STEMI'de Trombüsle Mücadele - Ertuğrul Okuyan

ST YKSELMEL MYOKARD NFARKTSNDE KORONER TROMBSLE MCADELE

Do.Dr.Erturul Okuyan

28 yanda, Bayan Hasta

Akut nferior MI tansyla ve 4 saatlik ar yaknmasyla bavurdu

Youn sigara iicisi Hiperlipidemisi mevcut Aile yks poziHf

PPKG srasnda distal embolizasyon %15 orannda gzlenebilmektedir ve ileme bal komplikasyonlarn sk bir nedenidir.

Distal embolizasyon oluanlarda 5 yllk mortalite %44 iken olumayanlarda %9dur

Distal embolizasyondan birincil olarak sorumlu trombs

younluudur

Burzotta F et al. Eur Heart J 2009;30:2193-2203

DSTAL EMBOL

Mekanik olarak mikrovaskler yata Ikayarak miyokardn devam eden iskemik nekrozuna yol aar.

Lokal olarak in-situ platelet adhezyonunu ve trombosisi uyararak doku perfzyonunun bozulmasna ve no-reow fenomenine yol aabilir.

Mikrovaskler spazm ve lokal enamatuar sreci uyararak daha fazla miyokard nekrozuna sebep olabilir

Mikrovaskler obstrksiyon

SubopHmal reperfzyon Artm enfarkt alan Azalm ventrikl fonksiyonu 5-yllk mortalitede 5 kat arI

Akut reperfzyon parametreleri

Thrombolysis in myocardial infarcHon(TIMI) ow

Myocardial Blush Grade(MBG) lem sonras EKG de ST segment rezolsyonu

LER TETKKLER -Myocardial contrast echo -Cardiovascular MRI(Gadolinium)

STENT TROMBOZU

Angiographic Stent Thrombosis A[er RouHne Use of Drug-EluHng Stents in ST-Segment ElevaHon Myocardial InfarcHon: The Importance of Thrombus Burden

Georgios Sianos, MD, PhD, , Michail I. Papafaklis, MD, Joost Daemen, MD, Soa Vaina, MD, Carlos A. van Mieghem, MD, Ron T. van Domburg, PhD, Lampros K. Michalis, MD, MRCP, Patrick W. Serruys, MD, PhD, FACC

Show more doi:10.1016/j.jacc.2007.04.059 Journal of the American College of Cardiology

Fazla trombs yk olan damarlarda primer PCI sonras stent trombozu oranlar anlaml olarak artmaktadr( 8.2% vs 1.3% p

TIMI TROMBS SINIFLAMASI

TIMI TROMBS 0

TROMBS YOK

TIMI TROMBS 1

TROMBS OLMA HTMAL VAR

TIMI TROMBS 2

TROMBS VAR EN BYK UZUNLUU DAMAR APININ 1/2 FAKAT 2

TIMI TROMBS 5

TOTAL TIKALI

Glimm et al. Circulation 2001;21:2550

Primer PCIda Koroner trombsn distal embolizasyonunu nleme

stratejileri 1-Trombs rezolsyonu iin Farmakolojik yaklamlar

2-AdjuncHve mekanik cihazlar(Trombs aspiarasyonu ve Embolik proteksiyon cihazlar)

Abciximab Eftifibatide Tirofiban

Reseptr affinitesi Hzl affinite Yava ayrlm Yarmasz inhibisyon

Yava affinite Hzl ayrlm Yarmal inhibisyon

Yava affinite Hzl ayrlm Yarmal inhibisyon

Etkinliin balangc 10-26 dakika 90-150 dakika 90-150 dakika

Vcttan atlm 12-24 saat 2-4 saat 2-4 saat

Atlm yolu Plasma proteazlar

Bbrek Bbrek(%30-60) Karacier (%40-70)

Dier -3 integrin (vitronectin), MAC-1 reseptr inhibisyonu

Gp2b/3a RESEPTR ANTAGONSTLER

Study GPI PopulaXon Access Site IC IV ICE, 2010 E[ibaHde ACS

(26%STEMI) Femoral IC bolus/18-h IV inf. IV bolus/18-h IV inf.

CICERO, 2010 Abciximab STEMI - IC bolus a[er thrombectomy

IV bolus a[er thrombectomy

Iverson et al ,2011 Abciximab STEMI - IC bolus/12-h IV inf. IV bolus/12-h IV inf.

Dominguez et al, 2009

Abciximab

STEMI Femoral

IC bolus a[er thrombectomy/12-h IV inf.

IV bolus a[er thrombectomy/12-h IV inf.

Wu et al, 2008 Tiroban ACS (63%STEMI)

- IC bolus/36-h IV inf. IV bolus/36-h IV inf.

Thiele et al, 2008 Abciximab STEMI - IC bolus /12-h IV inf. IV bolus/12-h IV inf.

Yang et al, 2007 Tiroban STEMI - IC bolus/36-h IV inf. IV bolus/36-h IV inf.

Bellandi et al, 2004 Abciximab

STEMI

Femoral

IC bolus/12-h IV inf. IV bolus/12-h IV inf.

