danami 2 august 2003.ppt

The DANAMI-2 TrialThe DANAMI-2 Trial

A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction

Henning Rud Andersen et al for the DANAMI-2 investigators

N Engl J Med 2003; 349: 733-42

High-risk ST elevation MI patients (>4 mm elevation), Sx < 12 hrs5 PCI centers (n=443) and 22 referring hospitals (n=1,129), transfer in < 3 hrs

Lytic therapyFront-loaded tPA 100

mg

(n=782)

Death / MI / Stroke at 30 Days

DANAMI-2: Study DesignDANAMI-2: Study Design

Primary PCIwith transfer

(n=567)

Primary PCIwithout transfer

(n=223)

Stopped early by safety and efficacy committee

N Engl J Med 2003; 349: 733-42

13.7%

8.0%

0%

4%

8%

12%

16%

30 D

ay D

eath

/ M

I / S

trok

e (%

)

Lytic Primary PCI

P<0.001 P=0.002Combined Transfer Sites

P=0.05Non-Transfer Sites

DANAMI-2: Primary ResultsDANAMI-2: Primary Results

Lytic Primary PCI Lytic Primary PCI

14.2%

8.5%

0%

4%

8%

12%

16%

12.3%

6.7%

0%

4%

8%

12%

16%

N=27 N=15N=80 N=48

N Engl J Med 2003; 349: 733-42

N=107 N=63

2.0%

1.1%

0%

2%

4%

6%

8%

6.3%

1.6%

0%

2%

4%

6%

8%

7.8%

6.6%

0%

2%

4%

6%

8%

10%

Lytic Primary PCI

P=0.35Death

DANAMI-2: ResultsDANAMI-2: Results

Lytic Primary PCI

P=0.15Stroke

Lytic Primary PCI

P<0.001Recurrent MI

N Engl J Med 2003; 349: 733-42

DANAMI-2: Risk of Recurrent MI Largely Drives DANAMI-2: Risk of Recurrent MI Largely Drives Results of the Composite EndpointResults of the Composite Endpoint

The DANAMI 2 Investigators state that:

“Although the rates of death, clinical reinfarction, and stroke were all reduced with angioplasty, the better overall outcome after angioplasty was driven primarily by the reduction in the rate of reinfarction. Our finding of a higher 30-day mortality rate among patients with reinfarction accords with recent results by Gibson et al. and indicates that clinical reinfarction in our trial was a severe event.”

Recurrent MI During Index Hospitalization is Recurrent MI During Index Hospitalization is Associated with Higher Mortality at 2 YearsAssociated with Higher Mortality at 2 Years

Kaplan-Meier survival estimates, by early reinfarction

Years 0 0.5 1 1.5 2

0.5

0.75

1 No early reinfarction

10.1%, n=19,265

Early reinfarction19.6%, n=836

Log-rank p<0.0001

Gibson CM et al, J Am Coll Cardiol 2003;42:7–16.

Similar to DANAMI 2, A Lower Rate of Recurrent MI Following Similar to DANAMI 2, A Lower Rate of Recurrent MI Following PCI Drives the Benefit Observed in Many of the Recent Primary PCI Drives the Benefit Observed in Many of the Recent Primary

PCI vs Fibrinolytic TrialsPCI vs Fibrinolytic Trials

*Pre-hospital administration.*Pre-hospital administration.PP<0.05: ReMI;death (PCAT only); stroke (PCAT only).<0.05: ReMI;death (PCAT only); stroke (PCAT only).Grines C, et al. Grines C, et al. Am Heart J.Am Heart J. 2003;145:47-57. 2003;145:47-57.

CAPTIM DANAMI-2 C-PORT PCAT

n 840 1,572 451 2,725PCI t-PA* PCI t-PA PCI t-PA PCI Lytic

Death 4.6% 3.7% 6.6% 7.6% 6.2% 7.1% 6.2% 8.2%

ReMI 1.7% 3.7% 1.6% 6.3% 5.3% 10.6% 4.8% 9.8%

Stroke 0% 1.0% 1.1% 2.0% 2.2% 4.0% 0.7% 1.9%

CM Gibson 2003CM Gibson 2003

If Recurrent MI Drives The Results of DANAMI 2 and Other If Recurrent MI Drives The Results of DANAMI 2 and Other Recent Trials, Can We Reduce The Risk of Recurrent MI Recent Trials, Can We Reduce The Risk of Recurrent MI

Following Fibrinolytic Administration?Following Fibrinolytic Administration?

