Evidencias sobre el Evidencias sobre el tratamiento del IAM en 2010tratamiento del IAM en 2010
Casa del Corazón, 10 de junio de 2010Casa del Corazón, 10 de junio de 2010
Hitos en el manejo del Hitos en el manejo del SCACESTSCACEST
1º1º etapa: etapa: MONITORIZACIONMONITORIZACION - d- desfibrilador externoesfibrilador externo (Lown) (Lown)- “Intensive Cardiac Care Unit” (Julian)- “Intensive Cardiac Care Unit” (Julian)
- monitorizacion ECG ------ desfibrilación- monitorizacion ECG ------ desfibrilación
2º2º etapa: etapa: RECANALIZACIONRECANALIZACION - fibrinolisis- fibrinolisis- angioplastia primaria- angioplastia primaria- coronariografia precoz- coronariografia precoz
Recomendaciones Sociedades CientíficasRecomendaciones Sociedades Científicas
19601960
19801980
20102010
Proteger del riesgo de Proteger del riesgo de muerte repentina por muerte repentina por fibrilación ventricularfibrilación ventricular
Reperfundir el miocardio Reperfundir el miocardio en vías de necrosis en vías de necrosis de forma inmediatade forma inmediata
Mortalidad (35 días)
retraso tto (h) fibrinolisis controlmejor mejor
0-1
1-2
2-3
3-6
6-12
12-24
0.5 1.0 1.5RRR
Boersma et al. Lancet 1996;348:771-75
Meta-análisis: - 22 estudios (>100 pts) - 50.246 pts (1983-93)
Beneficio de la trombolisis en función Beneficio de la trombolisis en función del retraso inicio síntomas - del retraso inicio síntomas -
tratamientotratamiento
0
20
40
60
80
0 3 6 9 12 15 18 21 24
retraso tratamiento (horas)
vidas
sal
vada
s / 1
000
pts
trata
dos
Primary PCI vs Thrombolysis in Primary PCI vs Thrombolysis in STEMI: STEMI:
Meta-analysis (23 RCTs, N=7739)Meta-analysis (23 RCTs, N=7739)
Adapted with permission from Keeley EC, et al. Lancet. 2003;361:13-20.
PCI
Thrombolytictherapy
0
5
10
25
15
20
Freq
uenc
y (%
)
Short-term Outcomes(4-6 weeks)
Death
P=.0002
NonfatalMI
P<.0001
RecurrentIschemia
P<.0001
Hemor-rhagicStroke
P<.0001
MajorBleed
P=.032
Death, Nonfatal
Reinfarction,or Stroke
P<.0001
Copyright ©2009 BMJ Publishing Group Ltd.
Rathore, S. S et al. BMJ 2009;338:b1807
Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals
Adjusted in hospital mortality as function of door-to-balloon time (modelled as fractional polynomial) with 95% confidence intervals
Door-to-balloonDoor-to-balloon Hospital mortalityHospital mortality
30 minutes 3.0%60 minutes 3.5%90 minutes 4.3%120 minutes 5.6%150 minutes 7.0%180 minutes 8.4%
p<0.001
Rathore, S. S et al. BMJ 2009;338:b1807
p < 0.001 for trend comparisonTaher T, et al.
J Am Coll Cardiol 2004;44:38–43
CAPTIM: 1 Year MortalityCAPTIM: 1 Year Mortality
Steg P, et al Circulation 2003; 108:2851-6.Steg P, et al Circulation 2003; 108:2851-6.
Pre HospitalLysis
PrimaryPCI
P=0.057 P=0.47
Pre HospitalLysis
PrimaryPCI
Delay < 2 hoursDelay < 2 hours Delay Delay ≥≥ 2 hours 2 hours
2,2%
5,7%
0%
5%5,9%
3,7%
0%
Fibrinolisis vs Angioplastia Fibrinolisis vs Angioplastia Importancia de los retrasos
Nallamothu and Bates, AJC, 2003;92:824-6
Retraso en la ACTP, min
Dife
renc
ias
en
mor
talid
adRi
esgo
Abs
olut
o, %
0 20 40 60 80 100
15
10
5
0
–5
ACTP mejorFibrinolisis mejor
23 estudios (n= 7419)p=0.006
2008
STE
MI E
SC G
UID
ELIN
ES20
08 S
TEM
I ESC
GU
IDEL
INES
Key questionsKey questionsat presentation:at presentation:
- Delay from onset?Delay from onset?
- PCI capability at this time?PCI capability at this time?
- Lysis contraindicated?Lysis contraindicated???
Widinsky P, et al. Eur Heart J 2009
Reperfusion therapy for ST elevation MI Reperfusion therapy for ST elevation MI Spain vs Europe (2004)Spain vs Europe (2004)
Espinosa MA, et al. Rev Esp Cardiol 2009;9:3C-10CEspinosa MA, et al. Rev Esp Cardiol 2009;9:3C-10C
P-PCIP-PCILysisLysisFacilitated PCIFacilitated PCINo ReperfusionNo Reperfusion
25%25%
43%43%
32%32% 33%33%
26%26%
36%36%
5%5%
Reperfusion therapy for ST elevation MI Reperfusion therapy for ST elevation MI in Spain (2008)in Spain (2008)
P-PCI*P-PCI*78737873
TNK**TNK**1230012300
* Data from SHCI 2008 Spanish Registry* Data from SHCI 2008 Spanish Registry** Data provided by** Data provided by Boehringer Ingelheim España, S.A. Boehringer Ingelheim España, S.A.
2008
STE
MI E
SC G
UID
ELIN
ES20
08 S
TEM
I ESC
GU
IDEL
INES
Top Related