trattamento delle sindromi coronariche acutesindromi...
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Trattamento delle Sindromi Coronariche AcuteSindromi Coronariche Acute
nel paziente anziano
Stefano SavonittoDi i i di C di l i
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Divisione di CardiologiaArcispedale S. Maria Nuova
Reggio Emilia
Proportion of men and women >85 year-old registered in the Swedish National hospital discharge registry
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Rosengren A. Eur Heart J 2012;33:562
Comparing mean ages of Italian ACS registries and guideline-building trials
80-NSTEACS STEMI
75- women
70-
65-
men women
year
s
65
60-
7468 68
63
meny
55-6362 62 62 60 59 59
Eur Heart J Acute CV Care
2012
BLITZ 4Eur Heart J
Acute CV Care 2012
BLITZ 4RITA III
Lancet2002
TIMI18
NEJM2001
ICTUSNEJM2005
TRITONLancet2009
HORIZONSNEJM2008
PLATOCirculation
2011
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Average enrolment / center / monthItalian Elderly
ACS Study
313 patients / 21 centres / 29 monthsYears
y
= 0.51 patients / centre / monthYears
2008-2010JACC Intv 2012
Years2005-2007
Eur Heart J 2010
266 patients / 23 centres / 33 months
= 0.34 patients / centre / month
302 patients / 14 centres / 59 monthsYears1996-2000
TIME studyElderly pts
= 0.37 patients / centre / month1996-2000Lancet 2002 Symptomatic
Stable CAD
2220 patients / 196 centres / 24 months
= 0.55 patients / centre / month
Years1998-2000NEJM 2000
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Metanalysis of PPCI vs lysis in elderly patients
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Bueno H, EHJ 2011;32:51-60
Senior PAMI: 30-day Outcome Based on Age-Stratified Randomizationased o ge St at ed a do at o
25
PCI Lysis
22 2220
25
PCI Lysis
1715
20
%
19 2022
16 16
22
15
20
%
7,1 7,7 7,7
11,3 12
5
10
5
10
0Death Death/CVA D/CVA/reMI
Age 70-80 (n=351)
0Death Death/CVA D/CVA/reMI
Age >80 (n=130)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Primary angioplastyPAMI pooled analysis (1990-1998)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
De Geare et al Am J Cardiol 2000;86:30–34
12-month outcomes
C it d i t All t litComposite endpoint All-cause mortality
1.0
urvi
val
1.0
val f
ree
ofin
g st
roke Primary PCI
Thrombolysis
0.8
mul
ativ
e Su
0.8
ativ
e Su
rviv
I or d
iasb
l
0.6
Cum
m
P=0.650.6C
umm
ula
deat
h re
M
P=0.31
Follow-up (days)360300240180120600
Follow-up (days)360300240180120600
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Bueno H, EHJ 2011;32:51-60
30-day mortality in STEMI by time
Mortality %
>= 75 yr
65 – 74 yr65 74 yr
< 65 yr
Women<65 Women 65-75 Women >75 Men<65 Men 65-75 Men >75
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Men 65 Men 65 75 Men 75 Uppsala Clinical Research Centre 2005
Changes in the management of ACS in the elderly 2006 vs 2001: The Franche Comté Registry
Non-adjustedAdjusted for propensity score
STE
STE
STESTE
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Schiele F, Eur Heart J 2009;30:987
>2006<2006
Changes 35-day survival in elderly pts with ACS 2001 vs 2006: The Franche Comté Registry
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Schiele F, Eur Heart J 2009;30:987
5-year death/MI in the FIR collaboration
SI= selective invasiveRI= routine invasive
>75>75y
65-74y65 74y
<65y
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Damman P et al. Heart 2012;98:207-13
5-year death/MI in the FIR collaboration according to age and genderaccording to age and gender
SI= selective invasiveRI= routine invasive
>75y
65-74y
<65y<65y
D P t l H t 2012 98 207 13
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Damman P et al. Heart 2012;98:207-13
Italian Elderly
ACS Study
Early aggressive vs initially conservative In elderly patients with NSTEACS and elevated Tn
y
Survival to primary endpoint in troponin positive patients
HR 0.43; 95% CI 0.23-0.80Logrank P=0.015
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Savonitto S. JACC Intv 2012;5:906-16
Italian Elderly
ACS Study
Kaplan Meier survival without primary endpointaccording to actual revascularization
