SCA nelle popolazioni a rischio i late presenters, l'irc, pregresso ictus. Alessandra Chinaglia

Dimensione: px

Iniziare la visualizzazioe della pagina:

Download "SCA nelle popolazioni a rischio i late presenters, l'irc, pregresso ictus. Alessandra Chinaglia"

Bernarda Santoro
7 anni fa
Visualizzazioni

1 SCA nelle popolazioni a rischio i late presenters, l'irc, pregresso ictus Alessandra Chinaglia

2 STEMI : i late presenters Quanti sono? Chi sono? Qual è l outcome? Come li dobbiamo trattare? Quali attenzioni?

3 Quanti sono? Polish Registry of Acute Coronary Syndromes STEMI patients hours: 2036 patients (10.5%) >24 hours: 2944 (15.1%) 25.6 % Ospedale Maria Vittoria STEMI hours: 33 (2,4%) >24 hours: 114 (8,3%) 10.7% Am J Cardiol 2011;107:

patients 12-24 hours: 2036 patients (10.5%) >24 hours: 2944 (15.1%) 25.

4 Chi sono? Ospedale Maria Vittoria STEMI: 147 oltre 12 ore dai sintomi STEMI <12 h (n=1225) STEMI >12 h (n=147) p Age (years) 66.0± ± Male gender 871 (71.1%) 95 (64.6) 0.10 Diabetes mellitus 197 (16.1%) 42 (28.6) <0.001 At Arterial lhypertension 620 (50.6) 92 (62.6) 6) Killip (17.4) 46 (31.1) <0.001 Creatinine (mg/dl) 115± ± ±0 1.3±0.6 < Chinaglia, Cerrato, Acute Cardiac Care Congress, ESC, 2013

p Age (years) 66.0±13.8 71.6±11.9 0.042 Male gender 871 (71.1%) 95 (64.6) 0.10 Diabetes mellitus 197 (16.1%) 42 (28.

5 Come li dobbiamo trattare? PL-ACS BRAVE-2 OAT

6 Come li dobbiamo trattare? OAT Death from any cause, nonfatal reinfarction, or NYHA class IV heart failure Late: 3 28 giorni Total occlusion of the infarct-related artery Exclusion criteria: i NYHA class III -IV, shock, creatinine> 2.5 mg, left main or 3 vessel disease, angina and ischemia N Engl J Med 2006;355:

Late: 3 28 giorni Total occlusion of the infarct-related artery Exclusion

7 Come li dobbiamo trattare? OAT 331 randomized early (<3 days ) Pazienti OAT: 11/147 (7%) Late: hours Total occlusion of the infarct-related artery Exclusion criteria: NYHA class III -IV, shock, creatinine> 2.5 mg, left main or 3 vessel disease, angina and ischemia European Heart Journal (2009) 30,

hours Total occlusion of the infarct-related artery Exclusion criteria: NYHA

8 Come li dobbiamo trattare? BRAVE patients ore Senza sintomi Primary end point: left ventricular infarct size (SPECT) Left ventricular infarct size: smaller in the invasive vs the conservative group (median, 13.0%; IQR, 3.0%-27.0%; P.001) JAMA, February 4, 2009 Vol 301, No. 5 JAMA. 2005;293:

ventricular infarct size (SPECT) Left ventricular infarct size: smaller in

9 Come li dobbiamo trattare? PL-ACS Late: 12 to 24 hours STEMI patients, hours: 2036 patients (10.5%) Invasive approach (coronary angiography performed hours from symptoms: 44.7% (PCI: 92%) Am J Cardiol 2011;107:

10 Come li dobbiamo trattare? STEMI <12 h (n=1225) STEMI >12 h (n=147) p Treatment : Coronary angiography PTCA 1161 (94.8) Cardiac surgery Total 32 (2.6) (97%) 132 (90%) 111 (75.5%) < (8.8%) < (84%) 15 pazienti non coronarografia: età / comorbidità / rifiuto Pazienti OAT: 11/147 (7%) Coronarografia immediata: 51%

1161 (94.8) Cardiac surgery Total 32 (2.6) 11193 (97%) 132 (90%) 111 (75.5%) <0.

