Dr. Elisabet R. UlmeteDr.CosmeArgerichGeneralHospitalofAcuteDiseases
BuenosAires,Argentina
EARLY MORTALITY AT 30 DAYS OF POST-AMI HEART FAILURE
HOWTOINTERPRETITANDHOWTOIMPROVEITSPROGNOSIS
AftercreatingtheCoronaryCareUnitandimplementingefficientantiarrhythmictherapeuticmeasures, heartfailure(HF)constitutesthemostfrequentcomplicationofAMIassociatedtoahighin-hospitalmortalityrate.
Itisdefinedastheinabilityofthehearttomaintainanappropriatebloodflowtosatisfythemetabolic requirementsoftissuesasaconsequenceoflossof functioningmyocardium.
INTRODUCTION
POST-AMIHEARTFAILUREKillip&KimballIndex.
Class Mortality
A: No heart failure 2 - 5 % B: Mild heart failure 10 – 20 % C: Acute pulmonary edema 30% D: Cardiogenic shock 50 – 60 %
INCIDENCEOFPOST-AMIHF Difficultiesofepidemiologicalanalysis
•Thedatacomefromdifferenttypesofstudies(registries,clinicaltrials,epidemiologicalstudies).
•DifferentdefinitionsofHFandinfarctionareused.
•PatientswithcardiogenicshockorwithHFpriortotheanalysisareincludedornot.
•Therearebiasesintheselectionofpatients.
•Differentpopulationsareevaluated(coronaryunits,alladmittancesinahospital,differentagegroups).
INCIDENCEOFPOST-AMIHFDifficultiesofepidemiologicalanalysis
Thecomparisonofclinicaltrialswithregistriesshowsthatpatientsinclinicalstudiesareyounger,withlessproportionofwomenandHFatadmittance,andwithgreaterchancesofreceivingreperfusionprocedures,aspirin,andbetablockers,sotheincidenceinthemisconsiderablylower.
INCIDENCEOFPOST-AMIHF
STUDY TERMOFTHESTUDY HF(%)
Epidemiologicalstudies
WHAS(USA) 2001 39.9
WHAS(USA) 2005 31.5
Registries
NRMI2/3(USA) 1994-2000 29
GRACE(SCA) 1996-2001 13
Clinicalstudies
Meta-analysis 1990-1998 29.4
(GUSTOI;GUSTOIIB;GUSTOIII;ASSENTIII
In-TIMEII 1997-1998 23
VALIANT(Registry) 1991-2001 23.1
Incidenceofpost-AMIHF 25-30
INCIDENCEOFPOST-AMIHFEarlysystolicdysfunctionoftheleftventricle
•Although they are related findings, HF and left ventricular systolic dysfunction (LVSD) are not synonyms.
•A 30-50% of patients with post-AMI HF does not have LVSD and HF is due to mitral dysfunction, arrhythmias, or left ventricular diastolic dysfunction.
•There might be LVSD without clinical signs of HF.
•Specifying the incidence of post-AMI LVSD is even more complex, since it is not evaluated as a routine in several institutions, there are different methods to measure it and the cut point for ejection fraction may vary.
•However, according to literature, a 25-60% of AMI patients will have LVSD, and more than 50% with early LVSD will also present HF.