LIPSIA-STEMI 2010 Abciximab

STEMI

- IC bolus/12-h IV inf IV bolus/12-h IV inf

EASY-MI, 2010 Abciximab STEMI Transradial IC bolus/12-h IV inf IV bolus/12-h IV inf

Galache Osuna et al,2006

Abciximab ACS (41%STEMI)

Radial or femoral IC bolus/12-h IV inf IV bolus/12-h IV inf

RANDOMIZED STUDIES 1590 paXents

Friedland S et al. Am J Cardiol 2011;108:1244-1251

What is The Reason to Prefer Local Coronary Infusion of IIb/IIIa

Inhibitors ??

Her bir trombosit yzeyinde 60 000 to 80 000 GP IIb/IIIa receptr bulunmaktadr. Tedavi, bu reseptrlerin en az %80ini bloke etmeyi amalamaktadr.

IC GP IIbIIIa receptor inhibitor uygulanmas ile daha fazla lokal konsantrasyon salanmakta ve platelet GP IIb/IIIa receptor occupancy artmaktadr.

Ayrca yksek lokal konsantrasyonlar, trombs disagregasyonu salayabilmektedir.

Abciximab, yksek lokal konsantrasyonlarda potent anH-enamatuar etki gsterir. Bu etki i.v. Uygulamada gsterilememiHr.

IC uygulama ile , post-PCI i.v. Uygulama gereksinimi ortadan kalkabilir ve bylece sistemik ila konsantrasyonlar minimize edilerek kanama olaylar azalabilir.

Abciximab bolus uygulamas, total dozun 75% ine karlk gelir.. Pharmacological data , single bolus (0.25 mg/kg) abciximab ile >80% of platelet aggregaHon inhibisyonu salanabildii ve bu etkinin saatlerce srdn gstermiHr.

Domiguez A et al. Atherosclerosis 2009;206:523-27

ICE CICERO Iversen Dominquez-Rodriquez Wu Thiele Yang EASY-AMI Overall (I-squared=20.1%,p=0.270)

1.07 (0.89-1.28) 1.03 (0.97-1.10) 1.10(0.96-1.24) 1.29 (0.96-1.76) 1.22 (1.01-1.48) 0.98(0.86-1.12) 1.27(0.98-1.64) 1.15 (0.96-1.37) 1.08 (1.02-1.15)

8.66 34.90 17.43 3.27 7.96 14.25 4.60 8.92 100.0

IC better IV better

Study RR (95% CI)

% Weight

0 0.5 1 1.5 2

GPIIb/IIIa IC versus IV TIMI 3 FLOW AFTER PCI


CICERO Iversen Wu Thiele Overall (I-squared=0.0%,p=0.552)

0.87 (0.36-2.12) 0.40(0.17-0.95) 0.33 (0.01-7.86) 0.20(0.01-4.10) 0.54 (0.30-0.96)

32.91 54.08 4.91 8.11 100.0

IC better IV better

Study RR (95% CI)

% Weight

0 0.5 1 1.5 2

GPIIb/IIIa IC versus IV SHORT-TERM TVR


CICERO Iversen Wu Thiele Yang Bellandi Overall( I-squared=0.0%,p=0.777)

0.69 (0.22-2.16) 0.20 (0.04-0.93) 0.49(0.05-5.27) 0.67(0.11-3.98) 0.19 (0.01-3.71) 1.05(0.07-15.70) 0.45 (0.23-0.90)

28.34 37.42 8.05 11.97 10.33 3.90 100.0

IC better IV better

Study RR (95% CI)

% Weight

0 0.5 1 1.5 2

GPIIb/IIIa IC versus IV 30 DAY MORTALITY


CICERO Iversen Dominguez-Rodriquez Wu Thiele Yang Overall( I-squared=0.0%,p=0.562)

1.11 (0.68-1.81) 0.69 (0.41-1.17) 0.67(0.12-3.65) 0.76(0.31-1.91) 0.80(0.22-2.87) 2.17(0.63-7.51) 0.92(0.68-0.1.24)

35.69 38.01 3.91 11.82 6.51 4.05 100.0

IC better IV better

Study RR (95% CI)

% Weight

0 0.5 1 1.5 2

GPIIb/IIIa IC versus IV SHORT-TERM BLEDNG EVENTS


Intracoronary Versus Intravenous Administration of Abciximab in Patients With ST-Segment Elevation

Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention With Thrombus

Aspiration

The Comparison of Intracoronary Versus Intravenous Abciximab Administration During Emergency Reperfusion of ST- Segment

Elevation Myocardial Infarction (CICERO) trial

ENZYMATIC INFARCT SIZE

Intracoronary (n=126)

Intravenous (n=122)

p

Peak CK, U/L 1214 1746 0.008

Peak CK-MB, U/L 154 232 0.003

Peak cTnT, g/L 3.03 4.36 0.008

Gu Y L et al. Circulation 2010;122:2709-2717

30 % Smaller in the IC group

Clinical Outcome at 30 Days

Intracoronary (n=271), n(%)