• Yes.

• Performance of early rescue PCI (early PCI of a closed artery), adjunctive PCI (early PCI of an open artery) , and delayed PCI are collectively associated with a reduction in recurrent MI after fibrinolytic administration.


Risk of Early Recurrent MI Following Thrombolysis in 20,101 Risk of Early Recurrent MI Following Thrombolysis in 20,101 PatientsPatients

4.5

1.6

0

1

2

3

4

5

No PCI PCI

% R

ecur

rent

MI

% R

ecur

rent

MI


P< 0.001

Is Performance of Rescue / Adjunctive / Delayed PCI After Fibrinolytic Is Performance of Rescue / Adjunctive / Delayed PCI After Fibrinolytic Administration Associated With Improved Mortality at 2 Years?Administration Associated With Improved Mortality at 2 Years?

• Yes.

• Performance of early rescue PCI (early PCI of a closed artery), adjunctive PCI (early PCI of an open artery) , and delayed PCI are collectively associated with a reduction in mortality.


2 Year Survival Following Rescue PCI2 Year Survival Following Rescue PCI

Gibson et al, Circulation 2002, 105:1909-1913

0.5

0.6

0.7

0.8

0.9

1

0 0.5 1 1.5 2

Log rank p=0.03

Survival was Improved in patients with 90 minute TIMI Grade 0/1 Flow who underwent rescue PCI

Years

Sur

viva

l

Rescue PCI

No Rescue PCI

2 Year Survival Associated with Adjunctive PCI in Patients with 2 Year Survival Associated with Adjunctive PCI in Patients with an Open Artery Following Thrombolytic Administrationan Open Artery Following Thrombolytic Administration

Gibson et al, Circulation 2002, 105:1909-1913

0.7

0.8

0.9

1

0 0.5 1 1.5 2

Survival tended to be improved in patients with an open artery at 90 minutes who underwent immediate adjunctive or delayed PCI

Years

p=0.11; after adjusting for stent use p=0.07 for adjunctive PCI

Immediate Adjunctive PCI

Delayed PCI

No PCI

Performance of Early PCI After Fibrinolysis is Associated with Improved Survival at 2 Years in 20,101 Patients

Years0 0.5 1 1.5 2

1

0.9

0.8

0.7

No PCI

PCI

Log rank p<0.0001

Surv

ival


Are The Benefits of PCI After Fibrinolysis True for Both Low Risk and Are The Benefits of PCI After Fibrinolysis True for Both Low Risk and High Risk Patients?High Risk Patients?

• Yes.

• Similar relative risk reductions in survival following PCI have been observed among low, intermediate and high risk patients.


1.7%

6.2%

15.0%

3.7%

10.3%

27.3%

0%

10%

20%

30%

PCI No PCI

p<0.001

Low RiskTRS 0-2

Mortality to 2 Years by In-Hospital PCI, Stratified by TIMI Risk Mortality to 2 Years by In-Hospital PCI, Stratified by TIMI Risk Score in 20,101 PatientsScore in 20,101 Patients

Mor

talit

y (%

)

p<0.001

Intermediate RiskTRS 3-4

High RiskTRS >5

p<0.001

PCI No PCI PCI No PCI


Are the There Recent Randomized Trials to Support PCI Are the There Recent Randomized Trials to Support PCI Following Fibrinolytic Administration?Following Fibrinolytic Administration?

• Yes.

• In August of 2003, the SIAM 3 and ALKK study were published contemporaneously with the DANAMI 2 Trial.