INCIDENCEOFPOST-AMIHFEarlyleftventricularsystolicdysfunction
STUDY TERM EFVALUE LVSD(%)
Registries
FrenchCCU 1995 ≤0.50 52
FrenchUSIC2000 2000 ≤0.50 46
Clinicalstudies
BEAT 1998-1999 <0.40 31.1
VALIANTregistry 1999-2001 ≤0.40 27.2
MAGIC 1999-2002 <0.50 60
EMIAT 1990-1995 ≤0.50 43
DIAMOND-MI 1998 ≤0.35 29
ARGAMI-2 1996 ≤0.40 28
TRACE 1990-1992 ≤0.35 39Robin A.P.Weier y col Am J Cardiol 2006;97 suppl 13F-25F
POST-AMIHEARTFAILUREHFprognosticfactorsatadmittance
HF NOHF p n=1778 n=11929
Age 72.5(63.7-79.5)64.0(54.1-72.9) <0.0001 Men 60.1 69.6 <0.0001 Background Diabetes 29.9 20.9 <0.0001 AMI 32 26.7 <0.0001 TIA/stroke 53.8 59.9 <0.0001 HTN 59.5 55.7 0.0026 Renalfailure 10 6.4 <0.0001
GRACE Registry 2004; 109: 494-499
POST-AMIHEARTFAILUREHFprognosticfactorsatadmittance
OR 95% CI
Advanced age 1.5 1.45 -1.60 High HR 1.23 1.22 -1.28
STEMI 2.1 1.84 - 2.47
NSTEMI 1.6 1.41 - 1.91
Prior use of diuretics 1.5 1.31 – 1.75
LBBB 1.6 1.30 – 2.10
GRACE Registry 2004; 109: 494-499
POST-AMIHEARTFAILURE
0
7,5
15
22,5
3027
15,6
30
15,7
STEMI NSTEMIColumna1
GRACE FRENCH CCU
NS
NS
Robin A.P.Weir y col. Am J Cariol 2006; 97 suppl: 13 F-25F
POST-AMIHEARTFAILUREHFprognosticfactorsatadmittance
%
0
15
30
45
60
CoronaryAngiography PTCA
31,8
54,2
26,00
46,50
WithHF WithoutHF
P<0.0001
POST-AMIHEARTFAILURE
GRACE Registry 2004; 109: 494-499
HFatadmiaance HFduringhospitalizacon
POST-AMIHEARTFAILURE•The analysis of data provided by the NRMI 2 and NRMI 3 reports that those patients wtih smaller infarctions tended to be older with pre-existing morbidity and a high incidence of prior AMI. These patients developed HF at admittance more frequently.
•On the contrary, the group with larger infarctions turned out to be younger, with a lower morbidity and a lower frequency of prior infarction. These patients showed HF more often after admittance.
•Thus, the extent of infarction is an important determinant for the incidence and time of appearance of post-AMI HF.
•Those with morbidity and pre-existing myocardial damage do not tolerate even small infarctions and develop HF early.
0
3
6
9
1212
4
8
2
Death Death/AMIColumna1
POST-AMIHEARTFAILUREMortalityat30days
n= 61041
Inci
denc
e (%
)
NO HF WITH HFHasdai y col. Am Heart J. 2003; 145: 73-79
POST-AMIHEARTFAILUREIn-hospitalmortalityandat6months
GRACE Registry 2004; 109: 494-499
WithHF WithoutHF Columna1%
P< 0.0001
P< 0.0001
POST-AMIHEARTFAILUREMortality
Sur
viva
l
Days
No HF Mild HF Severe HF Shock
n= 15078 P < 0.0001
Kashani y col Eur. Heart J 2004: 25: 1702- 1710
POST-AMIHEARTFAILUREMortality
OR 95% CI
HF at admittance 1.68 1.62 – 1.75
Age 1.58 1.55 – 1.61
Stroke 1.36 1.29 – 1.44
Diabetes 1.21 1.17 – 1.26
Prior HF 0.92 0.88 – 0.97
Am. J. Cardiol 1996; 78: 1124 - 1128
Intrahopitalaria
POST-AMIHEARTFAILUREIn-hospitalmortality
P< 0,001
Circulation. 2002;105:2605-2610.)
HFatadmi]ancePostadmi]anceHFColumna1
POST-AMIHEARTFAILUREMortality
•BothpatientswithHFatadmittancethatfailedtosolveitclinicallyduringhospitalizationandthosewhodevelopedHFonlyafteradmittance,showaworseevolutionthanthosewithHFatadmittanceandsolvedduringhospitalization.
