velix) 1. Ease of administration – anytime, anywhere 2. Rapid action – saves myocardium 3. More potent than alteplase 4. Weight adjusted dosing – prevents over / under dosing 5. No allergic reactions / hypotension 6. Fibrin specificity – reduces bleeding 7. Reduced plasma clearance – long half-life – single dose 8. High PAI-1 resistance – stays longer in blood 9. Efficacy comparable with alteplase 10. More effective than alteplase in late-treated patients 11. Less incidence of bleeding than alteplase 12. Best suited for pre-hospital thrombolysis
Tenecteplase vs. Reteplase
Indian Registry for TNK-t. PA – Demography Parameter No of patients N (%) Age, yrs (Mean ± SD) Weight, kg ( Mean ± SD) Sex ratio (M: F) Total 10, 120 55. 74 ± 11. 12 69. 22 ± 10. 44 4. 98 Females 1693 (16. 72) 58. 39 ± 11. 23 65 ± 10. 45 - Elderly 2287 (22. 59) 70. 73 ± 5. 24 69. 11 ± 11. 00 3. 34 Hypertensives 5929 (58. 58) 56. 81 ± 10. 63 70. 13 ± 10. 28 4. 70 Diabetics 4080 (40. 32) 57. 86 ± 10. 37 70. 29 ± 10. 24 4. 65 Hyperlipidemics 2522 (24. 92) 57. 5 ± 11. 22 70. 38 ± 10. 61 4. 95 Smokers 3343 (33. 03) 54. 43 ± 11. 24 70. 79 ± 9. 97 28. 32 Patients with h/o IHD 1832 (18. 10) 57. 28 ± 10. 92 69. 70 ± 10. 22 6. 63 Patients treated within 3 hrs* 6561 (64. 83) 55. 52 ± 10. 98 68. 96 ± 10. 44 0. 20 Patients treated within 3 -6 hrs* 2859 (28. 25) 56. 02 ± 11. 03 69. 62 ± 10. 24 0. 20 Late treated (>6 hrs*) 700 (6. 91) 56. 66 ± 12. 58 70. 03 ± 11. 16 5. 25 Killip class III & IV 845 (8. 34) 56. 87 ± 11. 21 69. 63 ± 10. 18 4. 41 IHD – ischemic heart disease, * - of onset of chest pain Indian Heart J. 2011; 63: 5 B 65 -68
Clinically successful thrombolysis in different subgroups * # * * @ * * - p< 0. 0001, # p = 0. 0006, @ p = 0. 0009 vs. total data using Chi-square test DM – diabetics, HT – hypertensives, IHD – ischemic heart disease Indian Heart J. 2011; 63: 5 B 65 -68
Safety of tenecteplase Parameter Bleed excluding ICH (%) Stroke without ICH (%) MI (%) Heart failure (%) Ventr tachyarrhythmia (%) Total (n = 10120) 3. 02 0. 07 0. 43 1. 41 2. 09 2. 19 Females ( n = 1693) 2. 84 0 0. 53 1. 3 2. 13 1. 83 Elderly (n =2287) 3. 5 0. 13 0. 7 2. 19@ 3. 89# 2. 89 DM (n = 4080) 3. 36 0. 02 0. 49 1. 67 2. 62$ 2. 03 HT ( n = 5929) 3. 22 0. 1 0. 46 1. 43 2. 07 1. 89 Hyperlipidemia ( n = 2522) 3. 49 0. 08 0. 44 2. 34* 3. 97# 3. 53ω Smokers (n = 3343) 2. 63 0. 12 0. 39 1. 73 2. 06 2. 57 H/o IHD ( n = 1832) 3. 55 0. 05 0. 6 1. 86 3. 06μ 3. 22β Patients treated within 3 hrs† (n = 6561) 3. 19 0. 09 0. 41 1. 27 1. 86α 2. 13 Patients treated within 3 -6 hrs† ( n = 2859) 2. 73 0. 03 0. 52 1. 71 2. 48 2. 20 Late treated (> 6 hrs) † (n = 700) 2. 71 0 0. 14 1. 57 2. 71 Killip class III & IV ( n= 845) 4. 26 0. 12 0. 71 2. 37 8. 17# 6. 27# @ p = 0. 0092; * p = 0. 0012; # p < 0. 0001; $ p = 0. 0033; μ p = 0. 0134; ω p = 0. 0001; β p = 0. 0097, α p = Indian Heart J. 2011; 63: 5 B 65 -68 0. 019, vs. total data using Chi-square test. † - of onset of chest pain
