S??d?as

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S??d?asµ??? Fa?µa?e?t??? ?a? ?peµßat???
??t?µet?p?s? t?? ????? ?µf???µat?? t?? ????a?d???
µe ???spas? t?? ST ? S???????? ????? ?at?????
???t??? ???t?ß??µ?a? ?e???a???? µe 24-???
???at?t?ta ???t??e???? ???e??p?ast????

• Ge?????? ?. ?apa???????, MD, MPH, FSCAI
• ?peµßat???? ?a?d???????
• ?at???? ???t?? ??????
• 20-4-2005

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Teµat?????a

• ?a??f?s??????a t?? ???
• ? ????? t?? ???µß???s?? st? ???
• ? a??e??p?ast??? ?? µ???d?? epa?a?µ?t?s?? st? ???
• ??e??e?t?µata ?a? µe???e?t?µata st? ?e?ape?a t??
  ??? µe ???µß???s? ? a??e??p?ast???
• ? ????? t?? s??dasµ???? fa?µa??-epeµßat????
  ?e?ape?a? st? ??? (Facilitated PCI)

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?a??f?s??????a ???
8
? T??µß???s? st? ???
plt0.001
plt0.03
The GUSTO Trial Results. Clin Res. 199341207-8.
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???? 3 ??? se ??? µet? ap? T??µß???s?
10
???? 3 ??? se ??? µet? ap? Stenting
11
S??s? TIMI ???? (90 min) ?a? T??t?t?ta?
p0.009
Simes, Circulation 1995.
12
S?????s? ???? ???? 3 µeta?? tPA-SK
plt0.001
pNS
N Engl J Med 19933291615-22.
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S?????s? tPA-rPA
plt0.05
pNS
Circulation 199694891-9 N Engl J Med
19973371118-23.
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NOVEL CONCEPTSOvercoming Thrombolytic Resistance
Fibrin
Platelets
Plasminogen activators - t-PA - r-PA - TNK-tPA
Antiplatelet therapy - aspirin - GP IIb/IIIa
inhibitors - dihydropyridines
Antithrombin therapy - heparin - LMWH
Thrombin
J Am Coll Card 1999341395-402.
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?e??t? GUSTO IIb ???e??p?ast??? vs T??µß???s?

• NNT for avoiding 1 death76
• NNT for avoiding 1 event (death/MI/CVA)25

N Engl J Med 19973361621-8.
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?e??t? PAMI-1 STEMI
J Am Coll Cardiol 199933640-6.
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?e??t? Stent-PAMI ? ????? t?? Stenting
Grines et al. N Engl J Med 19993411949-56.
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? ???s? ??ast????? GP IIb/IIIa st? ??? ?e??t?
CADILAC
Hypothesis Stenting was superior to PTCA and not
inferior to PTCAAbciximab with respect to
composite end point. P values compare abciximab
vs. non-abciximab groups.
N Engl J Med 2002346957-66.
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S?????s? ???e??p?ast????-T??µß???s??
?eta-?????s? (1)
plt0.001
p0.02
p0.007
plt0.001
JAMA 19972782093-2098.
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S?????s? ???e??p?ast????-T??µß???s??
?eta-?????s? (2)
plt0.0001
p0.002
plt0.0001
p0.0004
Lancet 200336113-20.
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??e??e?t?µata-?e???e?t?µata ???t??e????
???e??p?ast???? - T??µß???s??

• ??? ??s???µe???
• ?µes? ??????s? lt 30 min
• ?????? ??????s? (IV Bolus)
• G?????? ??a??? epa?a?µ?t?s?? a??? ate??? (???? 3
  ??? se 50-60)
• ?p?t???µ??? epa?a?µ?t?s? e?? ?????? ??a???? p????
  lt 3 hrs, ? gt 3 hrs
• ???d???? a?µ???a????? ???

• ??µ?d??aµ??? ???ast????
• ?????? d?a????e?? ?pe?????? a?t???a? lt 90 min,
  real world 150 min
• S?µa?t???? ?????? ??e?st?? a?t???a? µe s???d?
  ?????s? t?? µ???a?d???
• ???? 3 ??? gt90
• ??ast??µ?t?s? ???d????
• ?aµ???? ???d???? ???

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?at?t?ta A?t???a? Ype?????? ??a t? ???
Gibson et al. Ann Intern Med 1999130841-847.
23
??s???µe?a µe ??µ?d??aµ??? ???ast????
American Hospital Association 2000.
24
?ed?µ??a NRMI-2 ?????? ????????? ?pe??????
??t???a? ?a? T??t?t?ta
T??t?t?ta ()
J Am Coll Cardiol 199633521.
25
Te?ape?a As?e??? µe ??? ?a? Metaf??? se
T??t?ß??µ?? K??t?? PRAGUE-2
plt0.02
plt0.05
pNS
Eur Heart J 20032494-104.
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DANAMI-2 (30 day Death/MI/Stroke)
p0.002
plt0.001
p0.05
Andersen at al. N Engl J Med 2003349733-42.
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??a??µ?d? ??a ???t??e?? ???e??p?ast???
S???????µe?? µe T??µß???s?
Dalby et al. Circulation 20031081809-1814.
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?????? ????????? ??t???a? st?? ?e??te? ?s?e??? µe
???
?e??t? ?????? ????????? (min)
MAASTRICHT 85
PRAGUE-1 80
AIR-PAMI 122
CAPTIM 82
DANAMI-2 90
PRAGUE-2 97
Circulation 20031081809-1814.
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?ed?µ??a NRMI 3/4 (1999-2002). ??a?µat????
?????? ????????? t?? ?pe?????? ??t???a? st??
???t??e?? ???e??p?ast???
Nallamothu et al. Circulation 2005111761-767.
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?p? t?? ?p??a?d?a?? ??? st? ??????????f???a
Roe et al. J Am Coll Cardiol 2001379-18.
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?pe????s? t?? ???? ??e???????µe??
???e??p?ast??? (Facilitated PCI)

• ?????? ?e?ape?a µe T??µß???s? ?/?a? GP IIb/IIIa
  a?ast??e?? ??a ??????? a????? epa?a?µ?t?s? t??
  ?pe?????? ??a t? ??? a?t???a?
• ?µes? µetaf??? ??a ???e??p?ast??? (p.? lt 6hrs)
  ??a ???st??? d??????? t?? a?t???a?

