Zorg voor het acute myocardinfarct: van locaal initiatief tot landelijke organisatie Gert van Houwelingen interventiecardioloog
Samenwerken in de keten: expertgroep myocardinfarct
Prehistorie: geen keten, geen overleg
Willem Einthoven 1860‐1927
Snaargalvanometer 1901
Eerste ECG
Einthoven W. Über die Form des menschlichen Electrocardiogramms. Pfügers Archiv maart 1895, pagina 101-123
1925
Eerste CCU 1965
1967
Moderne CCU
Vroeger……. • • • • • • • • •
Morfine Coumarines Heparine Digoxine Lidocaine Procainamide Aspirine Nitroglycerine Beta‐blokkers
Geruptureerde plaque
Thrombus
Thrombolyse tijdperk Amery et al.(52) reported on a randomized series of 167 patients in which streptokinase did not reduce mortality as compared with heparin. A number of these same investigators subsequently conducted a larger trial with 764 patients.(51) In the latter trial, overall mortality was significantly lower in the streptokinase treated group than the heparin-treated group (18.5 vs 26.3%; 0.027 P> 0.01), although in contrast to the German study (49) there was not a significant difference in the mortality within the first 24 hours. 51. HEIKINHEIMo R, AHRENBERG P, HON KAPOHJA H, IISALO E, KALLIO V, KONTTINEN Y, LESKINEN 0, MUSTANIEMI H, REINIKAINEN M, SIITONEN L: Fibrinolytic treatment in acute myocardial infarction: A preliminary report. Advances Cardiol 4: 241, 1970 52. AMERY A, ROEBER G, VERMEULEN HJ, VERSTRAETE M: Single-blind randomized multicentre trial comparing heparin and streptokinase treatment in recent myocardial infarction. Acta Med Scand (suppl 505): 1, 1969
STANFORD WESSLER and LAURENCE A. SHERMAN Antiplatelet Aggregant Agents and Thrombolytic Compounds in Myocardial Infarction: Current Status Circulation 1972;45;911‐918 Mortality Rate Variations. Institutional mortality rates vary from 10 to 45% among patients hospitalized with acute myocardial infarction. Mechanisms of Death. In hospitals without coronary care units approximately 45% of deaths from acute myocardial infarction are caused by primary arrhythmias, 40% by pump failure, 10% from cardiac rupture (a form of pump failure), 3% from pulmonary or systemic arterial embolization, and 2% from noncardiovascular causes such as infection, hemorhage, or renal failure.
ISIS 2: 1985, n= 16027 placebo vs aspirine vs STK vs combinatie
ISIS 3: 1991, n= 41299 STK vs tPA vs APSAC
Primaire PCI (spoedinterventie)
Drip or ship? Danami
Prague
Meta analyse Keeley Lancet 2003
Meta-analysis of 23 randomised trials of primary angioplasty versus thrombolysis - short term clinical outcome Key: PCI = percutaneous coronary intervention; MI = myocardial infarction; CVA = cerebrovascular accident Adapted from Keeley EC, Boura JA, Grines CL. N = 7739.
Harde eindpunten
September 2004: start regionaal overleg
Na 2008: ROAZ focusgroep AMI
Hartinfarct per regio
2015: Euregio expertgroep MICK
Time = muscle
ON‐TIME ‐2 Acute myocardial infarction diagnosed in ambulance or referral center ASA+600 mg Clopidogrel
Placebo
N=984 6/2006-11/2007
Tirofiban *
Transportation Angiogram
Tirofiban provisional
PCI centre
PCI
Angiogram
Tirofiban cont’d
*Bolus: 25 µg/kg & 0.15 µg/kg/min infusion
Ongoing Tirofiban In Myocardial Infaction Evaluation
Ischemic Time 60 min 76
20
25
19
16
d-t-b 35 min
0
60
120
180
Ischemic Time (min) SO-1st Contact Door-Angio
Preparation Angio-Balloon
Transportation
[ Mean transport distance: 25 km/ 17 miles ]
On‐Time 2 studie in het MST Secondary Endpoint
30 day N=126
1 year N=124
Death 3/126 2.4% 5/124 4.0% Cardiac death 2/124 1.6% Non cardiac 3/124 2.4% Recurrent MI 2/124 1.6% Death/rec. MI 6/124 4.8% Card death/MI 3/124 2.4%
On‐Time 2 mortaliteit naar leeftijd 1‐yr mortality
HDTirofiban
Placebo
Age > 66 yr
17/248 6.8%
29/260 11.1%
Age < 65 yr
8/422 1.9%
9/396 2.3%
Mortaliteit na het acute myocardinfarct
Sterfte aan kanker en hart‐ en vaatziekten, per 1000 mannen/vrouwen, gestandaardiseerd, 1970–2005
2008
ACACIA studie (MJA 2008; 188 (12) 691‐697)
ACACIA (2)
organisatie • Regionaal overleg Stichting Hartcentrum Twente • ROAZ focusgroep myocardinfarct • Acute Zorg Euregio focusgroep MICK • NVVC Connect
Uw hart ‐ onze zorg!
• De patient staat nu centraal !
Nieuwe samenwerkingsverbanden
Euregionaal
Egypte
Noord Amerika
Intergallactisch…..
Vragen?
