Primary PCI

Prof A N PatnaikDr RAMACHANDRA BARIK

Dr Lalita Nemani

Define

STEMI only

Urgent angioplasty(with/out stenting)- Preferably in ≤90min

No TLT before or parallel

Open the infarct—related

Delayed PCI

PCI After TLT 1.Rescue(REACT/MERLIN/RESCUE) 2.Facilitated(BRAVE/HERO/CAPITAL/WASTE/ASCEND)

Of its kinds

STEMI

Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardialinfarction. Circulation 2007;116:2634-53.

Today’s evening• Abbreviating time is everything

1.Best transfer Protocol

2. Reverse Paradox

• PPCI vs. TLT

• Who need it?

• PPCI in Octagenerian

• Set up

1.Your Lab 2.Surgical Back up

Contd......

• Operator skill

• Initial therapy in ICCU

• Radial vs. Femoral

• Optimal anticoagulation

• POBA/ BMS/DES

• Hardware

• IABP/ECMO-When and its role

Contd....

• In cath lab

• After cathlab=ICCU

• Predischarge triage

• Finance

• Take home message

Politician also knows.....time is life

Time is muscleEvery minute counts

Gersh BJ, Stone GW, White HD, et al. Pharmacological facilitation of primary percutaneous coronary intervention for acute myocardial infarction: is the slope of the curve the shape of the future? JAMA 2005;293:979-86

Terkelsen CJ, Sorensen JT, Maeng M, et al. System delay and mortality amongpatients with STEMI treated with primary percutaneous coronary intervention.JAMA 2010;304:763-71.

Primary PCI vs. TLT

Choice

(TIMI)-3 Flow in 95% vs 54%(TLT)

Gersh BJ et al. Pharmacological facilitation of PPCI for STEMI: is the slope of the curve the shape of the future? JAMA 2005;293:979-86

Stone GW et al. Comparison of angioplasty with stenting,with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957-66

PCI IS THE BEST

OPTION

PAMI Trial-1997

POBA provides a small-to-moderate, short-term clinical advantage over TLT with t-PA.

PPCI when it can be accomplished promptly at experienced centers, should be considered an excellent alternative method for myocardial reperfusion.

The investigators and centers participating in the GUSTO IIb Angioplasty Substudy ,Cleveland Clinic,USA

A 2003 meta-analysis

23 randomized trials

7739 patients

Reductions in short-term death (7% vs 9%, P 0.0002),

fatal reinfarction (3% vs 7%, P 0.0001),

stroke (1% vs 2%, P 0.0004)

Keeley EC et al. Primary angioplasty versus intravenous thrombolytictherapy for acute myocardial infarction: a quantitative review of 23randomised trials. Lancet 2003;361:13-20

But TLT is the invaluable in certain conditions because delay in opening artery causes

• CHF/ readmissions/OPD visits increases

independently with mortality(HR/OR=1.1)

detrimental in age<65, presenting within 2 hours

Death+ reinfarction+disabling stroke at 30 days was significantly < PCI in 2 of the studies, with a trend toward significance in the underpowered third study

“DIDO=Door-in-door-out=30”

Pretransfer TLTCAPTIMWEST

“Number Paradox”

Golden’s Hour:2-3Hrs.

Evidence

Evidence....

Evidence..

• MITRA STUDY(Maximal therapy in AMI)

• SWISS STUDY

• DANAMI II

• SHOCK(Shock)

• NRMI-II(CHF)

Then what to choose?Then what to choose?

“Reperfusion paradox” vsBest transfer protocol

Coordinate...to reduce

Initial management

=MONA

Oxygen

Aspirin

Nitroglycerin

Opioids(Morphine)

Cath lab standard

Adjunctive Antithrombotic Therapy

• Antiplatlets

• Anticoagulation

Antiplatlets

Antiplatlets

GROUP IIB-IIIA Inhibitors

Anticoagulants

‡The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.§The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).

Access

No but you better understandNo but you better understand

Shock

• Killip IV

• Ionotrope optimum

• Control IV fluid

• CPR

• IABP/ECMO

• LVAD

• CABG

IABP but use it!!!!!!!!

• No Δ in infarct size at 3-5 days

• No Δ in all cause death at 6 months

Ohman EM, et al. Use of aortic counterpulsation to improve sustained coronary artery patency during AMI.RCT. The Randomized IABP Study Group. Circulation 1994.Stone GW et al, (PAMI-II) Trial Investigators. J Am Coll Cardiol 1997; 29:1459.

Brodie BR et al,IABP, before PPCI reduces catheterization laboratory events in high-risk patients with AMI . Am J Cardiol 1999

Patel MR,et al. CRISP AMI Trial. JAMA 2011; 306:1329.