Mortality with tenecteplase amongst different subgroups of STEMI patients * * * # . * p < 0. 0001 vs. total data using Chi-square test; # p = 0. 04 , vs. total data using Chi-square test. DM – diabetics, HT – hypertensives, IHD – ischemic heart disease 15 -Mar-18 Indian Heart J. 2011; 63: 5 B 65 -68
Conclusion The results of this large observational study in clinical practice, in 10, 120 patients of STEMI, confirm safety and efficacy of indigenous tenecteplase in Indian STEMI patients including high-risk subgroups. This study reiterates the importance of early thrombolysis for better success rates and highlights the recognition of high-risk subgroups of STEMI patients who may have higher mortality and adverse outcomes compared to others. Indian Heart J. 2011; 63: 5 B 65 -68
INDIAN REGISTRY* UPDATED: 20. 09. 2009. PATIENT’S DATA RECORDED = 2100 * Prescription event monitoring as part of Pharmacovigilance
INDIAN REGISTRY Value Number of centers 248 Number of patients 2100 Mean age (years; ± SD) 56. 98 ± 12. 11 Mean weight (kg; ± SD) 69. 37 ± 10. 81 Male: Female (n) 1751 : 349 H/O Hypertension (n(%)) 1074 (51. 14%) H/O Diabetes mellitus (n(%)) 843 (40. 14%) H/O Hyperlipidemia (n(%)) 634(30. 19%) H/O Smoking (n(%)) 648 (30. 86%) H/O IHD (Past) (n(%)) 394 (18. 76%) Chest pain-to-Elaxim time (minutes; Median (1 st quartile-3 rd quartile) THROMBOLYSIS CLINICALLY SUCCESSFUL 120 (60 -180) 1821 (86. 71%)
INDIAN REGISTRY
INDIAN REGISTRY Adverse events reported Indian Registry Any bleeding (excluding ICH*) 4. 62% 21. 76% ICH (without Gp. IIb/IIIa inhibitors) 0. 48% 0. 93% Stroke (Non-ICH) 0. 24% 1. 78% Myocardial re-infarction 3. 33% 4. 10% Ventricular arrhythmias 5. 71% 20. 5% Mortality (All cause) 3. 48% 6. 18% * ICH = Intracranial hemorrhage ASSENT-2
2013 ACCF/AHA Guideline for Management of STEMI Primary PCI is the recommended method of reperfusion: Øwhen it can be performed in a timely fashion by experienced operators.
2013 ACCF/AHA Guideline for Management of STEMI Emergency medical services transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI with an ideal FMC-to-device time system goal of 90 minutes or less.
2013 ACCF/AHA Guideline for Management of STEMI Immediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non-PCI capable hospital, with an FMC-to-device time system goal of 120 minutes or less.
2013 ACCF/AHA Guideline for Management of STEMI In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI at non-PCI-capable hospitals when the anticipated FMC-todevice time at a PCI-capable hospital exceeds 120 minutes because of unavoidable delays.
