Download - Ischemic Heart Disease · 2021. 4. 11. · TRATAMIENTO DE LOS SNDROMES CORONARIOS AGUDOS CRNICOS Pharmacotherapy • Fibrin-specific agents (TNK preferred). • If PCI is performed,

Dra. María Thiscal López Lluva. Médico Especialista en

Cardiología y Hemodinámica.Hospital General Universitario, Ciudad Real

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TRATAMIENTO DE LOS SÍNDROMES CORONARIOS AGUDOS Y CRÓNICOS

Ischemic Heart DiseaseCLINICAL UPDATES AND FUTURE TRENDS

Los contenidos de este vídeo representan la opinión personal del experto y no reflejan necesariamente una opinión oficial

de la sociedad científica.


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SSTT-segment EElevation MMyocardial IInfarctionST-segment Elevation Myocardial Infarction (I)


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• Reperfusion therapy should be administered to all eligible patients with STEMI with symptom onset within the prior 12 hours (81,82). (Level of Evidence: A).

• Primary PCI is the recommended method of reperfusion when it can be performed in a timely fashion by experienced operators (82-84). (Level of Evidence: A).

• EMS transport directly to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI, with an ideal FMC-to-device time system goal of 90 minutes of less* (70-72). (Level of Evidence: B).

• Inmediate transfer to a PCI-capable hospital for primary PCI is the recommended triage strategy for patients with STEMI who initially arrive at or are transported to a non-PCI-capable hospital, with an FMC-to-device time system goal of 120 minutes or less* (83-86). (Level of Evidence: B).

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.

2017 ESC Guideline for the Management of acute myocardial infarction in patients presenting with ST-segment elevation myocarial infarction.

ST-segment Elevation Myocardial Infarction (II)


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ST-segment Elevation Myocardial Infarction (III)

Rescue PCI (fibrinolytic failure)

PHARMACOINVASIVE STRATEGY

Routine early PCI (successful reperfusion)


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Fibrinolytic-based Pharmacoinvasive Strategy (I)

Non-PCI capable hospital or overtaxed

health system

Diagnosis likely from acute coronary artery

occlusion (i.e. multiple CAD RF or segmental WMA)

Anticipated PCI-related delay > 60

minutes

Lower-risk (STEMI TIMI Score ≤ 5) & absence of

cardiogenic shock

Early Onset of symptoms (ideally < 3 hr but up to 12 hr)

No absolute contraindication to

fibrinolytics of high risk of bleeding

Factors Favoring Fibrinolytic-based

Pharmacoinvasive Strategy

González PE, Omar W, Patel KV, de Lemos JA, Bavry AA, Koshy TP, et al. Fibrinolytic Strategy for ST-Segment-Elevation Myocardial Infarction: A Contemporary Review in Context of the COVID-19 Pandemic. Circ Cardiovasc Interv. 2020 Sep;13(9):e009622. doi: 10.1161/CIRCINTERVENTIONS.120.009622. Epub 2020 Sep 4.


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Pharmacotherapy• Fibrin-specific agents (TNK preferred).• If PCI is performed, UFH of enoxaparin

until time of revascularization. Otherwise, enoxaparin should be given until discharge or up to 8 days.

• Aspiring: loading dose 325 mg and then 81 mg daily.

• Clopidogrel: ‣ ≤ 75 years: loading dose 300 mg. ‣ > 75 years: loading dose 75 mg• No GP IIb/IIIa inhibitors.• Secondary prevention with high intensity

statins, beta blockers, ACE inhibitors/ARBs.

Invasive therapy• Inmediate rescue PCI: if persistent chest

pain, hemodynamic or electrical instability, or electrocardiographic markers of failed reperfusion 60-90 minutes after lytic therapy.

• Routine early angiography and PCI: ideally shoud take place between 2-24 hr; particularly PUI patients in whom COVID-19 is effectively ruled out.

• COVID-19 + patients: angiography can occur after convalescence from active infection.

• Low-risk patients: if successful reperfusion with lytic therapy can consider outpatient angiography.

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Fibrinolytic-based Pharmacoinvasive Strategy (II)

González PE, Omar W, Patel KV, de Lemos JA, Bavry AA, Koshy TP, et al. Fibrinolytic Strategy for ST-Segment-Elevation Myocardial Infarction: A Contemporary Review in Context of the COVID-19 Pandemic. Circ Cardiovasc Interv. 2020 Sep;13(9):e009622. doi: 10.1161/CIRCINTERVENTIONS.120.009622. Epub 2020 Sep 4.


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Percutaneous coronary intervention (PCI) (I)

Dalby M, Bouzamondo A, Lechat P, Montalescot G. Circulation. 2003 Oct 14,108(15):1809-14. doi: 10.1161/01.CIR.0000091088.63921.8C. Epub 2003 Oct 6.


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Percutaneous coronary intervention (PCI) (II)


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Percutaneous coronary intervention (PCI) (III)

• > 600.000 PCI procedures performed annually in the US. • Patient complexity and procedural risk.• Major complications of PCI are rare but can be catastrophic if not

successfully managed.• Operators should be prepared for complications.• Learning From Complications: How to Be a Better Interventionalist course

(Seattle, 2018): Dissection. Perforation. No reflow. Unexpected hemodynamic collapse. Entrapped equipment.


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Percutaneous coronary intervention (PCI) (IV)

1. A standard set of equipment and resources to prepare for PCI complications.


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Percutaneous coronary intervention (PCI) (V)

2. Regular drills of physicians and staff.3. ¿Minor or mayor complication? 1. ¿Complete or immediately terminate a planned PCI procedure? 2. ¿Act immediately or pause to evaluate? 60-second rule: Assess the patient. Communicate the suspected complication to the staff. Confirm the diagnosis of the complication or evaluate for

alternatives. Consider multiple treatment options. Call for assistance from colleagues.


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Dual AntiPlatelet Therapy• DAPT is recommended for secondary prevention following ACS.• Long-term DAPT prevents recurrent ischemic events, but increases the risk

of bleeding.• Personalizing DAPT intensity and duration is mandatory.• Bleeding prediction models have been validated for patients treated with

DAPT after PCI.• ¿How scores apply to patients with ACS managed medically?


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Risk prediction models

• DAPT score is mentioned within this document as a tool that has been developed to support decision making

• Do not incorporate risk scores into formal recommendations.


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TaRgeted Platelet Inhibition to CLarify the Optimal StrateGY to Medically Manage Acute Coronary Syndromes• Double-blind, placebo-controlled randomized cardiovascular outcomes trial.• 966 sites in 52 countries.• UA or non-STEMI + planned medical management treatment strategy

without PCI + 1 enrichment factor: age ≥ 60 years, previous MI, DM or PCI or CABG ≥ 30 days before.

• PRECISE-DAPT, PARIS and DAPT bleeding risk scores.• The performances of the 3 bleeding risk scores were: Reasonable. Similar to their performance in patients treated with PCI. Similar accuracy to predict bleeding.

Alberto Alcocer, 13 - 1º. D • 28036 MadridTel.: 91 353 33 70. Fax: 91 353 33 73

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