Anticoagulation-ACTAnticoagulation ACT

HEPARIN ONLY 250 to 350 seconds 

+GIIB-IIIA 200-250

POST Procedural No heparin

Sheath removal ≤150-180sec

Heparin reversal 100 Unit=1mg of Protamin Sulphate IV bolus

Manual aspiration thrombectomy

• 1.Microvascular function improves

• 2.Decrease death

• 3.MCE

I IIa IIb III

Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008;371:1915–20

Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012;307:1817–26

No reduction infarction size in large AWMI

Culprit vs. Bystanders

Culprit vs. Bystanders

PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable(2013 STEMI guideline).

I IIa IIb III

Preventive Angioplasty in Myocardial Infarction=PRAMI2008 through 2013, at five centers in UK465(234/234)Subsequent PCI for inducible ischemia/refractory angina composite of death/nonfatal MI/refractory angina significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery

STENTS

BMS/DES is useful I IIa IIb III

BMS:High bleeding risk/noncomply with 1 year of DAPT/ anticipated invasive or surgical procedures in the coming year

I IIa IIb III

DES should not be used if unable to tolerate/comply with a prolonged course of DAPT.

I IIa IIb III

Harm

POBA vs. BMS

tenting further reduced subsequent TLR but not shown a survival advantage

1. Stone GW et al. Comparison of angioplasty with stenting,with or without abciximab, in acute myocardial infarction. N Engl J Med2002;346:957-662. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stentimplantation for acute myocardial infarction. Stent primary angioplasty in myocardialinfarction study group. N Engl J Med 1999;341:1949-56.

BMS vs. DES

DES greater reduction in TLR BUT not associated with improved survival because added late ST

Stone GW et al. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009;360:1946-59.

Brar SS et al. Use of drug-eluting stents in acute myocardial infarction: a systematic review and meta-analysis. J Am Coll Cardiol 2009;53:1677-89.

TYPHOON, PASSION, SESAMI, DEDICATION, and HORIZONS AMI

DES for STEMI

• TVR reduction >>BMS

• No extra stent thrombosis with DAP

• PCI with DES is not mandatory in STEM

• BMS may be preferable in cases in which comorbid

conditions, compliance, or financial means may interfere with the required duration of dual-antiplatelet therapy after DES placement

POBA vs.BMS vs. DES(G1/G2)

Keeping to right is right

BMS Vs DES( G1)• no significant difference in mortality, (8.5 versus

10.2 percent; HR 0.85,(95% CI 0.70-1.04).

• TLR was lower with DES (12.7 versus 20.1 percent; HR 0.57, 95% CI 0.50-0.66).

• No Δ in the cumulative rate of ST (5.8 versus 4.3 percent; HR 1.13, 95% CI 0.86-1.47). VLS (events after two years) was higher for DES (HR 2.81, 95% CI 1.28-6.19).

• No Δ in the cumulative rate of reinfarction (9.4 versus 5.9 percent; HR 1.12, 95% CI 0.88-1.41). 2Y- the rate significantly increased for DES (HR 2.06, 95% CI 1.22-3.49).

De Luca G, et al. DES vs BMS in primary angioplasty: a pooled patient-level meta-analysis of randomized trials. Arch Intern Med 2012; 172:611.

BMS vs DES -G2Cobalt-chromium everolimus-eluting stents (CoCr-EES)

• one-year risk of cardiac death/ MI was reduced with the former but not the latter (odds ratio [OR] 0.63, 95% CI 0.42-0.92 and 0.86, 95% CI 0.50-1.49).

• one-year risk TVR was reduced with the former but not the latter (OR 0.45, 95% CI 0.29-0.66 and 0.60, 95% CI 0.34-1.05).

• the one-year risk of definite stent thrombosis was reduced with the former but not the latter (OR 0.32, 95% CI 0.11-0.78 and 0.44, 95% CI 0.12-1.79).

• lower one-year rates of cardiac death or MI, definite stent thrombosis, and target vessel revascularization

The COMFORTABLE AMI trial

• WITH Biolums as polymer the MCE FURTHER REDUCED

Drug-eluting balloon plus BMS

• First human trial

• not significantly different between the DEB-BMS and BMS groups

• Drug is paclitaxel

Belkacemi A, J Am Coll Cardiol. 2012 Jun;59(25):2327-37. Epub 2012 Apr 11.

Direct Stenting

• significantly lower rate of all-cause death

• Lesser no flow/slow flow

• Better myocardial preservation

HORIZON AMI Loubeyre C et al. A RCT of direct stenting with conventional stent implantation in selected patients with AMI . J Am Coll Cardiol 2002; 39:15.Ly HQ et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol 2005; 95:383.Antoniucci D, et al. Direct infarct artery stenting without predilation and no-reflow in patients with acute myocardial infarction. Am Heart J 2001; 142:684.