Intravenous (n=263)

p

Mortality 5 (1.8) 7 (2.7) 0.524

Cardiac mortality 4 (1.5) 6 (2.3) 0.492

TVR 9 (3.3) 10 (3.8) 0.764

ReinfarcXon 3 (1.1) 4 (1.5) 0.721

In-stent thrombosis 1 (0.4) 3 (1.1) 0.366

MACEs 15 (5.5) 16 (6.1) 0.786

Gu Y L et al. Circulation 2010;122:2709-2717

Intracoronary Compared with Intravenous Bolus Abciximab Application

During Primary Percutaneous Coronary Intervention

The Abciximab Intracoronary versus intravenously Drug

Application in ST-Elevation Myocardial Infarction (AIDA STEMI) trial

Holger Thiele, MD; Jochen Whrle, MD; Rainer Hambrecht, MD; Harald Rittger, MD; Ralf Birkemeyer, MD;

Bernward Lauer, MD; Petra Neuhaus, PhD; Oana Brosteanu, PhD; Peter Sick, MD; Marcus Wiemer, MD; Sebastian Kerber, MD; Ingo Eitel, MD; Klaus Kleinertz, MD; Gerhard Schuler, MD

on behalf of the AIDA STEMI Investigators

ST-Segment-Resolution

Early ST-Segment Resolution (%)

IV A

bciximab

IC A

bciximab

Freq

uenc

y

p=0.37

Conclusions

This randomized, multi-center, large-scale trial involving more than 2000 STEMI patients undergoing primary PCI showed that IC abciximab bolus administration is safe.

The IC bolus administration of abciximab does not add a benefit in comparison to the standard IV bolus with respect to the combined primary study endpoint consisting of death, reinfarction, or new congestive heart failure within 90 days.

The IC route might be related to reduced rates of new congestive heart failure.

IC bolus doses of GPIIb/IIIa inhibitors

Bolus Dose Infusion dose

Abciximab 0.25mg/kg 0.125g/kg/min

E[ibaHde 180 g/kg 2g/kg/min

Tiroban 10 g/kg 0.15g/kg/min


Guiding catheters without side holes must be prefer to administer i.c. GPIIb/IIIa inhibitors

MORE BENEFIT FROM IC GpIIb/IIIa

High thrombus burden; aspiraHon thrombectomy (-)

Symptom duraHon is long (>4 hour)

High risk paHents (type B2/C lesions, dissecHon,no-reow)

TROMBEKTOM LE BRLKTE YAPILIRSA ?

ATTEMPT VER TABANI

Burzotta F et al. Eur Heart J 2009;30:2193-2203

INFUSE AMI TRIAL

INFUSE AMI TRIAL: Intracoronary bolus dose of abciximab delivered with a dedicated infusion catheter (Clear-Way) versus no bolus with or without thrombus aspiraHon in paHents treated with bivalirudin

INFUSE-AMI is tesHng the hypothesis that the intracoronary administraHon of an abciximab bolus with or without thrombus aspiraHon before stent implantaHon compared to no infusion with or without thrombus aspiraHon reduces infarct size among paHents undergoing primary PCI for anterior STEMI who are treated with bivalirudin.

Date of download: 12/8/2014 Copyright 2014 American Medical Association. All rights reserved.

From: Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction: The INFUSE-AMI Randomized TrialJAMA. 2012;307(17):1817-1826. doi:10.1001/jama.2012.421

More than 1 reason for study exclusion were present in some patients who were not eligible for randomization. Cardiac magnetic resonance imaging (cMRI) at 30 days was not performed in 70 enrolled patients for the following reasons: patient refusal or withdrawn consent for cMRI (n=27); patient inability to complete the cMRI (most commonly for claustrophobia) (n=15); death before the 30-day cMRI (n=13); too ill (n=4); patient forgot (n=4); contrast contraindication (n=2); other (n=5). In addition, despite being performed, the cMRI study was not evaluable for the primary end point of infarct size in 29 patients because of technical issues in image acquisition, including incorrect image sequencing, inadequate inversion recovery time, excessive breathing artifact, and missing slices. CABG denotes coronary artery bypass graft; GPI, glycoprotein IIb/IIIa inhibitor; IC, intracoronary; LAD, left anterior descending coronary artery; PCI, percutaneous coronary intervention; and TIMI, Thrombolysis in Myocardial Infarction.

Figure Legend:

INFUSE AMI -SONU

In paHents with large anterior STEMI presenHng early a[er symptom onset and undergoing primary PCI with bivalirudin anHcoagulaHon, infarct size at 30 days was signicantly reduced by bolus intracoronary abciximab delivered to the infarct lesion site but not by manual aspiraHon thrombectomy.