61.5%56.4%

0%

20%

40%

60%

SIAM III TrialSIAM III Trial

J Am Coll Cardiol 2003;42:634-41

rPA + Delayed PCIrPA + Early PCI

EF at 6 monthsp=0.018

25.6%

50.6%

0%

20%

40%

60%

Death/reMI/ischemicevents/TLR at 6 months

p=0.001

rPA + Delayed PCIrPA + Early PCI

Randomized trial of thrombolysis (rPA) with transfer for early PCI (within 6 hours; n=82) or thrombolysis with delayed angiography at 2 weeks (n=81) in patients with acute MI presenting at community hospitals

90%82%

0%

20%

40%

60%

80%

100%

ALKK TrialALKK Trial

Circulation. 2003;108:1324-1328

Medical TherapyPTCA

Event-free* Survival at 1 Yearp=0.06

96%89%

0%

20%

40%

60%

80%

100%

Survival at Long-term (mean 56 months)

follow-up p=0.02

Randomized trial of angioplasty (n=149) or medical therapy (n=151) in stable patients 8-42 days post acute MI

Medical TherapyPTCA* Survival free of reinfarction, ischemia-driven (re) PTCA, CABG, or rehospitalization for severe angina

If PCI After Fibrinolysis is Associated with Benefit, was PCI If PCI After Fibrinolysis is Associated with Benefit, was PCI Frequently Performed After Fibrinolysis in DANAMI 2?Frequently Performed After Fibrinolysis in DANAMI 2?

No.

As stated by the authors:“The frequency of rescue angioplasty was low.”

Rescue angioplasty was performed infrequently (15 cases, 1.9% of patients)

If PCI After Fibrinolysis is Associated with Benefit, Could the Results in the If PCI After Fibrinolysis is Associated with Benefit, Could the Results in the Fibrinolytic Arm Have Been Improved in DANAMI 2?Fibrinolytic Arm Have Been Improved in DANAMI 2?

Observational and randomized trial data from other trials presented above suggest that outcomes may have been improved if PCI had been performed more frequently after fibrinolysis, but this cannot be ascertained from the data at hand in DANAMI 2.


Are Prolonged Door to Balloon Times Associated With Higher Are Prolonged Door to Balloon Times Associated With Higher Mortality?Mortality?

• Yes.

• Door to balloon delays beyond 90 minutes are associated with a rise in mortality.

4.2 4.6 5.16.7

8.5 7.9

0

2

4

6

8

10

0-60 61-90 91-120 121-150 151-180 >180

Mor

talit

y (%

)

N=27,080P < 0.00001

NRMI-2: Primary PCI Door-to-Balloon time vs. Mortality

Door-to-Balloon Time (minutes) JAMA 2000; 283:2941-7.

Primary PCI for STEMIPrimary PCI for STEMITime to Reperfusion and 30-Day MortalityTime to Reperfusion and 30-Day Mortality

Time to Reperfusion (h)Time to Reperfusion (h)

Brodie BR, et al. Brodie BR, et al. J Am Coll Cardiol.J Am Coll Cardiol. 2003;41(suppl A):368A. De Luca G, et al. 2003;41(suppl A):368A. De Luca G, et al. J Am Coll Cardiol.J Am Coll Cardiol. 2003;41(suppl A):368A. 2003;41(suppl A):368A.

00

Mor

talit

y (%

)M

orta

lity

(%)

11

22

33

55

66

44

<3<3 3-63-6

0.9

2.3 2.2

>6>6

Time to Reperfusion (h)Time to Reperfusion (h)

00

22

44

66

1010

1212

88

<2<2 2-42-4

2.5

5.6

4-64-6

9.6

P=0.04 ( 3h v 3h) P<0.001

n=1,7911994-2001

n=2,002

3.1

>6>6

CADILLAC Zwolle

Was the Door to Balloon Delay in Performing PCI 3 Hours in Was the Door to Balloon Delay in Performing PCI 3 Hours in DANAMI 2?DANAMI 2?

• No.

• It was actually much quicker at 90 to 110 minutes.

• Are door to balloon times among transfer patients this quick in the United States?

• No.

• Currently, the median delay in the US is 185 minutes, only 4.8% of arteries are opened in under 90 minutes as suggested by the ACC/AHA guidelines.


DANAMI vs US AMI: DANAMI vs US AMI: Are We As Quick in the US?Are We As Quick in the US?

Pinto D, et al. Pinto D, et al. Cardiovascular Reviews and Report.Cardiovascular Reviews and Report. 2003;24:267-276. 2003;24:267-276.

0

Med

ian

Tim

e (m

in)

DANAMIOn-Site Primary PCI

DANAMITransfer Primary PCI

US AMITransfer Primary PCI

90

110

185

50

100

150

200

225

25

75

125

175

Is There A Time Dependence of the Potential Advantage of PCI Is There A Time Dependence of the Potential Advantage of PCI Over Fibrinolysis?Over Fibrinolysis?