•Post-AMIHFdoesnotonlyaffectmortalitybutalsomorbidityofpatientsthatpresentit:
withHF withoutHF p
Re-AMI 3.0%2.7% =0.002
Stroke 2.2% 1.4% <0.001
VT/VF 11.2% 9.0% <0.001
Circulation. 2002;105:2605-2610.
POST-AMIHEARTFAILUREPathophysiology
In a setting of AMI, the determinants of heart failure are:
1.- Size of infarcted area
2.- Ventricular distensibility
3.- Functional state of remaining myocardium
4.- Mechanical complications
5.- Rhythm disorders
SIZEOFINFARCTEDAREA
• TheextentofventricularfunctionalterationcausedbyAMIisdirectlyproportionaltotheextentofthenecroticareaandcirculatoryconditionsthatsurroundit.
• Withthelossofanamountenoughofmyocardialmass,thepumpfunctionisdecreased.Theminute-volume,systolicvolume,bloodpressure,anddp/dtmaxdecreaseandtheendsystolicvolumeincreases.Paradoxicalsystolicexpansionoftheinfarctedareadecreasesthesystolicvolumeevenmore.
• Theleftventricle(LV)dilatesduringthefirsthoursanddaysafterAMI,sothatregionalandglobalpressureincreaseaccordingtoLaplace’sLaw.
• ThedegreeofdilationdependsonthesizeoftheAMI,permeabilityoftheinfarctrelatedartery(IRA))andactivationoftherenin-angiotensin-aldosteronesystem(RAAS).
• TheprobabilitytodevelopHFsymptomscorrelatestoventricularfunctionparameters.
• Thefirstalterationisareductionofdiastolicrelaxationthatisobservedininfarctionsthatcompromise8%ofventricularmass.
• With≥15%losses,ejectionfractionreducesandvolumeandendsystolicpressureincrease.
• ThesignsofHFappearwith≥25%lossesofventricularmass.
• Cardiogenicshockaccompaniesa≥40%contractionalteration
SIZE OF INFARCTED AREA
FUNCTIONALSTATEOFREMAININGMYOCARDIUM
• Extensivecoronaryarterydiseasemaycompromiseirrigation,aswellaspriorinfarctionsandfibrosisthatcouldalteritsperformance.
• Themyocardialterritoryinriskconstitutedbyischemiccells,butthatcouldberecovered,isextremelyimportant.ViabilitydependsontheexistenceornotofanappropriateresidualflowafterIRArecanalizationorthepresenceofcollateralcirculationdevelopedbeforeAMI.
• Onthecontrary,thelossofcollateralarteriessecondarytoocclusionoftheresponsiblevessel,aconditionthatwillgenerateremoteischemia,isanotherfactorthatcontributestoventricularfunctionimpairment.
COMPENSATINGMECHANISMS• Thedecreaseofsystolicvolumetriggerscardiacandperipheral
compensatingmechanismstomaintainapropertissueperfusion.However,eachofthemmaylead,inaparadoxicalanddirectorindirectway,anevengreaterimpairmentandthusgenerateaviciouscirclethatwillhavetobeinterruptedwithapropertherapeuticstrategy.
• Duetotheimplicationsintheevolutionofpatientswithpost-AMIHF,amongperipheralmechanismsitistheneurohormonalsystemactivationthatstandsout(sympatheticnervoussystem,RAAS)sinceitdeterminesanincreaseofsystemicvascularresistancethatleadstoagreaterdeclineofventricularfunction,multiorgandysfunction,anddeath
COMPENSATINGMECHANISMS• Intheparticularcaseofcardiogenicshock,thisclassicalparadigmof
peripheralcompensationmaynotbeobservedincertainpatients,butonthecontrary,reducedvascularresistanceisverifiedbythedevelopmentofsystemicinflammatoryresponsesyndrome(SIRS)duetothereleaseofinflammatorymediators(cytokines)thatleadtoanexaggeratedexpressionoftheenzymeinducingnitricoxide(iNOS).