ACS Study
Revascularization (n=119)Revascularization (n 119)Event rate 22%
No revascularization (n=194)Event rate 37%
Logrank P=0.0077
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Italian Elderly
ACS Study
All-cause and cardiac mortality inItalian Elderly ACS and PARTNER
y
30%Mean age 82 years in both cohorts Mean age 84 years
30%-
25%- 71%
All cause
Cardiac46%
20%-
15% 85%15%-
10%- 23.816 9
85%
26.8
5%-
0
13.4 11.116.9
13.0
0-Trial
N=313RegistryN=332
PARTNER (surg)N=351
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
NEJM 2012, March 28Morici N, Am J Cardiol 2013
Cumulative risk estimate of death up to 405 days of follow up
(Morici N, Am J Cardiol 2013)
Italian Elderly
ACS Study
0.20
ACS Study
0.16
0.18Cumulative incidence of Death
120/645 pts (18.6%)
Rat
e
0.12
0.14120/645 pts (18.6%)
Eve
nt R
0.080.10
Cumulative incidence of CV Death
97/645 pts (15.0%)E
0 02
0.040.06
Cumulative incidence of NCV Death
Days0 60 120 180 300 360240 4050.00
0.02 Cumulative incidence of NCV Death
23/645 pts (3.5%)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Contribution of cardiac death to overall death in the elderly(each column represents the % of cardiac death)
100-General population Hospitalised patients
80-
menwomengeneral
81
60-
g
4149
40-
20-
41
3739 40 4039
20
0-ISTAT CDC Medicare Italian ElderlyBreastProstate HipISTAT>75y
CDCGorina Y
Aging trends 2006
Medicare>67y
Newschaffer CJJ Nat Cancer Inst 2000
Italian ElderlyNSTEACS
>75yAm J Cardiol 2013
Breast cancer>80y
J Clin Oncol 2011
Prostate cancer>65y
Newschaffer CJJ Nat Cancer Inst 2000
Hipfracture
>65yBMJ Musc.Skel Dis
2011
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Independent predictors of death at logistic regressionIn the whole study cohort (Morici N, Am J Cardiol 2013)
Italian Elderly
ACS Study
All-cause death(N° of events=120)
Ejection Fraction* 29.989
Wald χ2
HR 95% CI p-value predictiveinformation
0.952 0.935-0.969 <0.001 35%
ACS Study
Blood haemoglobin* 10.664
Age* 6.607
Creatinine Clearance* 4.716
0.845 0.763-0.935 0.001 13%
1.054 1.013-1.098 0.010 8%
0.986 0.973-0.999 0.030 6%
Cardiovascular death(N° of events=97)
Ejection Fraction 27 109 0 950 0 932-0 969 <0 001 45%Ejection Fraction 27.109
Creatinine Clearance 6.215
Blood haemoglobin 3.372
0.950 0.932-0.969 <0.001 45%
0.982 0.968-0.996 0.013 10%
0.900 0.805-1.007 0.066 6%
1 032 0 986 1 079 0 174 3%
Noncardiovascular death(N° of events=23)
Age 1.844
i 18 8
1.032 0.986-1.079 0.174 3%
0 96 0 4 2 0 3 0 001 42%Blood haemoglobin 18.875
Age 13.151
Ejection Fraction 4.559
0.596 0.472-0.753 <0.001 42%
1.165 1.073-1.265 <0.001 29%
0.952 0.910-0.996 0.033 10%
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5
Hazard Ratio (HR)
Mechanisms Leading to Pharmacokinetic Variations of Antithrombotic Drug Effects in the Elderlyg y
Capodanno & Angiolillo JACC 2010;56:1683 1692
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Capodanno & Angiolillo. JACC 2010;56:1683-1692
Safety Concerns in the Elderly with ACSBleeding Risks by Age
17,9 18,520
14,115sion
N=74.271N=74.271
10,39,710Tr
ansf
us
4,55%
RB
C T
0
%
0<65 yrs 65-75 yrs > 75 yrs
Non-CABG Overall
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
C G O
GP IIb/IIIa inhibitors in the Elderly
Pooled data from EPIC, CAPTURE, EPILOG and EPISTENT Trial
AbciximabPlacebo
AbciximabPlacebo
11,8 11,6 11,8
8
10
12
30 d
ay
poin
t(%)
6,15,35
6
7
maj
or
atio
ns (%
)
5,36,5
7,2
4
6
8
urre
nce
of 3
posi
te e
nd-p
3,1
4,43,7
3,2
,
2
3
4
urre
nce
of m
ng c
ompl
ica
0
2
<55 55 - 70 >70
Occ
uco
mp
0
1
2
<55 55 - 70 >70O
ccbl
eedi
nAge (y) Age (y)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Mak et al, Drugs Aging 2002
30-day bleeding and one-year mortality high risk subgroups
UHF
30-day Major Bleeding UHF
One-year Mortality
Age >75 FemaleUHFpre-treat Diabetes Age >75
RenalFailure Female
UHFpre-treat DiabetesRenal
Failure
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Lincoff AM, JAMA 2004;292:696
Cangrelor in The Elderly?
Non–ST-segment elevation acute coronary syndrome in 25.7% (5.7% had unstable angina), and STEMI in 18.2%.