11 Quali attenzioni? B.D. uomo 61 anni PS: dolore toracico da 48 ore

12 Coronarografia

13 I-II giornata IABP IV giornata mobilizzazione V giornata: perdita di coscienza, coma, respiro stertoroso, deviazione dei bulbi oculari e risposta in decerebrazione al nocicettivo

14 Angiografia O l i Occlusione d dell ttratto tt medio-distale di di t l d della ll arteria t i b basilare il

15 Quali attenzioni? ECOCARDIOGRAMMA 16/5 17/5 18/5 19/5 20/5 21/5 Eparina ev X X Fondaparinux X X X MONITORAGGIO ECOCARDIOGRAFICO

16 S.A. donna 64 anni PS: dolore toracico 4 giorni prima, dispnea, PA 80/60 CONTROLLO CLINICO

17 Qual è l outcome? STEMI <12 h (n=1225) STEMI >12 h (n=147) p In-hospital complications AVB 63 (5.1) 16 (10.9) Atrial Fibrillation 130 (10.6) 26 (17.7) 7) Heart Failure 298 (24.3) 75 (51) <0.001 Acute Pericarditis 59 (4.8) 14 (9.5) Heart or septal rupture 3(02) (0.2) 6(41) (4.1) < Shock at presentation 214 (17.5) 24 (16.4) 0.7 Stroke 5 (0.4) 5 (3.4) <0.001 IABP 102 (8.3) 14 (10.3) CPAP 44 (3.6) 13 (9.8) In-hospital death 69 (5.6) 19 (12.9) Acute Cardiac Care Congress, ESC, 2013

5) 0.016 Heart or septal rupture 3(02) (0.2) 6(41) (4.1) <0.001001 Shock at presentation 214 (17.5) 24 (16.4) 0.7 Stroke 5 (0.4) 5 (3.

18 Quanti sono? Da 1/10 a 1/4 STEMI STEMI : i late presenters Chi sono? Pazienti con caratteristiche di rischio elevato Qual è l outcome? Gravato da scompenso, FA, ictus, rottura, pericardite, mortalità Come li dobbiamo trattare? Coronarografia a tutti Atteggiamento invasivo precoce se scompenso, angina, shock, <24h (48?) Rivascolarizzazione se scompenso, angina, shock, 3v, TC, arteria pervia, <24h No PCI se >24 h + occlusione totale + no scompenso, angina, shock, 3v, TC Uso limitato di stent medicati Q li tt i i? Quali attenzioni? Monitoraggio clinico ed ecocardiografico ossessivo!

Coronarografia a tutti Atteggiamento invasivo precoce se scompenso, angina, shock, <24h (48?

19 SCA e pregresso ictus (ischemico) Quanti sono? Chi sono? Qual è l outcome? Come li dobbiamo trattare? Quali attenzioni?

20 Quanti sono? Registri Canadesi (ACS I, ACS II, GRACE/GRACE2, CANRACE) patients NSTE-ACS History of CVD: 1377 (9.8%) CRUSADE patients NSTE-ACS Prior stroke : 2465 (10.8%) TRITON TIMI patients NSTE-STE ACS Prior stroke : 3.8 % PLATO patients NSTE-STE ACS Prior stroke : 6.2 % Lee, Am J Cardiol 2010;105: )

21 Chi sono? Lee, Am J Cardiol 2010;105:

22 Qual è l outcome? In-hospital outcome Mortality: adjusted OR 1.43, 95% CI 1.06 to 1.92, p = Lee, Am J Cardiol 2010;105: )

23 CAD+CVD CVD CAD+CVD CVD Mortalità Stroke Circ Cardiovasc Qual Outcomes. 2012;5:

24 Come li dobbiamo trattare? In multivariable analysis, in-hospital revascularization was independently associated with lower 1-year mortality (adjusted OR 0.48, 95% CI 0.33 to 0.71, p<0.001) Lee, Am J Cardiol 2010;105: )

25 Sottotrattamento? Buon senso? Lee, Am J Cardiol 2010;105:

26 Sottotrattamento Lee, Am J Cardiol 2010;105:

27 Come li dobbiamo trattare?

28 Of the randomized patients, 1152 (6.2%) had a history of stroke or TIA RRR 38% RRR 19% James, Circulation. 2012;125:

29 there is no safe ground to treat ACS patients with a previous stroke or TIA routinely with prasugrel or ticagrelor rather than with clopidogrel. In patients with a history of cerebrovascular disease, the net clinical benefit with ticagrelor compared with clopidogrel is heavily challenged Stroke. 2012;43:

30 ACS + previous stroke/tia + FA CHA2DS2-VASc (Congestive heart failure/left ventricular dysfunction, Hypertension, Age 75 [doubled], Diabetes, Stroke [doubled] Vascular disease, Age 65 74, and Sex category [female]). European Heart Journal (2012) 33, Arch Intern Med. 2010;170(16):

31 573 pazienti, PCI TAO + clopidogrel vs TAO+ clopidogrel + ASA Yet practice should not be changed on the basis of this study alone. Dewilde, Lancet Feb 12

32 SCA: pregresso TIA / ictus Quanti sono? Il 10% circa Chi sono? Pazienti con caratteristiche di rischio elevato Qual è l outcome? Gravato ato da sanguinamenti e mortalità Come li dobbiamo trattare? Evitare prasugrel, cautela con ticagrelor Rivascolarizzare dove possibile Evitare stent medicati, in particolare se storia di FA Quali attenzioni? Valutazione del rischio emorragico (durata della triplice terapia)

33 SCA e insufficienza renale cronica Quanti sono? Chi sono? Qual è l outcome? Come li dobbiamo trattare? Quali attenzioni?