In patients undergoing primary PCI treated with UFH, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-

bolus eptifibatide, or high-bolus dose tirofiban), whether or not patients were pretreated with clopidogrel. (For GP IIb/IIIa inhibitor administration in patients not pretreated with clopidogrel, Level of Evidence: A; for GP IIb/IIIa inhibitor administration in patients pretreated with clopidogrel, Level of Evidence: C)

STEMI IV Antiplatelet Therapy: Recommendations

I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III


In patients undergoing primary PCI with abciximab, it may be reasonable to administer intracoronary abciximab.(Level of Evidence: B)

These agents might provide more benefit in selective use, such as in patients with large anterior MI and/or large thrombus burden (TIMI thrombus grade >3)

Levine et al. J Am Coll Cardiol 2011;58:917-24

Primer PKG'de adjuvant mekanik yntemler (Manuel - Mekanik Aspirasyon, Distal-

Proksimal Proteksiyon): Kime, nasl?

Primer PKG'de adjuvant mekanik yntemler ne salyor??

Trombs younluunu azaltarak; -Distal embolizasyonu azaltyor, -Direkt stentlemeyi salyor, - Vazokonstriksyonu azaltyor, -Damar apnn daha iyi belirlenmesini salayp

malappozisyon gelimesini engelliyor, -Gerek aterosklerotik darln gzkmesini salayarak

bu darln medikal tedavi ile stabilize olup olamayacan gsterebiliyor

De Luca G et al. Int J of Cardiol BASKIDA

PPKG SIRASINDA KULLANILAN ADJUVANT MEKANK YNTEMLER

Manuel Aspirasyon Mekanik Aspirasyon Distal-Proksimal Proteksiyon

Distal embolizasyon zaman

Napadono ,2005

ASPRASYON CHAZLARI MANUEL MEKANK

EXPORT ANGIOJET

DIVER CE X-SIZER

PRONTO THROMCAT

QUICKCAT RINSPIRATOR

THROMBUSTER

RESCUE

TVAC

PROTEKSYON CHAZLARI DSTAL

FLTRE BALON TIKAYICI

Angioguard Guardwire

Filterwire TriActive Cardioshield (Emboshield)

Theron

Spider RX MoMa

Interceptor Arteria

PROKSMAL PROKSS

KERBEROS RINSPIRATOR

PARODI

De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE REMEDIA VAMPIRE TAPAS TOPLAM(%95 CI)

0.19(0.01-4.08) 0.33 (0.01-8.11) 0.35(0.01-8.93) 0.64 (0.15-2.72) 0.94 (0.18-4.77) 1.00(0.19-5.22) 0.97(0.06-15.66) 0.52(0.25-1.08) 0.58 (0.34-0.98)

6.59 4.01 3.78 12.55 8.02 7.51 2.69 54.82 100.0

Manual trombektomi iyi

alma RR (95% CI)

%

0.1 0.5 1 2 5 10

De Luca G et al. Eur Heart J 2008;29:3002-3010

P=0.04

Kontrol iyi

MANUEL ASPRASYON-30 GN LM

DEAR MI De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE VAMPIRE TAPAS TOPLAM(%95 CI)

2.28(0.91-5.71) 1.73 (0.61-4.88) 2.03(1.00-4.11) 5.49(0.59-50.79) 1.93 (0.70-5.32) 1.42(0.73-3.60) 1.70(0.94-3.05) 1.29(0.92-1.82) 1.59 (1.26-2.00)

5.49 4.79 9.60 0.73 4.95 8.33 15.20 50.91 100.0


alma RR (95% CI)

%

0.1 0.5 1 2 5 10


P

DEAR MI De Luca ve ark. EXPIRE EXPORT EXPORT ALIMASI PIHRATE VAMPIRE TAPAS TOPLAM(%95 CI)

9.48(4.11-21.85) 3.85 (1.22-12.14) 5.91(3.08-11.35) 2.27(0.73-7.07) 1.63 (0.92-2.90) 2.33(1.21-4.48) 3.32(2.07-5.33) 1.77(1.36-2.29) 2.44(2.04-2.92)

2.54 2.06 4.84 2.58 11.86 7.68 12.55 55.99 100.0


alma RR (95% CI)

%

0.1 0.5 1 2 5 10


P

Trombektomi ve Emboli Koruma Cihazlarnn AM deki Rol: Randomize almalarn Metaanalizi Bavry et al. Eur Heart J 2008

30 randomize alma: n=6415 13 manuel aspirasyon %47 5 mekanik aspirasyon %38 12 emboli koruma cihaz %15

%

Manuel Aspirasyon

6

3

0

Adjuvant cihaz Sadece PKG P=0.05

P=0.018

Proteksiyon cihaz

2.7

ST YKSELMEL M 30 ALIMA 6 AY MORTALTE

4.4

Mekanik Aspirasyon

2.8 5.3

3.1 3.4

P=0.69

Bavry A A et al. Eur Heart J 2008;29:2989-3001

11 alma ,n=2686, izlem median 1 yl, PSN total mortalite

PKG yaplan STEMI hastalarnda trombektomi (zellikle manuel trombektomi) klinik sonular olumlu etkiler, GpIIbIIIa inh ek yarar salayabilir.

STEMI de Trombektominin Klinik Etkisi :ATTEMPT

Metaanaliz: de Luca et al.