• Yes.

• Delays in door to balloon times of over 60 minutes beyond that of a center’s door to needle time may nullify the benefits of primary PCI.

Benefits of PCI vs Lysis: The Importance of Timing

Kent DM et al Eff Clin Pract 4: 214, 2001

Are There Potential Benefits of Even Quicker Fibrinolytic Are There Potential Benefits of Even Quicker Fibrinolytic Administration Such as Pre Hospital Fibrinolytic Therapy?Administration Such as Pre Hospital Fibrinolytic Therapy?

• Yes.

• A recent meta analysis of 6 trials suggests a relative risk reduction in mortality of 16%

• The CAPTIM trial suggests that pre hospital therapy administered to those patients with a short duration of symptoms (< 2 hours) may be associated with improved clinical outcomes over primary PCI.

Favors Favors No. of Quality Pre-hospital In-hospital

Study Patients Score OR (95% CI) Thrombolysis Thrombolysis

Results of Randomized Trials of Results of Randomized Trials of Pre-hospital Thrombolysis on Hospital MortalityPre-hospital Thrombolysis on Hospital Mortality

All TrialsAll Trials

Morrison LE, et al. Morrison LE, et al. JAMA.JAMA. 2000;283:2686-2691. 2000;283:2686-2691.

MITI, 1993 360 0.91 0.69 (0.30-1.57)

EMIP, 1993 5469 0.85 0.86 (0.72-1.03)

GREAT, 1991 311 0.78 0.56 (0.25-1.23)

Roth et al, 1990 116 0.65 0.80 (0.17-3.77)

Schofer et al, 1990 78 0.63 0.46 (0.04-5.31)

Castaigne et al, 1989 100 0.48 0.74 (0.14-3.56)

Overall 6434 0.83 (0.70-0.98)

CAPTIM 1-Year ResultsCAPTIM 1-Year Results

Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill. George Washington University Symposium; November 16, 2002; Chicago, Ill.

Sx Sx 2 h 2 h

0.0

DeathSx Sx 2 h 2 h

5.0

7.5

2.5

Pre-hospital Lysis Primary PCI

2.2

5.7

DeathP=0.057

0.0

7.5

10.0

2.5


5.9

3.7

DeathP=0.47

5.0

Perc

ent

CAPTIM 1-Year ResultsCAPTIM 1-Year Results

DeathSx Sx 2 h 2 h

Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - Touboul P. Presented at: The 18th International Symposium on Thrombolysis and Interventional Therapy in Acute Myocardial Infarction - George Washington University Symposium; November 16, 2002; Chicago, Ill. George Washington University Symposium; November 16, 2002; Chicago, Ill.

Sx Sx 2 h 2 h

0.0

5.0

7.5

2.5


1.3

5.3

Shock Randomization to DCP=0.032

0.0

7.5

2.5


0.0

3.6

Shock Randomization to AdmP=0.0007

5.0

Perc

ent

Is Restoration of Epicardial Blood Flow Before PCI Associated Is Restoration of Epicardial Blood Flow Before PCI Associated with Improved Clinical Outcomes in STEMI?with Improved Clinical Outcomes in STEMI?

• Yes

0.5 1.0 1.5 2.0

0.5 1.0 1.5 2.0

Facilitated PCI in STEMI: Pre-PCI Angiographic Findings and MortalityFacilitated PCI in STEMI: Pre-PCI Angiographic Findings and Mortality

In both primary PCI and adjunctive/In both primary PCI and adjunctive/rescue PCI, TIMI flow grade before PCI rescue PCI, TIMI flow grade before PCI is associated with long-term mortalityis associated with long-term mortality

In adjunctive/rescue PCI, TIMI myocardial In adjunctive/rescue PCI, TIMI myocardial perfusion before PCI is associated with perfusion before PCI is associated with long-term mortalitylong-term mortality

Stone GW, et al. Stone GW, et al. Circulation.Circulation. 2001;104:636-641. 2001;104:636-641.