Timely reperfusion is the more important than the choice of reperfusion The timeliness of treatment with either PPCI or thrombolysis as per ACC 2007 guidelines is a strong predictor of overall mortality. However, no association is observed with choice of reperfusion therapy. Untimely PPCI has worse prognosis than timely fibrinolysis and untimely fibrinolysis has poor prognosis than timely PPCI. JAMA 2010, 303 (21): 2148 -55
On-site FT better than delayed PCI-related delays are extensive among patients transferred for transfer for PCI (X-PCI) and are associated with poorer outcomes. No differential excess in mortality was seen with X-PCI compared with on-site fibrinolysis (O-FT) even with long PCI-related delays, but as XDB door-to-needle times increase, the mortality advantage for X-PCI over O-FT declines Circulation. 2011; 124: 2512 -2521
Despite the clinical superiority of PAMI, thrombolytic therapy is the default treatment in many countries due to the practical limitations of PAMI
Fibrinolysis Vs PPCI – “Real World Applicability” Country Fibrinolysis PPCI • Canada & Western Europe 66% 2. 5 – 11% • UK 71. 6% 11 – 21% • Germany 36 – 42% 10 – 25% • France 32 – 45% 13 – 18% • Israel & Scandinavia 35 – 45% 11 – 17% • Australia & New Zealand 43 – 53% 8. 7 – 17. 4% Eur J Clin Pharmacol 2009
CREATE data 20468 patients, a prospective registry study in 89 centres from 10 regions and 50 cities in India 59% received thrombolytics and 8% got PCI, with 9% mortality.
2013 ACCF/AHA Guideline for Management of STEMI Reperfusion at a Non-PCI capable Hospital In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischaemic symptoms within the previous 12 hrs when it is anticipated that primary PCI cannot be performed within 120 min of FMC.
Emerging Modalities Pharmacoinvasive Management (PCI following TNK) is a better , safer option than PAMI as proved recently. It widens the time window for PCI This seems to combine the benefits of Mechanical and pharmacological strategies in reperfusion JACC Sept 2007
‘Best of both worlds’ : Local rapid cheap Thrombolysis to majority & PCI Routinely
TRANSFER-MI Trial Design: TRANSFER-MI was a randomized study comparing pharmacoinvasive strategy (transfer to PCI center for routine early PCI within 6 hrs) with standard treatment (early transfer only for failed reperfusion) for high-risk STEMI patients receiving thrombolysis at non-PCI centers (N=1, 060). The primary endpoint was 30 -day composite of death, reinfarction, recurrent Ischemia, CHF, shock. 30 Day Composite (death, reinfarction, recurrent ischemia, CHF, shock) OR = 0. 537 p =0. 0013 % of pts Results • Early PCI within 6 hrs after thrombolysis was associated with a 6% absolute reduction in the primary study composite endpoint. Standard 16. 6% vs Pharmacoinvasive 10. 6% (OR = 0. 0013 = 0. 537 [. 368, 0. 783]: p = 0. 0013 (Figure) Conclusions • Challenges findings of older studies regarding timing of fibrinolysis and PCI • Pharmacoinvasive strategy was safe and effective • Findings provide important information for shaping future guidelines Standard Kastrani, K et al. Presented at ACC, 2008 Patients 1060 Pharmacoinvasive @2008, American Heart Association. All rights reserved.