• Theexcessiveproductionofnitricoxideanditsderivativessuchasperoxynitriteproducedeleteriouseffectssuchasinhibitionofcardiaccontractility,systemicvasodilationinduction,suppressionofmitochondrialrespirationofnon-ischemicmyocardiumandavariabledecreaseofadrenergicresponse.
Consideringthesignificanceofthesizeoftheinfarctionasakeydeterminanttodeveloppost-AMIHF,theconceptofthepossibilityofmodifyingithaspromotedthedevelopmentofalargenumberofexperimentalandclinicaltrialsoverthelastfewdecades.Theeffortstolimittheextentoftheinfarctedareahavebeenguidedbydifferentapproachesto:
1. Earlyreperfusion
2. Reductionofmyocardialenergydemand
3. Manipulationofmyocardialenergyproductionsources.
4. Preventionofreperfusioninjury.
POST-AMIHEARTFAILURE Howtoimproveprognosis
POST-AMIHEARTFAILUREReductionofAMIsize
Generalmeasures
Theytendtooptimizeabalancebetweenmyocardialoxygeninputanddemandto savetheischemicareasthatsurroundtheinfarction.
✓Physicalandemotionalrestofthepatienttolowertheheartrate. ✓Oxygenation:kineticsupport,oxygenmask,bronchodilators,noninvasive ventilationorendotrachealintubationformechanicalrespiratoryassistance. ✓Maintainapropersystolicpressure. ✓Managementoftachyarrhythmiaandbradyarrhythmia. ✓Correctionofelectrolyticdisordersandacid-basestate. ✓Managementofassociatedconditions:severeanemia,infectionsaccompanied byfeverandtachycardia.
REDUCTIONOFSIZEOFAMIReperfusion
0
25
50
75
100KILLIP>1 KILLIP1Columna1
TIMI 3 post PTCA BLUSH Solution of ST
p=0.001
p<0.001
p=0.002
Giuseppe De Luca y col. Am. Heart J. 2009; 158: 416-21
%
REPERFUSIONSurvivalinKillipandKimball>1
100
90
80
70
60
50
400 60 120 180 240 300 360
MBG 2 - 3
MBG 0 - 1
p< 0.001
Su
rviv
al (
%)
Days
Giuseppe De Luca y col. Am. Heart J. 2009; 158: 416-21
POST-AMIHEARTFAILUREReperfusion
• Thetwostrategiesofreperfusiondevelopedoverthelastdecades,apharmacologicalonewithfibrinolyticdrugsandprimaryangioplasty(PTCA),achieveanaccelerationoftherecanalizationprocessofIRA,maximizingtheamountofmyocardiumsaved,takingintoaccountasrulethattimeandnotthetypeofreperfusionisthecriticallyrelevantaspect.Thus,arecoveryofLVsystolicfunctionisachieved,aswellasanimprovementinsurvivalintheshortandlongterm.
• PrimaryPTCAproducesasuperiorbenefitinsurvivalcomparedtofibrinolyticagents.ThissuperiorityisdirectlylinkedtoabetterpatencyofIRA(90%vs65%).
POST-AMIHEARTFAILUREReperfusion
•PrimaryPTCAalsoachievesahigherLVEFatdischargeandlowerpercentagesofre-infarction,stroke,andHF.
•However,adelayfromthemomentatwhichthepatientgetsintouchwithmedicalcareuntilperformingtheangioplasty(PTCA),makesthisbenefitnotbealwaysachieved,andinthiscase,fibrinolyticdrugsarearesourcethatmaybeusedmorequickly.
POST-AMIHEARTFAILUREReperfusion
Time of delay (minutes)
1 2 3 4
30
60
90
120
0
Odds Ratio
Am. Heart J. 2002; 144 (3)
p < 0.02
Fibrinolytictreatment
.-Earlypresentation(≤3hsincetheonsetofsymptoms,delayforaninvasivestrategy).