0.8

0.9

1.0

00.7

3- way log-rank3- way log-rankPP=0.0013=0.0013

TFG 0/1TFG 0/1

TFG 2TFG 2TFG 3TFG 3

Surv

ival

Surv

ival

0.8

0.9

1.0

00.7

Log-rankLog-rankPP=0.03=0.03

Surv

ival

Surv

ival

TMPG 2/3TMPG 2/3TMPG 0/1TMPG 0/1

1 2 4 6

94

98

100

090

Log-rank Log-rank PP for trendfor trendPP=0.009=0.009

Surv

ival

(%)

Surv

ival

(%)

TIMI 0/1 (1,657)TIMI 0/1 (1,657)

TIMI 3 (n=375)TIMI 3 (n=375)TIMI 2 (n=295)TIMI 2 (n=295)

MonthsMonths

92

96 4.4%4.4%

0.5%0.5%

2.8%2.8%

3 5

Gibson CM, et al. Gibson CM, et al. Circulation.Circulation. 2002;105:1909-1913. 2002;105:1909-1913.

62.457.9 54.7

0

20

40

60

80

TIMI 3 on cath lab arrival TIMI 3 after leaving cath lab Never had TIMI 3

Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

% C

onva

lesc

ent L

VEF

Convalescent LV Function by Patency Group: Global Ejection Convalescent LV Function by Patency Group: Global Ejection FractionFraction

P=0.004

Probability of Regional LV Dysfunction (Abnormal Chords) Increases as Time to Probability of Regional LV Dysfunction (Abnormal Chords) Increases as Time to Achieve Reperfusion IncreasesAchieve Reperfusion Increases

Lundergan CF, et al. Lundergan CF, et al. Am J Heart.Am J Heart. 2002;144:456-462. 2002;144:456-462.

PACT Substudy: Time to Reperfusion and LV Function in MIPACT Substudy: Time to Reperfusion and LV Function in MI

Time (h)Time (h)

0.600.60

Prob

abili

tyPr

obab

ility

0.650.65

0.700.70

0.750.75

0.900.90

0.950.95

0.800.80

22 66 1010Odds RatioOdds Ratio

00 11 22 33

0.850.85

44 88 44

30

Time Delay(min)

60

90

120

Door-to-Thrombolysis in Myocardial Infarction (TIMI) Time and MortalityDoor-to-Thrombolysis in Myocardial Infarction (TIMI) Time and Mortality

Juliard J-M, et al. Juliard J-M, et al. Am J Cardiol.Am J Cardiol. 2003;91:1401-1405. 2003;91:1401-1405.

After linear logistic regression, After linear logistic regression, only age, gender, and door-to-only age, gender, and door-to-TIMI grade 3 time (OR 1.27/ TIMI grade 3 time (OR 1.27/ 15 min) were independently 15 min) were independently correlated with in-hospital correlated with in-hospital mortalitymortality

Similar to the OR of Similar to the OR of 1.6/ 25 min in GUSTO IIb trial 1.6/ 25 min in GUSTO IIb trial (Berger PB et al, (Berger PB et al, CirculationCirculation 1999;100:14-20)1999;100:14-20)

00 1 h1 h > 1 h> 1 h

22

44

66

P<0.05

n=105n=105

1.8

6.7

n=394n=394

Mor

talit

y (%

)M

orta

lity

(%)

88

11

33

55

77

Can Glycoprotein IIbIIIa Inhibition Be Administered Safely Can Glycoprotein IIbIIIa Inhibition Be Administered Safely Following Fibrinolysis in the Cath Lab?Following Fibrinolysis in the Cath Lab?

• Yes.

• Non-randomized trial data suggests that this is not only safe but tends to be associated with reduced mortality.

GP IIb/IIIa Inhibitor Use With Early PCI After Full-Dose Fibrinolytic Therapy: Clinical GP IIb/IIIa Inhibitor Use With Early PCI After Full-Dose Fibrinolytic Therapy: Clinical Outcomes and Bleeding ComplicationsOutcomes and Bleeding Complications

GP IIb/IIIa Inhibitor (n=1,032)

No GP IIb/IIIa Inhibitor (n=2,386)

Odds Ratio* 95% CI

Mortality (%) 4.6 6.6 0.71 0.49-1.01 CHF (%) 6.8 6.5 1.23 0.87-1.74Re-infarction (%) 1.8 1.5 1.07 0.56-2.03Re-PCI (%) 2.1 3.3 1.27 0.75-2.16CABG (%) 1.6 2.8 0.64 0.36-1.15ICH (%) 0.4 0.9 0.60 0.19-1.90Severe Bleeding (%) 2.2 1.7 1.64 0.93-2.88Moderate Bleeding (%) 7.1 6.5 1.47 1.07-2.02Mod-Severe Bleeding (%) 10.2 8.1 1.64 1.24-2.16