34 Quanti sono? Filtrato glomerulare Cockcroft-Gault formula GRACE (11774 patients with ACS) 355; 11% 1679; 1176; Ospedale Maria Vittoria 52% 37% (3210 patients with ACS)

35 Qual è l outcome? Hospital outcomes Heart 2003;89:

36 Qual è l outcome? Medi, Int Med J 2011

37 Come li dobbiamo trattare? James, BMJ 2013;347:f4151

38 Come li dobbiamo trattare? HR 0.77; 95% CI 0.65 to % HR, 0.72; 95% CI,0.58 to % 8,9% 7,9% 14% 10% Circulation. 2010;122:

39 Management of acute coronary syndrome in patients with chronic kidney disease: if we don't risk anything, we risk even more. Asim, Nephron Clin Pract. 2011;119(4):c333-6;

41 NAROSE Circ Cardiovasc Interv Aug;6(4): doi: /CIRCINTERVENTIONS /CIRCINTERVENTIONS Epub 2013 Aug 13. Triple antithrombotic therapy is the independent predictor for the occurrence of major bleeding complications: analysis of percent time in therapeutic range. Naruse Y, Sato A, Hoshi T, Takeyasu N, Kakefuda Y, Ishibashi M, Misaki M, Abe D, Aonuma K; Ibaraki Cardiovascular Assessment Study (ICAS) Registry. Source Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan. Abstract BACKGROUND: Triple antithrombotic therapy increases the risk of bleeding events in patients undergoing percutaneous coronary intervention. However, it remains unclear whether good control of percent time in therapeutic ti range is associated with reduced d occurrence of bleeding complications in patients t undergoing triple antithrombotic therapy. METHODS AND RESULTS: This study included 2648 patients (70±11 years; 2037 men) who underwent percutaneous coronary intervention with stent in the Ibaraki Cardiovascular Assessment Study registry and received dual antiplatelet therapy with or without warfarin. Clinical end points were defined as the occurrence of major bleeding complications (MBC), major adverse cardiac and cerebrovascular event, and all-cause death. Among these 2648 patients, 182 (7%) patients received warfarin. After a median follow-up period of 25 months (interquartile range, months), MBC had occurred in 48 (2%) patients, major adverse cardiac and cerebrovascular event in 484 (18%) patients, and all-cause death in 206 (8%) patients. Multivariable Cox regression analysis revealed that triple antithrombotic therapy was the independent predictor for the occurrence of MBC (hazard ratio, 7.25; 95% confidence interval, ; P<0.001). The time in therapeutic range value did not differ between the patients with and without MBC occurrence (83% [interquartile range, 50%-90%] versus 75% [interquartile range, 58%-87%]; P=0.7). However, the mean international normalized ratio of prothrombin time at the time of MBC occurrence was 3.3±2.1. Triple antithrombotic therapy did not have a predictive value for the occurrence of all-cause death (P=0.1) and stroke (P=0.2). CONCLUSIONS: Triple antithrombotic therapy predisposes patients to an increased risk of MBC regardless of the time in therapeutic range.

43 11480 subjects, mean age 75.6 years Lamberts, Circulation. 2012;126:

44 Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic c stroke or transient t ischaemic c attack in high-risk patients ts (MATCH): randomised, double-blind, placebo-controlled trial. Life-threatening bleedings: absolute risk increase 1.3% [95% CI 0.6 to 1.9]). Lancet Jul 24-30;364(9431):331-7.

45 Come li dobbiamo trattare? BRAVE patients ore Senza sintomi JAMA, February 4, 2009 Vol 301, No. 5

Documenti analoghi

Il Management delle Sindromi Coronarie Acute oggi Il paziente anziano e con IRC grave

Il Management delle Sindromi Coronarie Acute oggi Il paziente anziano e con IRC grave Filippo M. Sarullo U.O. di Riabilitazione Cardiovascolare Ospedale Buccheri La Ferla FBF Palermo NSTE-ACS: ETA & Mortalità