.-PTCAisnotanoptionbecause: -Laboratorynotavailable -Difficultvascularaccess -Difficultiestoobtainaccesstoanexperimentedhemodynamicslab..-Delaysforaninvasivestrategy -Prolongedtransportation -(door-to-balloon)-(door-to-needle)time>1h -Door-to-balloontime>90minutes
POST-AMIHEARTFAILUREChoiceofreperfusiontreatment
ACC/AHA Guidelines 2006
Invasivestrategy
.-Trainedhemodynamicslaboratoryavailable -Door-to-balloontime<90minutes -(door-to-balloon)-(door-to-needle)time<1hour
.-AMIofhighrisk:Cardiogénicshock;Killip≥3
.-Contraindicationsforfibrinolyticdrugs(includingincreasedriskofbleedingandstroke).
.-Delayedpresentation(>3hours).
.-DoubtfuldiagnosisofAMI
Ifadmittanceis<3handthereisnodelayforaninvasivestrategy,therearenopreferencesforanyofthe2modalities.
POST-AMIHEARTFAILUREChoiceofreperfusiontreatment
ACC/AHA Guidelines 2006
POST-AMIHEARTFAILUREChoiceofreperfusionmanagement
• Takingintoaccountthatthebenefitsgrantedbyfibrinolyticagentsoccurwhentheyareadministered,preferablywithinthefirsthouroftheonsetofsymptoms,themodalityofpre-hospitalfibrinolysiswasevaluatedinseveraltrials.
• Comparedwithin-hospitalfibrinolysis,itproduced,inameta-analysisof6434patients,asignificantreductionofmortality.(oddsratio:0.83;95%CI0.70-0.98p=0.03).
• Thecomparisonofpre-hospitalfibrinolysiswithtransfertoacenterforPTCAintheCAPTIMstudy,didnotrevealsignificantdifferencesintermsofmortalityorinthecompositeendpoint(re-infarction,stroke,deathat30days).
POST-AMIHEARTFAILUREPre-hospitalfibrinolyticdrugsvstransferforPTCA
P= 0.058 P< 0.032
CAPTIM Circulation 2003; 108 : 2851- 6
0
1,5
3
4,5
6
Deathat30days Shock
Pre-hospFB PTCAColumna1
POST-AMIHEARTFAILURERescuePTCA
PTCA CONTROL P (%) (%)
Mortality 7.3 10.4 0.09
HF 12.7 17.8 0.05
Re-infarction 6.1 10.7 0.04
Stroke 3.4 0.7 0.04
Bleeding 16.6 3.5 < 0.001
Wijeisundera y col JACC 2007; 49: 422-430
POST-AMIHEARTFAILUREMicrovasculardamage
• Inspiteofrestoringepicardialflow,manypatientsdisplaysuboptimalmyocardialperfusion.Thissuggeststhatpost-AMIHFmayalsodevelopasaconsequenceofextensivenecrosisassociatedtoseveremicrovasculardamage.
• Thehighmortalityratelinkedtoimpairedmyocardialperfusion,makesevidenttheneedtotryhardertoimprovecirculationinsmallvessels,beyondrestoringepicardialflow.
• Althoughseveralfactorsmaycontributetomicrovasculardysfunction,microvascularreperfusioninjuryhasbeenconsideredasthemaindeterminantofthisphenomenon.
POST-AMIHEARTFAILUREMicrovasculardamage
TYPESOFREPERFUSIONINJURY
Stunning:prolongedcontractiledysfunctionofmyocytessavedbyreperfusionbecauseofcellmetabolismalterationsthatreduceenergyproduction.
No-reflowphenomenon:progressivemicrovascularreperfusiondamage.
Arrhythmiasbyreperfusion
Lethalreperfusioninjury:celldeathinducedbycellreperfusion.
