Toekomst van de reanimatie: standpunt van de cardiolooog
Prof dr Johan Bosmans Interventiecardioloog Universitair Ziekenhuis Antwerpen
Toekomst van de reanimatie: voorkomen is beter dan (misschien) genezen
Sterftecijfer Vlaanderen 2002 verdeling doodsoorzaken mannen hart- en vaatziekten 9% 2%
kanker
7%
longziekten
1%
33%
2%
diabetes
1%
dementie cirrose
13%
? ongevallen/zelfmoord andere 32%
Sterftecijfer Vlaanderen 2002 verdeling doodsoorzaken vrouwen hart- en vaatziekten 12%
3%
kanker
4%
longziekten
1%
40%
4%
diabetes dementie
2%
cirrose ?
11%
ongevallen/zelfmoord andere 23%
Het ACUTE Hartinfarct
Progressie myocardnecrose
40 min
% viabel myocard ischemie
100
necrose
80
3u
60 % 40 20
1 dag
0 0 6 12 18 tijd na coronaire occlusie
Infarct artery patency and prognosis 30 d. mortality 10
Ejection fraction 70
8,9 7,5
8
**
65
62
**
6
4
4
60 55
2 0
55
56
50 TIMI 0-1
TIMI 2
TIMI 3 bij 90 min
n=317
n=275
n=370
Gusto angiographic study, NEJM 1993
TIMI 0- 1
TIMI 2
TIMI 3
Time-Dependent Benefit of Reperfusion Therapy Absoluut benefit/1000 treatments
100
Reimer/Jennings 1977 Bergmann 1982 GISSI-I 1986
80 60 40 20 0 0
2
4
6
8
Reperfusion Time (hours) Adapted from Tiefenbrunn AJ, Sobel BE. Circulation. 1992;85:2311-2315.
10
12
Contra-indicaties thrombolyse
Absolute contra-indicaties Hemorrhagische CVA , Ischemisch CVA <6maanden majeur trauma/chirurgie < 3 maand G-I bloeding < 1maand Aorta dissectie Gekende stollingsstoornis
Relatieve contra-indicaties TIA <6 maand, refractaire hypertensie Orale antico, niet comprimeerbare puncties Actief peptisch ulcus, ernstig leverlijden Endocarditis, traumatische rescuscitatie Zwangerschap of post partum (1 week)
Rescue PTCA na trombolyse
Reperfusie criteria ST daling > 5O% Serum merkers: verhouding t 60’/t 0 myoglobine: > 4 CK-MB : > 3.3 cTnI: >2 85-90% TIMI 2-3 Tanasijevic et al, JACC,1999
Rescue PTCA Geen tekens van reperfusie Hemodynamische labiliteit Groot infarct best < 6h na begin van symptomen.
Rescue PCI : REACT - trial
R-PCI 93.8% (ci 89.8%-97.7%) Conserv 87.2% (ci 81.7%-92.7%) R-Lysis 87.3% (ci 81.9%-92.8%)
p=0.13
Gershlick. NEJM 2005;353:2758
Behandeling Acuut Hartinfarct Urgente Ballondilatatie
Casus primaire PCI akuut inferolateraal infarct
Rates of TIMI Grade 3 Flow
The 90 Minute Wall:
85
80 60 60
60
57
63
40 20
rP A N PA TN K 40 PT C A
0
tP A
% TIMI 3 Flow
100
Primary PCI vs. thrombolytic therapy Frequency (%)
25
PTCA Lysis
p<0.0001
21
20 p<0.0001
14
15 p=0.0002
10
9
p=0.0003
p<0.0001
7
6,8
7 5
5
p=0.032
6
6,8 p=0.0004
2,5 1
0 Death
Death excl. Shock
Nonfatal MI
Recurrent ischemia
2
Total CVA
8 5,3
p<0.0001
0,05
1,1
Hemorr. CVA
Major bleeds
Death/ CVA/AMI
Keeley Lancet 2003;361:13
Reperfusie therapie : acuut hartinfarct % mort. 10
no treatment streptokinase accelerated t-PA
8 6
primaire PCI
4
PCI+adjuvante therapie( ?)
2 20
40
60
80
100 % TIMI 3 flow
Primary PCI and time
30 minutes delay increases 1-year mortality by 7.5% De Luca, Circulation 2004
Primaire PTCA and hospital time % mort. 7
6,4
6 5 3,7
4
4
3 2 1 1 0 t<60 min N =104
61-75 min n = 109
76-90 min n = 76
Berger et al, Circulation, 1999 (Gusto II substudy)
t>90 min n = 14O
Time to PTCA
NRMI-2: Primary PCI Institutional Volume vs. Mortality 10
N=27,080 P < 0.00001
Mortality (%)
8,0 8
6,2 6
4,7
4 2 0
<1
1-3
>3
Institutional Monthly Volume of Primary Angioplasty Cases
ST- Elevation AMI : management 1. Check intake ASA / nitrates SL 2. Give Beta blockers 3. Initiate Reperfusion therapy
Thrombolyse
PTCA
DENMARK 5.4 mill. inhabitants 5 PCI centers 24 referral hospitals 62% of Danish population Transport distance up to 95 US miles (mean 35 miles)
100 US miles
DANAMI-2
DANAMI-2
Referral hospitals Planned: 1,100 pts.
Fibrinolysis PCI (front loaded tPA)
Incl.
1,129 pts.
Angioplasty centers Planned: 800 pts.
Fibrinolysis PCI (front loaded tPA)
443 pts.
DANAMI-2
Time from onset of symptoms to treatment (1,572 patients) Hospitals
Referral
Pre-hospital
Invasive
Pre-hospital
Door-to-needle
Door-to-needle
Transportation
Referral
Pre-hospital
Invasive
Pre-hospital
0
60
Door-toballoon
In-door-out-door
Door-to-balloon
120 Min.
180
240
DANAMI-2
Primary end points within 30 days 1,572 patients 15
p=0.0003 13.7
p=0.35
10
7.6
p<0.0001 6.6
8.0
6.3 p=0.15
5
2.0
1.6
1.1
0 Death
Reinfarction
Disabling stroke
Fibrinolysis
PCI
Combined
NNT=18
DANAMI-2
Events during transportation (n=559) A tria l fib rilla tio n VT VF o 2 -3 A V b lo c k In tu b a tio n (n ) D e a th (n )
2 .5 % 0 .2 % 1 .4 % 2 .3 % 0 0
ST elevation MI (<12 h after onset of pain) Aspirin – heparin – nitrate * Admission in
Admission in non-PCI-center
PCI-center
or first medical contact outside hospital • Hemodynamic instability YES Transfer **
(shock / cardiac failure/ malignant arrythmias)
• contra-indication thrombolysis
PCI center
NO
Transfer to PCI center Pro transfer:
Primary PCI ** First medical contact-to-balloon time < 90± ±30 min Consider IIB-IIIa antagonists
OR
Thrombolysis start clopidogrel
transfer time<60’, ischemia >3u
Failed ***
Pro thrombolysis: transfer time>60’, ischemia<3u
* nitrate SL unless systolic bloodpressure<100mmHg and/ or heart rate<50bpm ** Consider pre-PCI lytic therapy if transfer time>60 min *** Electrocardiographic and clinical evaluation 60-90 min after initiation of thrombolysis
Rescue PCI
Case-Fatality Rate (%)
Case-Fatality in Ghent during 1983-1999 in men 25-69 years All Hospitalised cases
60
50
40
30
20
10
0 83
84
85
86
87
88
89
90
91
Year
92
93
94
95
96
97
98
99
Prof. G. De Backer, Ghent
