High Impact STEMI Journal Articles

in 2015

Timothy A. Mixon MD FACC FSCAI

Interventional Cardiology

Baylor Scott & White Health

Associate Professor of Medicine

Texas A&M College of Medicine

J Am Coll Cardiol 2015; 66:62-73

Cardiac Arrest and Resuscitation

• OOH arrest with ROSC high mortality

• However, therapies exist to improve outcomes

• Best survival is seen among…

– CPR administered promptly (shorter “down time”)

– Early defibrillation

– Presence of a “shockable” rhythm

– Therapeutic hypothermia

– Early coronary angiography +/- PCI

• 64% with OOH arrest arrive comatose

– Need a grid for decision making

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Case Example

• 70 y/o man brought to ED after asytolic arrest

• Occurred during dialysis

• Prolonged CPR (> 45 minutes)

• pH < 7.0

• Had survived two prior episodes of cardiac

arrest treated with PCI (once) and TH

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4

Conclusion• Grid: a good starting point

– Helps most with extremes

• Highlights need for more research:– Early angiography vs. delayed/selective

– Quantitative impact of various features on survival and neurological recovery

• Must change public reporting for cardiac arrest patients

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Angiography after Fibrinolysis:

When is the optimal time?

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J Am Coll Cardiol Intv 2015; 8:166-74

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Background

• ≈ 20% are not within 60 minutes of PPCI

– Candidates for fibrinolysis

• Fibrinolytics reduce mortality

• Strategies after lytics

– Observe for failed reperfusion

– Transfer for immediate angiography +/- PCI

– Transfer, selective (or delayed) angiography

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Immediate vs. Selective Angiography

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0

2

4

6

8

10

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Primary End Death Re-MI RefractIschem

Immediate PCI Conserv/Rescue

Length of stay 7 vs. 9 days p=.0001Conclusion: “…a strategy of immediate transfer for PCI

after…fibrinolytics…is better than continuing standard

management at the same centre”

Among “routine therapy”, urgent cath required in 1/3

Results show:1. Fewer acute ischemic

events2. Trend toward lower re-

infarction3. No difference in

mortality4. Nonsignificant trend

toward increased bleeding

Results from CARESS-in-AMI

Remaining Question…?

What is the optimal timing for angiography

after fibrinolytics?

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Early lytic failure / reocclusion

Risk of bleeding / Adverse interaction between lytics and PCI

Favors Early Favors Delayed

Patient Level Meta-analysis

• Combined patient level data on 1,238 pts from 7 RCT

• Fibrinolytics given transfer for angiography

– Randomized to immediate arm vs. delayed arm

– Each trial had exceptions for clinically required early angiography

• Three groups, based on time from drug to angio

0-2 hours

2-4 hours

> 4 hours

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Results

• Data results

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ConclusionPutting it into Perspective

• If delay to PPCI (FMC2b>120 min) fibrinolysis

• Immediate transfer to PPCI center warranted

• Early angiography, probably “urgent,” results in

1. Decreased recurrent ischemia,

2. Strong signals of reduced death/MI (if performed early)

3. No increased bleeding

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Risk vs. Benefit of Prolonged DAPT

STEMI Patient Population

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J Am Coll Cardiol 2015; 65:2211-22

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What is the optimal duration for antiplatelet medication among patients who receive stents for AMI?

Background

• Stent Thrombosis

– DES require prolonged DAPT to prevent

• Recurrent MI

– Among AMI survivors, risk of recurrent MI

– CURE Trial showed benefit with 9-12 month DAPT

• Competing forces

– Desire shorter DAPT to lower bleeding

– ? Longer DAPT prevent more events

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DAPT Trial

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0

1

2

3

4

5

6

7

DAPT

Placebo0.4%

1.4%

4.3%

5.9%

2.1%

4.1%

HR 0.29p<.001

HR 0.71p<.001

HR 0.47p<.001

HR 1.00p=0.98

HR 1.36P=.05

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Benefits and Risk of Extended DAPT

among AMI Patients

0

1

2

3

4

5

6

7

8

StentThrombosis

MACCE MI Bleeding All death

DAPT (MI)

Placebo (MI)

DAPT (No MI)

Placebo (No MI)

Same effect

Same effect

Same effect

Greater effect after MI

Conclusion: Prolonged DAPT after

AMI

• Reduces late stent thrombosis– 0.5% vs 1.9% (HR 0.27, p< 0.001)

• Reduces MACE (greater extend than non MI pts)– 3.9% vs. 6.8% (HR 0.42, p<0.001)

• Reduces MI– 2.2% vs. 5.2% (HR 0.42, p<0.001)

• Equal all-cause death

• Increased bleeding– 1.9% vs. 0.8% (HR 2.38, p-0.005)

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STEMI with Multivessel Disease

Stent one…or stent all?

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Primary PCI

Culprit artery vs. Multivessel PCI

Background:– Guidelines assign Class III to lesions beyond culprit

– Based on a prior era (different techniques, pharmacology, predictability)

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Is it safe…even desirable…to perform multivessel intervention at the time of PPCI?

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CvLPRIT Trial• 296 patients at 7 U.K. centers (presenting within 12 hours of pain onset)

• Randomized to culprit only vs. complete revascularization (during index admission)

– 2/3 at time of PCI

– 1/3 staged during index admission

• Primary endpoint, composite of:

– All-cause death

– Recurrent MI

– Heart failure

– Ischemia-driven revascularization

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CvLPRIT in Perspective

• Congruent findings with PRAMI

• Small numbers, underpowered

– Play of chance?

– All endpoints directionally consistent, but all ns

• End Results

– Guidelines changed III IIb

– COMPLETE Trial will provide needed clarification

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Causes of Death after STEMI

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Prior studies have documented causes and incidence of early death after STEMI

Data on long term mortality rates and causes is less well studied

J Am Coll Cardiol 2014; 64: 2101-8.

Causes of Death after STEMI

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0

5

10

15

20

25

30 day 1-year 5-year

CV Death All Cause Death

92%

74%

59%

% of death attributed to CV causes

Causes of early death:

1. Cardiogenic shock

2. Anoxic brain injury3. Malignant arrhythmia

Subsequent Annual Risk

of CV death…<1.5%

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Relationship of CV vs. non-CV

Death over Time

Thank you for your attention!

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