30 gnlk Mortalite

Manuel aspirasyon cihazlar ile mortalitede bir azalma,

Mekanik aspirasyon cihazlar ile mortalitede bir art saptanrken,

Emboli proteksiyon cihazlar ile mortalitede bir fark saptanmamtr

SONU PPKG'de adjuvant mekanik yntemler

Trombektominin PPKG sonularna etkisi: Metaanaliz Mongeon FP, CirculaHon Cardiovascular IntervenHons 2010 21 alma, 4299 hasta (16 alma 3365 hasta manuel trombektomi)

Sonu: Trombektomi reperfzyonu olumlu etkiliyor ama 1 aylk klinik sonulara etkisiz

Thrombus Aspiration during Primary Percutaneous Coronary Intervention

TAPAS Trial

Tone Svilaas, M.D., Pieter J. Vlaar, M.Sc., Iwan C. van der Horst, M.D., Ph.D., Gilles F.H. Diercks, M.D., Ph.D., Bart J.G.L. de Smet, M.D., Ph.D., Ad F.M. van den Heuvel, M.D., Ph.D., Rutger L. Anthonio, M.D., Ph.D., Gillian A. Jessurun, M.D., Ph.D., Eng-Shiong Tan, M.D., Albert J.H. Suurmeijer, M.D., Ph.D., and Felix Zijlstra, M.D., Ph.D.

N Engl J Med 358(6):557-567 February 7, 2008

TAPAS TRIAL

Manuel Aspirasyon N=1071, tek merkez, randomize,6F Export Aspirasyon+ direkt stent vs stent MBG 0-1 %17,1 vs %26.3 ,P

STEMI de trombs aspirasyonu bazal klinik ve anjiyograk zelliklerden bamsz olarak konvansiyonel PKG ye gre daha iyi reperfzyon ve klinik sonu salar.

One year follow up

All cause mortality: 38% reduction

Cardiac death: 46% reduction

Cardiac death/MI: 43% reduction Vlaar et al. Lancet 2008;371:1915-20..

PIHRATE: PPKG de Trombs Aspirasyonu +Direkt Stent

Dudek et al. Am Heart J 2010;160:966-72

EXPIRA

Erken sonu:

2 yllk sonular:

Sardella G. American Heart AssociaXon 2009 ScienXc Sessions; November 14, 2009; Orlando, FL.

Hangi hastada yararl? Kime yapalm? Erken gelen vs ge gelen?

Thrombus AspiraXon in ST- ElevaXon myocardial infarcXon

in Scandinavia (TASTE trial)

Ole Frbert, MD, PhD - on behalf of the TASTE invesHgators Departement of Cardiology rebro University Hospital

Sweden

Main results at 30 days

TASTE ALIMASI

TASTE (Thrombus aspiraHon during ST-segment elevaHon myocardial infarcHon) almas, STEMIde trombs aspirasyonu ile ilgili en nemli almadr .

TASTE almasna 7244 hasta alnm, 3621i trombs aspirasyonu koluna, 3623 kontrol grubuna randomize edilmiHr.

TASTE and previous studies

0 1000 2000 3000 4000 5000 6000 7000 8000

Liistro

DEAR-MI

EXPIRA

PIHRATE

X AMINE ST

MUSTELA

Kalto[

Chevalier

PREPARE

VAMPIRE

INFUSE-AMI

AIMI

JETSTENT

TAPAS

TASTE

Number of paXents

TASTE

TASTE -30. GN SONULAR

30. gn sonunda lm oranlar asndan 2 grup arasnda fark yok.

All-cause mortality at 30 days

HR 0.94 (0.72 - 1.22), P=0.63

Per protocol analysis based on

actual treatment:

HR 0.88 (0.66 - 1.17), P=0.38

ReinfarcXon at 30 days

HR 0.61 (0.34 - 1.07), P=0.09

Per protocol analysis based on

actual treatment:

HR 0.67 (0.36 - 1.20), P=0.19

TASTE-1.YIL SONULARI

Lagerqvist B1, Frbert O, Olivecrona GK, Gudnason T, Maeng M, Alstrm P, Andersson J, Calais F, Carlsson J, Collste O, Gtberg M, Hrdhammar P, Ioanes D, Kallryd A, Linder R, Lundin A, Odenstedt J, Omerovic E, Puskar V, Tdt T, Zelleroth E, stlund O, James SK. Outcomes 1 year a[er thrombus aspiraHon for myocardial infarcHon. N Engl J Med. 2014 Sep 18;371(12):1111-20. doi: 10.1056/NEJMoa1405707.

TASTE- 1. YIL

Bir yllk takipte primer sonlanm olan tm nedenli lmler aspirasyon yaplanlarda %5.3, yaplmayanlarda %5.6 olarak bulunuyor (p=0.57). Miyokart infarktsyle tekrar hastaneye yaI ve stent trombozu da iki grupta benzer kyor.