Odds Ratio represents odds of the event for patients receiving GP IIb/IIIa inhibitors. Bleeding reported by GUSTO scale categories. Odds Ratio represents odds of the event for patients receiving GP IIb/IIIa inhibitors. Bleeding reported by GUSTO scale categories. Adapted with permission from Roe MT, et al. Safety of adjunctive glycoprotein IIb/IIIa blockade during rescue/early percutaneous Adapted with permission from Roe MT, et al. Safety of adjunctive glycoprotein IIb/IIIa blockade during rescue/early percutaneous coronary intervention following full-dose fibrinolytic therapy for acute myocardial infarction. Poster presented at the American College of coronary intervention following full-dose fibrinolytic therapy for acute myocardial infarction. Poster presented at the American College of Cardiology 52nd Annual Scientific Session; March 30-April 2, 2003; Chicago, Il.Cardiology 52nd Annual Scientific Session; March 30-April 2, 2003; Chicago, Il.

P=0.06


GP 2b3a Inhibition After Full Dose LysisGP 2b3a Inhibition After Full Dose Lysis

Assess risk of ICH: High Risk: elderly female, low body weight,

elevated blood pressure, elevated Cr, inferior MI

Low Risk: young male, large, normotensive, normal Cr, anterior MI

Assess Fibrinogen Depletion:Stat fibrinogen on pt. arrival, ? above 100TNK does not deplete fibrinogen, drug of choice for

combination with PCItPA drops near 100 for 18-24 hrsrPA often dips below 100 for 18-24 hrs


ConclusionsConclusions

• Time is muscle irrespective of the reperfusion strategy (drug or device)

• Benefits of PCI over fibrinolytic therapy are explained at least in part by a reduction in recurrent MI among patients treated with PCI

• In the modern era of interventional cardiology (stents, thienopyridines, GP 2b3a inhibition), the performance of PCI after fibrinolytic administration may reduce the risk of recurrent MI and may be associated with reduced long term mortality compared to fibrinolysis alone



• Safety and efficacy of full dose fibrinolytic monotherapy is well characterized while half dose fibrinolytic monotherapy is not well characterized

• Half dose fibrinolysis with simultaneous full dose GP 2b3a inhibition (“combination therapy”) is equal in clinical efficacy to fibrinolytic monotherapy but is associated with more major bleeding (GUSTO V, ASSENT 3)

• This is in contrast to full dose fibrinolytic monotherapy followed by full dose GP2b3a inhibition in the cardiac catheterization laboratory (hours later) which in non-randomized data tends to be associated with lower mortality (4.6% vs 6.6%, p=0.06) yet with a slight rise in moderate (7.1% vs 6.5%) and severe (2.2% vs 1.7%) bleeding



• Future prospective randomized trials will assess the efficacy of a variety of fibrinolytic and other pharmacologic agents before PCI and the concept of “facilitated PCI”


Designs of Upcoming Facilitated PCI TrialsDesigns of Upcoming Facilitated PCI Trials

ASSENT 4 TNK Heparin/ASAADVANCE TNK +

IntegrilinIntegrilin

TITAN Integrilin in ER

Integrilin in cath lab

FINESSE r-PA r-PA + abciximab in ER vs CCL


Selection of the Optimal Reperfusion Options for the STEMI Patient: 2003Selection of the Optimal Reperfusion Options for the STEMI Patient: 2003

Full Dose Fibrinolytic Monotherapy •Door to balloon (D-B)

> 90 min•Lack of access to skilled PCI center•(D-B) – (D-N) > 1 h•< 1 h from symptom onset

Invasive Strategy • Cardiogenic shock (age < 75)• Bleeding risk• Diagnosis in doubt

(pericarditis/aneurysm)• Door to balloon < 90 min• Skilled PCI center available, defined

by:– Operator experience > 75 cases/yr– Team experience > 36 primary PCI/yr

• Age > 75• Symptoms > 2-3 hCM Gibson 2003CM Gibson 2003

danami 2 august 2003.ppt

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