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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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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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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2
3
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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
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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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5
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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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