Mekanik Trombektomi

AIMI (Ali A et al ,JACC 2006;48:244-252) ReoliHk trombektomi+PKG vs PKG nfarkt alan (12.5 vs 9.8, p0.03) ve mortalite (%4.6 vs 0.8, p

0.02) daha yksek JETSTENT (Migliorini et al, JACC 2010; 56:1298-1306) Stent ncesi RT vs stent

6 ay MACE dk %11.2 vs %19.4, p 0.011 1 yl olaysz sakalm yksek%85 vs %75, p 0.009

Comparison Of Manual AspiraXon With RheolyXc Thrombectomy In Acute Myocardial InfarcXon: The Final 6-

Month Results Of The SMART Primary PCI Trial

Comparison Of Manual AspiraHon With RheolyHc Thrombectomy In Acute Myocardial InfarcHon: The Final 6-Month Results Of The SMART Primary PCI Trial

Guido Parod, Renato ValenH, Angela Migliorini1, Nazario Carrabba1,Akiko Maehara, Ruben Vergara,Benedea Bellandi1, Gary Mintz3, David Antoniucci,

MAT or RT allow only incomplete removal of thrombus in the seng of AMI. RT as compared to MAT is more eecHve in thrombus removal and is associated with a beer myocardial reperfusion.

lemden nce lem Srasnda

TIMI trombs snflamas (0-5) Hava Embolisi -Aspirasyon kateteri kartlrken hava klavuz kateterde haps olabilir

Damar Anatomisi -Tortyoz -Kalsifikasyon -Kk damar

Drag and drop effect

Aspirasyon kateteri klavuz kateterden kana kadar negatif basnta kartlmaldr

Klavuz kateter ile aspirasyon kateteri co-axial olmaldr. Olmaz ise klavuz kateterin ucunda taklarak trombsn dmesine sebep olabilir

Aspirasyon kateteri kartldktan sonra klavuz kateter mutlaka aspire edilmelidir

%10 ASPRASYON BAARISIZ

Belirgin proksimal tortyozite (> 2 kvrm) Kalsifik lezyon Bifrkasyon lezyonu Cx arter

Vink MA et al. J Am Coll Cardiol Intv 2011;4:634-642

PRMER PKG TROMBOASPRASYON

Klavuz tel ile sorumlu lezyon geildikten sonra AKIM TIMI 0-1 TIMI 2-3 IC TROFBAN TROMBOASPRASYON/ANJYOJET TROMBUS YOUNLUU

AZ OK (TIMI TROMBUS

STYM-Primer PKG 2009

Primer PKG srasnda aspirasyon trombektomi yaplmas nerilir


Primer PKG srasnda aspirasyon trombektomi yaplmas nerilir

STYM-Primer PKG 2011


ESC/EACT 2010 Klavuzu IIA (A)

EXPRA TAPAS Metaanaliz Bavry et al Metaanaliz de Luca et al Meta analiz Bavry et al Burzoa F TAPAS

PPKG Manuel trombektomi

IIa

PPKG manuel trombektomi IIa

YEN ORAL ANT-TROMBOST AJANLAR

Neden yeni anXtrombositer ila?????

.Klopidogrelin akHf metaboliHne dnmesinin yava olmas, geri dnsz balanmas ve etkisinin hastalar arasnda deikenlik gstermesi(geneHk polimorzm) gibi snrllklar var .Klopidogrelle ilikili olarak iskemik olay sklnn ykseldiine iaret eden kantlar artmaktadr.

Hasta Poplasyonu

123 hasta 18 yanda

Ran

dom

izas

yon 180 mg ykleme dozu ile

600 mg ykleme dozu ile

Plasebo (n=11)* * Tm hastalara ASA verildi.

Ykleme dozu Son doz

Tedaviye Devam (6 hafta)

Balang (1. gn)

Sonlanm (10. gn)

ONSET almas

1. Gurbel PA, et al. Circulation 2009;120:2577-85.

Tikagrelor 90 mg, 6 hafta sreyle gnde iki kez (n=52)*

Klopidogrel 75 mg, 6 hafta sreyle gnde bir kez (n=51)* Belgelenmi stabil KAH Devam eden ASA tedavisi

(75-100 mg/gn)

Faz II, ok merkezli, randomize, ift kr, paralel gruplu alma1

Conclusions First study to comprehensively characterize onset and offset of the antiplatelet effect of ticagrelor compared with clopidogrel in stable CAD patients.

3 Major Findings: - Ticagrelor onset is very rapid and markedly greater than high loading dose clopidogrel - Greater inhibitory eect of Hcagrelor is sustained during maintenance - Ticagrelor oset as determined by IPA slope was signicantly faster than clopidogrel

These eects may explain the lower occurrence of the primary endpoint with Hcagrelor therapy as compared to clopidogrel therapy in PLATO whereas numerically less CABG-related bleeding occurred in the Hcagrelor group despite greater platelet inhibiHon.