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Bhatt DL et al. NEJM 2013 Ahead of print
RADIAL VERSUS FEMORAL APPROACH: META-ANALYSIS OF RANDOMIZED TRIALS
Major bleeding 0.05 2.3 0.27 (0.16-0.45) <0.001D+MI+stroke 2.5 3.8 0.71 (0.49-1.01) 0.058D MI stroke 2.5 3.8 0.71 (0.49 1.01) 0.058Death 1.2 1.8 0.74 (0.42-1.30 0.29MI 2.0 2.9 0.76 (0.49-1.17) 0.21Stroke 0.1 0.5 0.39 (0.09-1.75) 0.22Access site crossover
5.9 1.4 3.82 (2.83-5.15) <0.001crossoverInability to cross the lesion
4.7 3.4 1.31 (0.87-1.96) 0.20
N= 4461
Absolute RR 1.8% (95% CI 1.0-2.5%, p= 0.001),
NNT =56 to prevent one major bleeding
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Jolly SS, Am Heart J 2009; 157:132-40
Revascularization procedures Revascularization procedures during index admissionduring index admission
ItalianItalian ElderlyElderly
ACSACS StudyStudyACSACS StudyStudy
100100--9090--8080--7070--
Early Early aggressiveaggressive
9494 9696
6060--5050-- 9696 97979797 100100
InitiallyInitiallyConservativeConservative
4040--3030-- 7070
96967878
DESDES54%54%
DESDES56%56%2020--
1010--00
54%54% 56%56%
00--Radial approachRadial approach stentingstenting Procedural Procedural
successsuccessPCIPCI
ProceduralProceduralsuccesssuccessCABGCABG
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
PCIPCI CABGCABG
Savonitto S. JACC Intv 2012; 5:906-16
Antithrombotic treatments during index admission
Italian Elderly
ACS Study
Early Aggressive (n=154)
Initially Conservative (n=159)
y
Drugs %
Aspirin 95 99Ticlopidine 4.6 1.94.6 1.9Clopidogrel 90 92
Unfractionated heparin 25 24Unfractionated heparin 25 24Enoxaparin 64 59
GPIIb/IIIa inhibitor 17 (24 in PCI) 6 (17 in PCI)Bivalirudin 3.8 1.3
Fondaparinux 8.5 8.5
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Savonitto S. JACC Intv 2012; 5:906-16
Adverse clinical events during index hospitalizationItalian Elderly
ACS Study
Early Aggressive (n=154)
Initially Conservative (n=159)
Death 8 (5 2) 5 (3 1)
py
Death 8 (5.2) 5 (3.1)Myocardial (re)infarction 3 (1.9) 5 (3.1)
N (%)
Severe recurrent ischemia 1 (0.6) 15 (9.4)Heart failure 11 (7.1) 4 (2.5)
0.0004
0.06( ) ( )Cardiac arrhythmia 3 (1.9) 3 (1.9)
Any stroke / Disabling 2 / 0 1 / 0NAny stroke / Disabling stroke
2 / 0 1 / 0TIMI major bleeding 0 1 (0.6)
N
CABG-related bleeding/transfusion
4 (2.6) 0
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Savonitto S. JACC Intv 2012; 5:906-16
Cumulative risk estimate of death up to 405 days of follow up
(Morici N, et al. Submitted)
Italian Elderly
ACS Study
0.20
ACS Study
0.16
0.18Cumulative incidence of Death
120/645 pts (18.6%)
Rat
e
0.12
0.14120/645 pts (18.6%)
Eve
nt R
0.080.10
Cumulative incidence of CV Death
97/645 pts (15.0%)E
0 02
0.040.06
Cumulative incidence of NCV Death
Days0 60 120 180 300 360240 4050.00
0.02 Cumulative incidence of NCV Death
23/645 pts (3.5%)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Reduced platelet inhibition on clopidogrel in elderly patients (the SENIOR PLATELET study)in elderly patients (the SENIOR PLATELET study)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Silvain J. Eur Heart J 2012; 33:1241-9
Excess of upper GI complications with low-dose aspirinDepending on previous clinical history
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Patrono C. NEJM 2005
Bleeding complications in CHARISMA
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Becker RC. Circulation 2010;121:2575
Bleeding complications in CHARISMA
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Becker RC. Circulation 2010;121:2575
Wiviott SD, NEJM 2007;357:2001
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
TIMI Major non-CABG bleedingafter day 3 for prasugrel by age
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Wiviott SD, NEJM 2007;357:2001
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Overall efficacy and safety in elderly patients
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Husted S, Circ CV Qual Outcomes 2012;5:680
Newer antiplatelet treatments compared to clopidogrel in ACS: Patients >75 y.o.