 Bioresorbable vascular Scaffolds

• Safe

• Feasible

• Available Size, short expiry is limitation

• Not approved/not guide lined

• Long term result awaited

PRAGUE-19 Study,87 pts/3 yrs//started in 2012/Abbott vascular

Intra coronary IIB-IIIA inhibitor(abciximab)

Death+ reinfarction, p=0.03

Death ,p=0.04)

TVR ,p=0.045)

Reinfarction; p=0.13

Raffaele Piccolo et al,Italy,Meta analysis,2012, Heart doi:10.1136/heartjnl-2011-301101

Intracoronary Adenosine

• A bolus injection of intracoronary adenosine (900 micrograms in 5 mL of 0.9% sodium chloride solution). Control patients received an intravenous bolus injection of adenosine (900 micrograms in 20 mL sodium chloride) during the procedure

• Elective intracoronary administration of high-dose adenosine as adjunctive therapy to

primary PCI reduces MVO

INTRA CORONARY TLT

• 2.5 lakhs unit STK

• Improves no reflow

• Improves TFC

• EPICARDIAL coronary looks beautiful

• At 6 months ,no gain add to viable myocardium

Murat Sezer et al, Turkey, N Engl J Med 2007; 356:1823-1834,

Date of download: 9/28/2013

Copyright © The American College of Cardiology. All rights reserved.

From: Effect of Intracoronary Streptokinase Administered Immediately After Primary Percutaneous Coronary Intervention on Long-Term Left Ventricular Infarct Size, Volumes, and Function

J Am Coll Cardiol. 2009;54(12):1065-1071. doi:10.1016/j.jacc.2009.04.083

Intracoronary hyperoxemic reperfusion therapy

• Safe and well tolerated

Dixon SR et al,Pilot study, J Am Coll Cardiol. 2002;39(3):387

Ischemic conditioning

• Ischemic preconditioning

• Ischemic post conditioning confer benefit

• Remote Ischemic conditioning

30sec-1min-30sec-1min-30sec

Kloner RA, Jennings RB.

Suboptimal reperfusion after PPCI/Complication Persistent stenosis or thrombosis

Coronary dissection

Intramural hematoma

Side branch occlusion

Coronary spasm

Distal macroembolism

Acute stent thrombosis

No-reflow phenomenon

Reperfusion injury

Capillary blistering and edema of endothelial cells

Edema and swelling of myocytes

PAMI:Age ≥70 yearsDiabetesLonger time to reperfusionInitial TIMI flow grade ≤1Left ventricular ejection fraction <50 percent

Ventricular Arrhythmias

• Immediate defibrillation or cardioversion for VF or pulseless sustained VT,

• Early (within 24 hours of presentation) administration of beta blockers.

• The prophylactic use of lidocaine is not recommended.

• VPC, NSVT not associated with hemodynamic compromise, and AIVR are not indicative of increased SCD risk needs less attention.

No reflow phenomenon

• 10 – 30 %

• Influences the long term results of PCI significantly.

• Minimised by NTG(25 microgram). Verapamil, diltiazem, GpIIBIIIA inhibitors, nikorandil(IONA), thrombectomy, intracoronary STK, ischemic post conditioning.

Rescue CABG < 3%

Aspirin should not be withheld

Short-acting intravenous GP IIb/IIIa receptor antagonists (eptifibatide, tirofiban) should be discontinued at least 2 to 4 hours before urgent CABG.

Clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG, if possible.

I IIa IIb III

I IIa IIb III

I IIa IIb III

RESCUE CABG

Abciximab should be discontinued at least 12 hours before urgent CABG.

Urgent off-pump CABG within 24 hours of clopidogrel or ticagrelor administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

Urgent CABG within 5 days of clopidogrel or ticagrelor administration or within 7 days of prasugrel administration might be considered, especially if the benefits of prompt revascularization outweigh the risks of bleeding.

I IIa IIb III

I IIa IIb III

I IIa IIb III

Role of third antiplatlet

Yes you may add,but bleeding matters

Sheath removal timing

• ACT <160 SEC

• SHEATH SIZE α compression time

• USE OF Group IIA-IIIB inhibitors

• After 6 hrs for femoral and 2 hours for Radial

Beware of Bleeding

Very Elderly (≥85 Years)

Claessen et al. Primary percutaneous coronary intervention for ST elevation myocardial infarction in octogenarians: trends and outcomes. Heart 2010;96:843–7

Danish Registry Supports Primary PCI in Elderly STEMI Patients-2013

Senior-PAMI-2005

Secondary prevention

• Beta Blockers: initiated in the first 24 hours unless C/I

• Renin-Angiotensin-Aldosterone System Inhibitors:within 24 hrs

• Lipid Management

Posthospitalization Plan of Care

•Prevent hospital readmissions•Should be used to facilitate the transition to effective•Outpatient care

I IIa IIb III

•Exercise-based cardiac rehabilitation•Secondary prevention programs

I IIa IIb III

Posthospitalization Plan of Care

Medication adherenceFollow-upDietary and physical activitiesCompliance with interventions for secondary prevention should be provided to patients with STEMI.

No smoking No secondhand smoke

I IIa IIb III

I IIa IIb III

CVD risk can begin before birth!!