POST-AMIHEARTFAILUREMicrovasculardamage
Mediatorsoflethalreperfusioninjuryandevaluatedstrategies
1) Oxidativestress.Antioxidants2) Intracellularcalciumoverload.Diltiazem,cariporide3) RapidrestorationofcellPH.4) Metabolicmodulation.Glucosetherapy,insulin,potassium5) Magnesium6) Inflammation.Pexelizumab;P-selectinantagonist7) Adenosine
POST-AMIHEARTFAILUREMicrovasculardysfunction
• Addedtotheinjurybyreperfusion,anothermechanismlinkedtomicrovasculardysfuncionisthedistalembolizationobservedinahighpercentageinthehighestKillipandKimbalindices.
• Inthisregard,pharmacologicaltherapy(IIb/IIIainhibitors)andmechanicaltherapy(manualaspirationofthrombus)havebeenproposedasstrategiestoprotectthemicrocirculationofthiscomplicationduringPTCA,andthuspreventagreaterdeteriorationofventricularfunction.
• Intheparticularsettingofshock,somestudiessuggestthatthrombusaspirationmayobtainabettersolutionforSTsegmentandasignificantreductionofin-hospitalmortality.
MicrovasculardysfunctionIIb/IIIainhibitorsandPTCAincardiogenicshock
% n= 300
ADMIRAL NEJM 2001 344: 1895-1903
0
4
8
12
16
CEP30days CEP6months
Withabciximab Withoutabciximab Columna1
P= 0.01
P= 0.02
• AlthoughpharmacologicalorinvasiverevascularizationhascausedasignificantdecreaseinthemortalityofAMIpatients,reperfusionisnotalwayseffectivetolimitmyocardialdamageandpreventventricularfunctionimpairment.
• Thisishowaventricularremodelingprocesscoulddevelop,bothintheinfarctedandnon-infarctedsegments,whichinturnprogressivelyworsenssystolicfunction,andsubsequentlytheprognosis.
• Thisprocessiscloselylinkedtoneurohormonalactivationofthesympatheticnervoussystemandtherenin-angiotensin-aldosteronesystem(RAAS),thushavingsignificanttherapeuticimplications.
POST-AMIHEARTFAILURE
POST-AMIHEARTFAILUREMortalityandACEI
StudyDrugFollow-upPlacebo(%)ACEI(%) P
SMILE Zofenopril 42days 6.5 4.9 NS 12mos14.1 10 0.01
SAVE Captopril 42mos2520 0.019
AIRE Ramipril 15mos2317 0.002
TRACE Trandolapril 26mos4235 0.001
ACEI: angiotensin converter enzyme inhibitors
POST-AMI HEART FAILUREMortality and ACEI
P< 0.0001
P< 0.0001
P< 0.0001
P= 0.0057
n= 5966%
Flather y col Lancet 2000: 1575- 1581
0
12,5
25
37,5
50
Mortality Re-hospduetoHF Re-AMI CEP
ACEI Placebo Columna1
• AlthoughACEIareeffectiveinpost-AMIHF,itwasobservedthataldosteroneofRAASisnotcompletelyinhibitedbytheseagents.
• Althoughthemechanismofthisaldosterone“escape”isnotclearlydefinedandtakingintoaccountthesignificantroleofitinpost-AMIHF,acompletehormoneblockadebeyondACEIisessentialtoachieveamoresustainedbenefit.
• Inthisregard,theVALIANTstudyevaluatedtheadditiveeffectsofvalsartan,anantagonistofangiotensinIIreceptors(ARAII)inpatientswithpost-AMIHF.
POST-AMI HEART FAILURE
• ThecombinationofACEIandARAIIdidnotyieldanadditionalclinicaladvantageintermsofmorbidityandmortality.Anyway,thisstudyshowednon-inferiorityofvalsartan,sointhosecasesinwhichACEIisnotwelltolerated(coughing),theycanbereplacedbythistypeofdrug.
• AthirdmodalitytoblockRAASisthroughaldosteroneblockadewithbeneficialeffectsastheRALESstudyshowedinchronicHF.
• Theseobservationshavepromotedtheevaluationofsuchstrategyinpatientswithpost-AMIHF.
