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

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

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

Quanti sono? Polish Registry of Acute Coronary Syndromes 2005 20062006 19453 STEMI patients 12-24 hours: 2036 patients (10.5%) >24 hours: 2944 (15.1%) 25.6 % Ospedale Maria Vittoria 2007-20132013 1372 STEMI 12-24 hours: 33 (2,4%) >24 hours: 114 (8,3%) 10.7% Am J Cardiol 2011;107:501 508

Chi sono? Ospedale Maria Vittoria 2007-2013 1372 STEMI: 147 oltre 12 ore dai sintomi STEMI <12 h (n=1225) STEMI >12 h (n=147) 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 (28.6) <0.001 At Arterial lhypertension 620 (50.6) 92 (62.6) 6) 0.006006 Killip 2 209 (17.4) 46 (31.1) <0.001 Creatinine (mg/dl) 115±13 1.15±13.8 13±0 1.3±0.6 <0.001001 Chinaglia, Cerrato, Acute Cardiac Care Congress, ESC, 2013

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

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;355:2395-407.

Come li dobbiamo trattare? OAT 331 randomized early (<3 days ) Pazienti OAT: 11/147 (7%) Late: 24-72 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, 183 191

Come li dobbiamo trattare? BRAVE-2 365 patients 12-48 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;293:2865-2872

Come li dobbiamo trattare? PL-ACS Late: 12 to 24 hours 19453 STEMI patients, 12-24 hours: 2036 patients (10.5%) Invasive approach (coronary angiography performed 12-24 hours from symptoms: 44.7% (PCI: 92%) Am J Cardiol 2011;107:501 508

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) 11193 (97%) 132 (90%) 111 (75.5%) <0.001 13 (8.8%) <0.001 124 (84%) 15 pazienti non coronarografia: età / comorbidità / rifiuto Pazienti OAT: 11/147 (7%) Coronarografia immediata: 51%

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

Coronarografia

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

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

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

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

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) 0.005 Atrial Fibrillation 130 (10.6) 26 (17.7) 7) 0011 0.011 Heart Failure 298 (24.3) 75 (51) <0.001 Acute Pericarditis 59 (4.8) 14 (9.5) 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 (3.4) <0.001 IABP 102 (8.3) 14 (10.3) 0.038038 CPAP 44 (3.6) 13 (9.8) 0.001 In-hospital death 69 (5.6) 19 (12.9) 0.001 Acute Cardiac Care Congress, ESC, 2013

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!

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

Quanti sono? Registri Canadesi (ACS I, ACS II, GRACE/GRACE2, CANRACE) 14070 patients NSTE-ACS 1999-2008 History of CVD: 1377 (9.8%) CRUSADE 17926 patients NSTE-ACS 2000-2002 Prior stroke : 2465 (10.8%) TRITON TIMI 38 13608 patients NSTE-STE ACS Prior stroke : 3.8 % PLATO 17926 patients NSTE-STE ACS Prior stroke : 6.2 % Lee, Am J Cardiol 2010;105:1083 1089)

Chi sono? Lee, Am J Cardiol 2010;105:1083 1089

Qual è l outcome? In-hospital outcome Mortality: adjusted OR 1.43, 95% CI 1.06 to 1.92, p = 0.019019 Lee, Am J Cardiol 2010;105:1083 1089)

CAD+CVD CVD CAD+CVD CVD Mortalità Stroke Circ Cardiovasc Qual Outcomes. 2012;5:541-549

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;105:1083 1089)

Sottotrattamento? Buon senso? Lee, Am J Cardiol 2010;105:1083 1089

Sottotrattamento Lee, Am J Cardiol 2010;105:1083 1089

Come li dobbiamo trattare?

Of the 18 624 randomized patients, 1152 (6.2%) had a history of stroke or TIA RRR 38% RRR 19% James, Circulation. 2012;125:2914-2921

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;43:3409-3410

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, 2569 2619 Arch Intern Med. 2010;170(16):1433-1441

573 pazienti, PCI TAO + clopidogrel vs TAO+ clopidogrel + ASA Yet practice should not be changed on the basis of this study alone. Dewilde, Lancet. 2013 Feb 12

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)

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

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)

Qual è l outcome? Hospital outcomes Heart 2003;89:1003 1008

Qual è l outcome? Medi, Int Med J 2011

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

Come li dobbiamo trattare? HR 0.77; 95% CI 0.65 to 0.90 22% HR, 0.72; 95% CI,0.58 to 0.89 17% 8,9% 7,9% 14% 10% Circulation. 2010;122:1056 1067

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;

NAROSE Circ Cardiovasc Interv. 2013 Aug;6(4):444-51. doi: 10.1161/CIRCINTERVENTIONS.113.000179. 1161/CIRCINTERVENTIONS 113 000179 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, 15-35 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, 3.05-17.21; 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.

11480 subjects, mean age 75.6 years Lamberts, Circulation. 2012;126:1185-1193

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. 2004 Jul 24-30;364(9431):331-7.

Come li dobbiamo trattare? BRAVE-2 365 patients 12-48 ore Senza sintomi JAMA, February 4, 2009 Vol 301, No. 5