A Race to Treatment: Early Fibrinolysis vs. Timely PCI

Transcription

1 A Race to Treatment: Early Fibrinolysis vs. Timely PCI

2 Faculty/Presenter Disclosure Faculty: Sunil Sookram, MD, FRCPC Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: AstraZeneca, Hoffman La Roche Consulting Fees: None Other: None

3 Faculty/Presenter Disclosure Faculty: Kevin Bainey, MD, MSc, FRCPC Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: AstraZeneca, Bristol Myers Squibb, Merck, Pfizer Consulting Fees: None Other: None

4 Faculty/Presenter Disclosure Faculty: Indy Ghosh, MD, CCFP (EM) Relationships with commercial interests: Grants/Research Support: None Speakers Bureau/Honoraria: AstraZeneca, BI, BMS/Pfizer, Bayer, Sanofi Aventis Consulting Fees: None Other: None

5 Objectives Discuss assessing patient risk to optimize reperfusion decisions Understand that time to treatment is the most important modulator of STEMI outcomes Review appropriate pharmacoinvasive strategy following fibrinolysis

6 Disclosure of Commercial Support This program has received financial support from AstraZeneca and Bayer in the form of an educational grant, and has been co developed in conjunction with the Canadian Association of Emergency Physicians (CAEP). Potential for conflict(s) of interest: Dr. Bainey, Dr. Ghosh and Dr. Sookram have all received payment from AstraZeneca. AstraZeneca licenses a product that will be discussed in this program: Brilinta (ticagrelor)

7 Mitigating Potential Bias Potential Biases are acknowledged and are mitigated by presenting data supported by national and international guidelines, and as follows: Information presented is evidence based Recommendations made are evidence or guidelines based rather than personal recommendations of the presenter Material has been developed and reviewed by an Educational Committee

8 Case Study

9 Case Study: Mr. Robinov Your Thoughts? 65 year old man No past medical history What will you do to evaluate Mr. Robinov? 60 min RSCP started at rest Has his son drive him to local hospital ERD, time since onset of symptoms 75 min

10 Mr. Robinov: Admission ECG

11 Mr. Robinov: Admission Tests ASSESSMENT 12 lead ECG: STEMI HR 98/min BP 178/98, RR 24 JVP 4 cm ASA, PPP and full Normal S1 and S2, no S3 Fibrinolytic therapy or primary PCI?

12 Fibrinolysis or Invasive Strategy? Assess Time and Risk Time since symptom onset Time required to transport to skilled PCI facility Risk of fibrinolysis Risk of STEMI ACC/AHA Guidelines: Am Fam Physician 2009;79(12):1080 6

13 Time to Treatment Is Crucial ACC/AHA guidelines The most important point in managing STEMI is minimizing the time from the onset of symptoms until the initiation of reperfusion therapy Fibrinolysis < 30 min PCI < 90 min ACC/AHA Guidelines: Am Fam Physician 2009;79(12):1080 6

14 Fibrinolysis Is Preferred if... Early presentation < 3 hrs of symptom onset and PCI not readily available Invasive strategy is not an option ACC/AHA Guidelines: Am Fam Physician 2009;79(12):1080 6

15 PCI Is Preferred if... Diagnosis of STEMI is in doubt Skilled PCI facility is available High risk from STEMI Contraindications to fibrinolysis Late presentation (> 3 hrs of symptom onset) Failed fibrinolysis ACC/AHA Guidelines: Am Fam Physician 2009;79(12):1080 6

16 Early Fibrinolysis vs. Primary PCI FL < 2 h vs. primary PCI < 2 h p = Pooled Analysis from CAPTIM and WEST Westerhout et al. Am Heart J 2011;161:283 90

17 Termination of MI Is Thought to Follow Rapid Early Reperfusion Rate of terminated MI vs. time to fibrinolytic therapy for acute STEMI Verheugt FW et al. Eur Heart J 2006;27:901 4

18 Case Study: Mr. Robinov Your Thoughts? 65 year old man No past medical history WHAT IF: lysis was not successful? 60 min RSCP started at rest Has his son drive him to local hospital ERD