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?e??t? TIMI 2A ???e??p?ast??? µet? ap?
?p?t???µ??? T??µß???s?
PNS
Topol et al. N Engl J Med 1987317581-8.
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? ?e??t? PACT
Ross et al. J Am Coll Cardiol 1999341954-62.
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?e??t? PACT TIMI 3 ???
plt0.001
plt0.001
J Am Coll Cardiol 1999341954-62.
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?ed?µ??a ?sf??e?a? st?? ?µes? S??d?asµ???
Te?ape?a ? ?e??t? SPEED
Herrmann et al. J Am Coll Cardiol 2000361489-96.
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?p?te?esµat???t?ta ?a? ?sf??e?a GUSTO-5
pNS
plt0.001
pNS
p0.07
Lancet 20013571905-14.
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?p?te?esµat???t?ta ASSENT-3
Lancet 2001358605-13.
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?p?te?esµat???t?ta ?a? ?sf??e?a ASSENT-3
Lancet 2001358605-13.
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?p?te?esµat???t?ta ?a? ?sf??e?a TIMI 10B TIMI
14
Schweiger et al. Am J Cardiol 200188831-6.
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? ?e??t? SIAM ?p?te??sµata st?? 30 ?µ??e?
p0.001
pNS
pNS
J Am Coll Cardiol 200342634-41.
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?e??t? GRACIA-2 ?p?te??sµata st??? 12 µ??e?
plt0.001
p0.07
Lancet 20043641014-5.
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?p?st??f? t?? ?p??µat?? ST sta 60 min µe
S??d?asµ??? Te?ape?a
p0.03
Am J Cardiol 200595611-614.
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?p?st??f? t?? ST ?a? T??t?t?ta
p0.028
Am J Cardiol 200595234-236.
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?p??es?

• ? s??d?asµ??? fa?µa??-epeµßat??? a?t?µet?p?s? t??
  ??? (???µß???s? /- GP IIb/IIIa a?ast??e??) µe
  ?µes? µetaf??? ??a a??e??p?ast??? (facilitated
  PCI) se as?e?e?? p?? pa???s?????ta? se ??s???µe?a
  ????? a?µ?d??aµ??? e??ast???? ße?t???e? t??
  e?d???s???µe?a?? ???t?t?ta

Papaioannou et al. Circulation 2004110537
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Methods-Study Population
AHA, New Orleans 2004
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Baseline TIMI 3 flow comparisons
Plt0.001
AHA, New Orleans 2004
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In-hospital mortality
P0.04
AHA, New Orleans 2004
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Comparison of in-hospital MACE
P0.003
MACE Death/Re-infarction/Emergent
revascularization/Stroke
AHA, New Orleans 2004
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STEMI TRSF subgroup analysis Baseline TIMI 3
flow based on specific treatment
Plt0.001 for trend
AHA, New Orleans 2004
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STEMI TRSF subgroup analysis In-hospital Death
and MACE results based on specific treatment
P0.03 for trend
P0.13 for trend
AHA, New Orleans 2004
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Figure 6 ?n-hospital TIMI Major and Minor
bleeding rates
PNS
PNS
AHA, New Orleans 2004
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S?µpe??sµata

• ? d?e???????µe?? a??e??p?ast??? se as?e?e?? µe
  ??? ep?t?????e? ?a??te?a a??e????af??? ?a?
  ??????? ap?te??sµata, pa??µ??a µe a?t? p??
  ?ata???f??ta? se as?e?e?? p?? ?e?ape???ta? µe
  p??t??e?? a??e??p?ast??? se t??t?ß??µ?a ???t?a
• ? s??d?asµ?? ???µß???s?? ?a? GP IIb/IIIa
  a?ast????? p??? t?? a??e??p?ast??? µ?????
  ep?t?????e? ta ?a??te?a ??????? ap?te??sµata
  ????? ep?p???? a?µ???a??e?

AHA, New Orleans 2004
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Facilitated PCI Improves ?utcomes ?rrespective of
DTB Time
Papaioannou et al. J Am Coll Cardiol 200545139A
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FINESSE Trial Design
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Reperfusion Options for STEMI patientsStep One
Assess Time and Risk
Risk of Lysis
Time Since Symptoms
Time Required to Initiate Invasive Strategy
Risk of STEMI
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Patient
Transport
Inhospital
Reperfusion
Door
FlowRestored
Onsetof MI
Drug Started
Data
Decision
Patient response
Current
Fibrinolysis
Cath
PCI
Primary PCI
Goal
D-N lt 30 min
5 min
D-B lt 90 min
Methods of Speeding Time to Reperfusion
Media campaign Patient education
MI protocolCritical Pathway Quality Imp. Program
Greater use of 911 Prehospital ECG Prehospital Rx
Bolus Lytics Dedicated PCI Team