25- 25-PLATO (n=2878) TRITON (n=1809)
clopid clopid
20- 20-Adj HR 0.89(IC 0.74-1.08)
HR 0.94(CI 0.75-1.18)
ticag prasug
15- 15-
10-18.3 17.2
10-18.3 17.2
Adj HR 1.18(IC 0.73-1.59)
HR 1.36
5-
0
5-
03.4 4.2
7.1 8.3(CI 0.81-2.27)
0- 0-D+MI+stroke PLATO non-CABG
major bleedingD+MI+stroke TIMI non-CABG
major bleeding
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Husted S. Circ CV Qual Outcomes 2012;5:680 Wiviott S. N Engl J Med 2007;357:2001
Prasugrel 5 mg improves platelet inhibition in the elderly(patients on chronic treatment)
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Capranzano P. Thromb Haemost 2011; 106:1149-57
Platelet inhibition studyPrasugrel 30+5 mg vs clopidogrel 300+75 mgPrasugrel 30 5 mg vs clopidogrel 300 75 mg
G b l PA JAMA 2012 308 1785 94
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Gurbel PA. JAMA 2012;308:1785-94
Overall efficacy and safety in the elderlyOverall efficacy and safety in the elderlyFigures derived by subtraction from the main paperFigures derived by subtraction from the main paper
30-25-20
prasugrel5 mg
clopidogrel75 mg
20-15-10- 24.6 24.1
19 1
Ischemicendpoints
5-0-
CVD+MI CVD MI stroke All cause
13.5 14.5 13.8 12.73.0 2.2
17.0 19.1endpoints
CVD+MI+stroke
CVD MI stroke All-causemortality
4.0-
3.0-
2.0-Bleeding1.0-
0-GUSTO
0.8 1.3 1.8 1.80.3 0.5 0.6 0.6
2.6 3.0g
endpoints
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
GUSTO SEVERE -LT
TIMI Maj TIMI fatal stroke TIMI Maj + min
2 000 patients2 000 patients >>75 years75 yearsRCTRCT
Italian Elderly
ACS-2 Study2,000 patients 2,000 patients >>75 years75 yearswith ACS treated invasivelywith ACS treated invasively
webweb
ACS 2 y
ClopidogrelClopidogrel Pras grelPras grel
webwebrandomrandom
ClopidogrelClopidogrel300+75 mg300+75 mg
PrasugrelPrasugrel60+5 mg60+5 mg
1212--month month 1212--month month followfollow--upup followfollow--upup
PrimaryPrimary endpointendpointth itth it ff llll t litt lit di ldi l ( )( )MIMI di blidi bli t kt k ddthe composite the composite ofof allall--causecause mortalitymortality, , myocardialmyocardial (re)(re)MIMI, , disablingdisabling strokestroke and and
rere--hospitalizationhospitalization forfor cardiovascularcardiovascular causescauses or severe or severe bleedingbleeding withinwithin 12 12 monthsmonths
PI: S. Savonitto, S. De Servi
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
PI: S. Savonitto, S. De ServiCoordinating Center: IRCCS Arcispedale S. Maria Nuova, Reggio Emilia
•78 y.o. man with recurrent bladder cancer and indication to re-TURB• July 2011, NSTEACS: PCI + BMS proximal-mid LAD, heavily calcified• October 2011, NSTEACS with anterior ST depression: severe restenosis LAD and, pAntero-apical akinesia; EF 0.45; moderate mitral rigurgitation• Bypass surgery: LIMA-LAD offpump, left toracotomy.
Day 3 post-surgery
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Donna di 85 anni senza patologie di rilievo, autosufficiente e attivaI° episodio di angor con pre-sincope. Centro spoke, domenica mattina.
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Donna di 85 anni senza patologie di rilievo, autosufficiente e attivaI° episodio di angor con pre-sincope. Centro spoke, domenica mattina
Terapia con nitrato, ASA, Clopidogrel 300 mg.Regressione del dolore, invio a hubg ,
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
A centro hub: ripresa di dolore
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
A centro hub: ripresa di dolore, coronarografia immediata
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Coronarografia immediata per via radiale destra
Coronaria destrarelativamenterelativamentepiccola, con stenosi 70%
FE 0.55
Minima elevazione TnTelevazione TnT
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto
Coronarografia immediata per via radiale destra
Coronaria destrarelativamente
Stop clopidogrelInizia tirofiban
relativamentepiccola, con stenosi 70% Indicazione a
AMIs-IVA in i it t iFE 0.55
Minima elevazione TnT
minitoracotomia senza CEC+ PCI Cx
elevazione TnTPaziente stabile
Intervento rinviatoIntervento rinviatodi 48 ore per wash-out clopidogrel
Data: 10-11 maggio 2013
Evento: Novara - Baveno
Titolo: ACS Treatment elderlyAutore: Stefano Savonitto