19 QUESTIONS? Enter questions in the text box on Text questions to questions to IMPORTANT: When ing, please enter question in the subject line only

20 The Role of Coronary Angiography/ PCI Post Fibrinolysis Time Fibrinolysis 35% reperfusion failure Rescue PCI 5% Ischemia driven cath. 60% reperfusion success Scheduled cardiac catheterization (6 24 hours) Adapted from Welsh RC & Armstrong PW, New Horizons in AMI

21 Fibrinolysis/Timely Angiography vs. PCI Early After Acute STEMI N=1915 Primary endpoint: death from any cause, shock, congestive heart failure or reinfarction up to 30 days Fibrinolysis/Angiography vs. PCI: p=0.21 Fibrinolysis was associated with a slightly increased risk of intracranial bleeding Armstrong PW et al. NEJM 2013;368:

22 Pharmacoinvasive Strategy Obliterates Risk of Recurrent MI Associated with Fibrinolysis Death Observed Event Rate, % Adjusted RR (95%CI) P value Rescue vs. Scheduled Primary PCI vs. Scheduled ( ) 1.44 ( ) Shock Rescue vs. Scheduled Primary PCI vs. Scheduled CHF ( ) 2.27 ( ) Rescue vs. Scheduled Primary PCI vs. Scheduled ( ) 3.28 ( ) <0.001 <0.001 ReMI Rescue vs. Scheduled Primary PCI vs. Scheduled ( ) 1.25 ( ) Rescue or Primary PCI Better Day Events by Treatment Received Scheduled Angiography Better Welsh RC et al. Am J Cardiol; published online 10 July 2014

23 With Successful Fibrinolysis You Can Wait! Successful pharmacological reperfusion + angiography within 24 hrs vs. primary PCI Scheduled PCI 5.5% Primary PCI 13.9% Rescue PCI 18.7% PPCI vs. Scheduled (after fibrinolysis) Log Rank: p<0.001 Relative Risk 2.32, 95%CI ( ) Welsh RC et al. Am J Cardiol; published online 10 July 2014

24 CCS Guidelines STEMI ASA 81 mg daily Indefinite Therapy Fibrinolytic therapy or no reperfusion therapy Primary PCI Add clopidogrel for at least 1 month and up to 12 months Add prasugrel* or ticagrelor for 12 months Patient ineligible for prasugrel* or ticagrelor Add clopidogrel for 12 months (consider 150 mg/day for 6 days) Tanguay et al. Can J Cardiol 2013;29:

25 Real World Management of Non Metropolitan STEMI Patients Alberta: STEMI STEMI Treatment Rural 45% 73% FL and pharmacoinvasive Urban 55% 70% primary PCI Shavadia J et al. Can J Cardiol. 2013;29:951 9

26 In Hospital Events Metropolitan and Non Metropolitan % Metro Non metro N=1990 N= ,4 12, ,8 4,3 6,5 5, ,65 0,62 Death CHF Shock Re MI Shavadia et al. CJC 2012;28:S188 9

27 QUESTIONS? Enter questions in the text box on Text questions to questions to IMPORTANT: When ing, please enter question in the subject line only

28 Key Messages Time to treatment is crucial Early fibrinolysis pharmacoinvasive strategy is as successful as timely primary PCI Prescribe appropriate pharmacoinvasive strategy: Timely rescue PCI for those who fail to reperfuse Scheduled angiography and PCI where appropriate for those who successfully reperfuse

29 Thank You! Content for this program was developed by the following steering committee members: Dr. Anil Chopra, Dr. Jean Grégoire, Dr. Anil Gupta, Dr. Eddy Lang and Dr. Robert Welsh COMMERCIAL SUPPORT ACKNOWLEDGEMENT: THIS EDUCATIONAL ACTIVITY IS SUPPORTED BY AN INDEPENDENT EDUCATIONAL GRANT FROM ASTRAZENECA and BAYER CANADA