NORDISTEMI Objective : To compare a strategy of immediate transfer for percutaneous coronary intervention (PCI) with an ischemia-guided approach after thrombolysis in patients with very long transfer distances to PCI. (J Am Coll Cardiol 2010; 55: 102– 10)
Methods NORDISTEMI A total of 266 patients with acute STEMI living in rural areas with more than 90 -min transfer delays to PCI were treated with tenecteplase, aspirin, enoxaparin, and clopidogrel and randomized to immediate transfer for PCI or to standard management in the local hospitals with early transfer, only if indicated for rescue or clinical deterioration. The primary outcome was a composite of death, reinfarction, stroke, or new ischemia at 12 months, and analysis was by intention to treat. (J Am Coll Cardiol 2010; 55: 102– 10)
NORDISTEMI (J Am Coll Cardiol 2010; 55: 102– 10)
SUMMARY OF STUDIES Studies (year) & Total randomized, n Major Inclusion Criteria Time from Lysis to routine early PCI (h) 30 day composite of mortality / re-infarction / ischaemia, N (%) Lysis + routine early PCI Lysis + ischaemia -guided PCI NORDI-STEMI 19 (2005 -2008) & 266 Symptoms of MI present for < 6 h, STelevation, expected time delay to PCI > 90 min, tenecteplase use 2. 7 (median) 13(10) 26 (20) TRANSFER-AMI 18 (2004 -2007) & 1059 Symptoms of MI present for < 12 h and ST-elevation. Only tenecteplase-treated patients used < 6 (3. 9 median) 39 (7) 58 (11) WEST 17 (2005) & 204 Age > 18 years, not pregnant < 24 (4. 9 median) 10 (10) 13 (13) Symptoms presumed secondary to STEMI lasting at least 20 min and ST-elevation / new LBBB CARESS-AMI 15 (2002 – 2007) & 600 Symptoms of MI present for < 12 h and ST-elevation / new LBBB/Killip class > 2/LV ejection fraction < 30% < 3 (2. 2 median) 13 (4) 32 (11) CAPITAL – AMI 14 (2001 -2004) & 170 Presentation < 6 h of onset of chest discomfort of > 30 min duration and ST-elevation / LBBB < 3 (1. 6 median) 12 (14) 29 (35)
SUMMARY OF STUDIES Studies (year) & Total randomized, n Major Inclusion Criteria Time from Lysis to routine early PCI (h) 30 day composite of mortality / re-infarction / ischaemia, N (%) Lysis + routine early PCI Lysis + ischaemia -guided PCI GRACIA-I 13 (20002001) & 500 Chest pain lasting 30 min to 12 h and ST-elevation / LBBB < 24 [16. 7 mean (SD 5. 6)] 12 (5) 16 (6) SIAMI III 11 (1998 – 2001) & 197 Symptoms of MI present for < 12 h + ST – elevation < 6 (3. 5 + 2. 3) 7 (8) 25 (31) < 1. 1 (n/a) N/A < 24 106 (7. 3) 199 (13. 5) Eligible for thrombolysis No secondary / iatrogenic MI PRAGUE – I 10 (1997 – 1999) & 199 Within 6 h of symptom and STelevation / LBBB Present to community hospital sans PCI facility Pooled (19972007) & 3195
2013 ACCF/AHA Guideline for Management of STEMI – Reperfusion therapy for patients with STEMI
“One Size fits all”
Around 24% of all people hospitalized in India in a single year fall below the poverty line due to hospitalization. An analysis of financing of hospitalization shows that large proportion of people; especially those in the bottom four-income quintiles borrow money or sell assets to pay for hospitalization. World Bank Report 2012
Conclusion 3 possible strategies for myocardial reperfusion in AMI Ø Thrombolysis with fibrin specific Tenecteplase Ø Post Tenecteplase PCI (Safe & equally good results) Ø PAMI
Conclusion Speed of reperfusion after an infarct is more important. It is immaterial whether pharmacological or mechanical or both. 1 70 % of patients present in hospital with no onsite PCI facilities. So prompt early use of fibrin specific therapy is the treatment of choice . 1. JACC Vol 50 2007
Conclusion Approaches should be complementary rather than competitive PAMI is preferred option but resources limited due to practical difficulties Thrombolytic therapy in the present era with fibrin specific drugs , should be given in all STEMI pts in timely and universal manner Pharmacoinvasive strategy (PCI following TNK) is a better , safer option than PAMI as proved recently by various trials. It widens the time window for PCI
Ant MI, PPCI to LAD, restenosis with total occlusion of LCx & significant stenosis of LMCA – After 3 months
Ant. MI, thrombolysed Day 2. . Borderline LAD
Скачать презентацию Thrombolysis in Era of PCI Dr Vinod Sharma
856b5d9e1ca8bc8f78b189fda3ceb174.ppt