Tikagrelor 180 mg ykleme dozu

(n=54)

Klopidogrel 600 mg ykleme dozu

(n=50)

1. Gurbel PA, et al. CirculaHon 2009;120:2577-85.

Tikagrelor 30 dakikada %41lik IPA deerine ulamtr.1

Ykleme Dozu Sonras 30. Dakika IPA Oranlar1

%41 IPA

%8 IPA

Tikagrelor 180 mg ykleme dozu

(n=54)

Klopidogrel 600 mg ykleme dozu

(n=50)

1. Gurbel PA, et al. CirculaHon 2009;120:2577-85.

Tikagrelor 2. saatte %88lik IPA deerine ulayor.1

Ykleme Dozu Sonras 2. Saat IPA Oranlar1

%88 IPA

%38 IPA

PLATO almas Tasarm1,2

Primer etkililik sonlanm: Kardiyovaskler lm, M ve inme bileimi

Primer gvenlilik sonlanm: Toplam PLATO majr kanama

N=18,624 AKSli hastalar (UA, NSTEM ya da STEM)

1. James S, et al. Am Heart J 2009;157:599-605. 2. Wallentin L, et al. N Engl J Med 2009;361:1045-57.

Tikagrelor (n=9,333) 180-mg ykleme dozu 90 mg 2x1 + ASA idame dozu

Klopidogrel (n=9,291) 300-mg ykleme dozu 75 mg 1x1 + ASA idame dozu

PLATO almas: zet

PLATO, tikagrelor ile gnmzdeki standart tedavide kullanlan klopidogreli karlatran bir klinik almayd.1,2

Toplam 18,624 AKSli hasta, hastaneye bavurmalarndan ksa bir sre sonra - semptomlarn balamasndan sonraki 24 saat iinde ve genellikle anjiyografi yaplmadan nce - randomize edildi.1,2

PLATO almas klinik uygulamay yanstacak biimde tasarland.1-3 Daha nce klopidogrel kullanlm olan hastalar da almaya alnd. almaya hem invazif tedavi (%72) hem de medikal tedavi (%28) gruplar

dahil edildi.

PKG ncesi 600 mga dek ykleme dozu uygulanabildi. AKSli geni bir hasta grubu alnd (UA, NSTEM ya da STEM).1,2

1. James S, et al. Am Heart J 2009;157:599-605. 2. Wallentin L, et al. N Engl J Med 2009;361:1045-57. 3. 3. Cannon CP, et al. Lancet 2010;375:283-93.

zet

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1. Ayda Bileik Sonlanm Riski

Her iki grupta da ASA kullanld. ARR: Mutlak risk azalmas, RRR: Rlatif risk azalmas

Tikagrelor, 1. aydaki KV lm, M ve inme bileik sonlanmn klopidogrele gre anlaml oranda azaltmtr.1

%5.4 %4.8

1. Wallentin L, et al. N Engl J Med 2009;361:1045-57.

%0.6 ARR

%12 RRR

Tikagrelor (n=9333)

Klopidogrel (n=9291) HR %95 GA P deeri 0.88 0.77-1.00 0.045

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1. Ylda Primer Bileik Sonlanm Noktas

Her iki grupta da ASA kullanld. nme asndan tedavi gruplar arasnda fark yoktur. ARR: Mutlak risk azalmas, RRR: Rlatif risk azalmas; NNT: Tedavi edilmesi gereken hasta says

Tikagrelor ile klopidogrele gre erken dnemde salanan mutlak risk azalmas 1 yllk tedavi sresince devam etmi.1

%11.7

%9.8

1. Wallentin L, et al. N Engl J Med 2009;361:1045-57.

%1.9 ARR

%16 RRR

Tikagrelor (n=9333)

Klopidogrel (n=9291) HR %95 GA P deeri 0.84 0.77-0.92

Tikagrelor, dk doz ASA alanlarda 1. yldaki KV lm klopidogrele gre %29 azaltmtr.1,2

Dk Doz ASA* Alanlarda 1. Ylda KV lm Riski1

Tikagrelor (n=8025)

Klopidogrel (n=8034)

HR %95 GA P deeri 0.71 0.60-0.84

Olay Tikagrelor,%

(n=3752) Klopidogrel, %

(n=3792) p deeri

KV lm, MI ve inme 9.4 10.8 0.07

Total lm, MI ve inme 9.8 11.3 0.05

KV lm, MI, inme, iskemi, TIA, arteriyal thromboz

13.3 15.0 0.03

MI 4.7 5.8 0.03

KV lm 4.5 5.5 0.07

Inme 1.7 1.0 0.02

Tm nedenlere bal lm 5.0 6.1 0.05

PLATO STE-ACS: Primer ve sekonder sonlanm

noktalar [

Klopidogrel iyi Tikagrelor iyi

1.0 2.0 0.5

HR (95% CI)

ACS, akut koroner sendrom; CI, gven aral ; CV, kardiyovaskler; HR, hazard raHo; MI, miyokart enfarkts; STE, ST-segment ykselmesi; TIA, geici iskemik atak. Steg PG, et al. CirculaCon 2010;122:21312141.