POST-AMI HEART FAILURE
POST-AMIHEARTFAILURE Eplerenone
RR (%) p
Total mortality 15 0.008
CV mortality 17 0.005
CEP 13 0.002
Sudden cardiac death 21 <0.03
Hosp due to HF 15 0.03
POST-AMI HEART FAILURE Eplerenone
RR (%) p
Total mortality 31 0.004
CV mortality 32 0.003
Sudden cardiac death 37 0.051
EPHESUS JACC 2005; 46: 425- 431
Follow-up at 30 days
• Initiallyusedorally,inthepre-thrombolyticera,assecondarypreventionfortheirbenefitsonmortalityandre-infarctionincidence,betablockerswereconsideredcontraindicatedinpatientswithpost-AMIHF,withtheideathatablockadeofsympatheticactivitycouldbeharmful.
• ThesuccessofACEIasfirst-linetherapytoimprovetheprognosisofAMIandtheadventofreperfusiontherapieshavemadeofbetablockingbenefitssomethinguncertain.
POST-AMI HEART FAILURE Beta blockers
POST-AMI HEART FAILURE CAPRICORN study
RR (%) p
Total mortality 23 0.031
CV mortality 25 0.024
Non-fatal AMI 40 0.014
Atrial fibrillation 59 0.003
Malignant arrhythmias 76 0.0001
Lancet 2001; 357: 1385- 1390
CONCLUSIONS
• HeartfailureisaveryfrequentcomplicationafterAMIassociatedtosignificantmortalityandmorbidity.
• Themaindeterminantisthelossoffunctioningmyocardiumthatstartsupaseriesofcompensatingmechanismsthatparadoxicallymayinduceagreaterandprogressivedeteriorationofventricularfunction.
• Thus,atimelyreperfusiontakingintoaccounttimeandnotthewaytoimplementit(fibrinolyticagentsorPTCA),appearsasthecriticaldeterminantoftheevolutionofpatientsthatpresentthiscomplication.
• BothIRArecanalizationandtheachievementofanappropriatemyocardialperfusionarekeytorecoverventricularfunctionthroughlimitingthesizeoftheAMI.
• Inthisregard,greatadvancesinreperfusionstrategiesandtechnologyhaveallowedtoobtainanefficientepicardialreperfusion.
CONCLUSIONS (cont’d)
• However,greatresultshavenotbeenachievedyetatmicrovascularlevel,whichstillconstitutesalimitationatthemomentofreducingthesizeofinfarction.
• Theimplementationoftherapiesthatactontheneurohormonalsystemactivation(SNS,RAAS)tendingtoreduceventricularremodelinginthesepatientshasbeenremarkablybeneficialwithasignificantimpactonmortalityandmorbidityintheshortandlongterm.
CONCLUSIONS (cont’d)
• Thecurrenttrendsinpost-AMIHFincidenceandprognosisevaluatedinlargeregistriessuchasGRACE,reportareductionofthiscomplicationovertime(9%decreaseinSTEMIand6.5%inNSTEMIbytheendof2005).
• Likewise,theWHASstudyverifiedadecreaseofin-hospitalmortalitywhencomparingtermssince1975toyear2005.
CONCLUSIONS (cont’d)
• Takingintoaccountthatthesefindingswereobservedinspiteofaprogressivelyolderpopulation,aswellaswithincreasingco-morbidities(diabetes,hypertension,priorHF,etc),thesebettertrendsprobablyreflectimprovementsinreperfusiontechniques,moreeffectiveadjuncttherapies,andincreaseduseoftherapeuticresourcesinthelastfewdecades.
• However,mortalitybypost-AMIHFisstillhighandthesetherapiesarestillunderusedinmanyplaces,soweshouldfocusoureffortsinensuringthateachandeveryelegiblepatientsistreatedappropriatelyaccordingtotheevidencetooptimizetheevolutionofthisseverecomplicationofAMI.
CONCLUSIONS (cont’d)