STE-ACS hastalarnda Ticagrelora bal primer sonlanm noktasnda azalma PLATO genel sonular ile uyumludur

92

PLATO STE-ACS: Primer Birleik sonlanm noktas1

1. Steg PG et al. CirculaHon 2010;122:21312141; 2. WallenHn L et al. N Engl J Med 2009;361:10451057

10.8%

9.4%

STE-ACS BRILINTA (n=3752) Klopidogrel (n=3792)

Randomizasyon sonras aylar

KV

lm

, MI v

eya n

me

(%)

12

10

8

6

4

2

0 0 2 4 6 8 10 12

HR (95% CI) = 0.87 (0.751.01) P=0.07

PLATO almas genel primer sonlanm noktas: HR: 0.84; 95% CI: 0.770.92; P

TRITON-TIMI 38: Hasta alm emas

UA/NSTEMI semptom balangc sonras

72 saat ve TRS 3

STEMI semptom balangcndan 12 saat - 14 gn sonra (Post-

STEMI)

STEMI semptom balangc sonras

12saat

(Primer PKG)

DiyagnosXk Kateterizasyon

Randomizasyon

alma lac Ykleme Dozu

Gnlk dame Tedavisi & Uzun Dnem Takip

* Elik eden tedavi ve cihaz seimi hekim insiyatifinde

Medikal tedavi veya CABG plan

PKG plan

PKG*

Wiviott SD et al. Am Heart J 2006;152:627-635

Randomize etme

TRITON-TIMI 38 almas 12.ay verilerine gre: Majr kanama oranlar klopidogrelden farkszdr

Tm Kohort 10 mg Endike Kohort Grubu

Wilcox R et al. Current Medical Research & Opinion 2014; 1-13

TRITON-TIMI 38:

Primer sonlanm noktasnda %19 azalma

Prasugrel

Klopidogrel

5

10

15

0 0 30 60 90 180 270 360 450

Randomizasyon sonra geen sre (gn)

Sonlan

m nok

tas (%

)

120

1.8 (111) 2.4 (146)

Non-CABG TIMI majr kanamalar

KV lm, MI, nme

p=0.03

p

TRITON-TIMI 38 prasugrel Ykleme Dozu

Wiviott SD et al. Am Heart J 2006;152:627-635

Prasugrel ykleme dozu: Mmkn olduunca erken veya PKG srasnda

AHA/ACC STEMI Klavuzu, 2013

TRITON-TIMI 38

STEMI Kohort (N = 3534)

Prasugrel STEMI hastalarnda 30.gnde KV lm ve tm nedenli lmleri anlaml olarak azaltmr.

Montalescot G. et al. Lancet 2009; 373: 723-31

Hasta (%

)

TRIPLET almas: 60 mg prasugrel ykleme dozu AKS-PKG hastalarnda klopidogrel 600 mg + prasugrel 60 mg ykleme dozu ile

benzer trombosit inhibisyonu salamr

DiodaX, et al. Circ Cardiovasc Interv 2013;6:567-74.

SWAP almas: Klopidogrel idame tedavisinden prasugrele hem yklemeli hem

yklemesiz gei, anXagregan etkinlii arrr.

LD=Ykleme Dozu; MD=dame Dozu; PRU=P2Y12 ReakHvite nitesi *p

The DAPT Study was designed in response to a request from the FDA to evaluate the eect of dual anXplatelet therapy beyond one year in subjects

treated with coronary stents.

DAPT-CONCLUSIONS

Following drug-eluHng stent treatment, conHnuaHon of thienopyridine plus aspirin beyond one year reduces the risk of stent thrombosis and MACCE compared with aspirin alone. RelaHve reducHons of 71% for ST, 29% for MACCE and 53% for M Myocardial infarcHon reduced both in the stent and in other locaHons Treatment benet on ST and MI consistent across drugs, for newer

and older stents, and across subjects with higher or lower risk of events

The benet of extended thienopyridine treatment was tempered by an increase in bleeding events (relaHve increase, 61%). Severe and/or fatal bleeding was uncommon.

ESC Miyokardiyal Revasklarizasyon Klavuzu

2014 AHA/ACC NSTE-ACS Klavuzu

1. 10. 2013 ACCF/AHA Guideline for the Management of ST-ElevaHon Myocardial InfarcHon. CirculaHon 2013;127:00-00. DOI: 10.1161/CIR.0b013e3182742c84

Tikagrelor

Tikagrelor

Tikagrelor ile nerilen idame ASA dozu 81 mgdir.

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EVE GTRLECEK MESAJLAR

Distal embolizasyon primer PCI da sklkla karmza kabilir ve azalm miyokardiyal perfzyon ve kt klinik sonularla ilikilidir.

GPI ile farmakolojik stratejilerin ilem baars zerine olumlu etkileri zellikle yksek riskli hastalarda belirgindir. IC. Kullanm etkinlii arrabilir

Manual aspirasyon cihazlar basit, hzl kullanm olup, 1 yllk klinik sonular olumlu etkileyebilir

EVE GTRLECEK MESAJLAR

Yeni anHtromboHk ajanlar Primer PKG da ilk seenek olmal

STEMI'de Trombüsle Mücadele - Ertuğrul Okuyan

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