totalCOR

2009

REUNIÃO HEMODIN
REUNIÃO ÂMICA
HEMODINÂMICA
E CARDIO
INTERVENCIONISTA
Prof. Dr. EXPEDITO E. RIBEIRO
LIVRE-DOCENTE CARDIOLOGIA- FM USP
SUPERVISOR SERVIÇO DE HEMODINÂMICA INCOR-HCFMUSP
DIRETOR SERVIÇO HEMODINÂMICA HOSP TOTALCOR
 PARTE 1
1.QUEM TEM TELHADO DE
VIDRO NÃO JOGA PEDRA
NO VIZINHO.
- O TRATAMENTO CLÍNICO
É SOBERANO!
van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
van Domburg, R. T. et al. Eur Heart J 2009 30:453-458; doi:10.1093/eurheartj/ehn530
Rates of occlusion, severe disease (>=70% stenosis), and patency according to graft type
and anastomosis site

Khot, U. N. et al. Circulation 2004;109:2086-2091

Rates of occlusion, severe disease (>=70% stenosis), and patency according to
graft type and anastomosis site

Khot, U. N. et al. Circulation 2004;109:2086-2091

Rates of occlusion, severe disease (>=70% stenosis), and patency
according to graft type and anastomosis site

Khot, U. N. et al. Circulation 2004;109:2086-2091

A Randomized Comparison of
Radial-Artery and Saphenous-
Vein Coronary Bypass Grafts
Nimesh D. Desai, M.D., Eric A. Cohen, M.D., C. David Naylor, M.D., D.Phil.,
Stephen E. Fremes, M.D. and the Radial Artery Patency Study Investigators

N Engl J Med
Volume 351;22:2302-2309
November 25, 2004
 Study Overview
• The radial artery was first used as a coronary bypass
graft in 1971, but there have been conflicting reports
about its patency as compared with that of
saphenous-vein grafts
• In this study, radial-artery grafts had a higher patency
rate at one year than control saphenous-vein grafts
• The advantage was particularly evident when the
radial artery was grafted to coronary vessels with
high-grade lesions
• This study supports the use of the radial artery as a
coronary bypass conduit in vessels with high-grade
stenosis
Clinical Characteristics of All Patients and Those
Who Underwent Follow-up Angiography

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Operative Data on All Patients and Those Who
Underwent Postoperative Angiography

Desai, N. et al. N Engl J Med 2004;351:2302-2309

 Angiographic End Points

Desai, N. et al. N Engl J Med 2004;351:2302-2309

 Angiographic End Points

Desai, N. et al. N Engl J Med 2004;351:2302-2309

Clinical Outcomes among the 561 Patients

Desai, N. et al. N Engl J Med 2004;351:2302-2309

 Conclusions
• Radial-artery grafts are associated with
a lower rate of graft occlusion at one
year than are saphenous-vein grafts
• Because the patency of radial-artery
grafts depends on the severity of native-
vessel stenosis, such grafts should
preferentially be used for target vessels
with high-grade lesions
Five-year patency of three
subgroups of conduits
96%
88%
82%

Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799

Comparative patencies of different in situ and free
arterial conduits at 5 years

RA=RADIAL

Hayward P. A.R. et al.; Ann Thorac Surg 2007;84:795-799

 PARTE 2
2. ATUALIZAÇÃO
DO TRATAMENTO
IAM
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
URGÊNCIA PRIMÁRIA
RO pós Sem
FIBRINOLÍTICO
FIBRINOLÍTICO Prévio
com sucesso

ATC FACILITAD
IAM A

ELETIVA SALVAMENTO
PAC estável “RESCUE”
Trat. lesão falha do
residual FIBRINOLÍTICO
Volume 278(23) 17 December 1997 pp 2093-2098
Comparison of Primary Coronary Angioplasty and
Intravenous Thrombolytic Therapy for Acute Myocardial
Infarction: A Quantitative Review
[Review]
Weaver, W. Douglas MD; Simes, R. John MD; Betriu, Amadeo
MD; Grines, Cindy L. MD; Zijlstra, Felix MD; Garcia, Eulogio MD;
Grinfeld, Lilliana MD; Gibbons, Raymond J. MD; Ribeiro, Expedito
E. MD; DeWood, Marcus A. MD; Ribichini, Flavio MD

From the Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich (Dr Weaver); National Health and Medical Research Council
Clinical Trials Centre, Sydney, Australia (Dr Simes); Hospital Clinico y Provincial, Barcelona, Spain (Dr Betriu); William Beaumont Hospital,
Royal Oak, Mich (Dr Grines); Ziekenhuis De Weezenlanden, Zwolle, the Netherlands (Dr Zijlstra); Hospital General Gregorio Maranon, Madrid,
Spain (Dr Garcia); Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (Dr Grinfeld); Mayo Clinic, Rochester, Minn (Dr Gibbons); Unicor
Hospital, Sao Paulo, Brazil (Dr Ribeiro); Spokane Heart Research Foundation, Spokane, Wash (Dr DeWood); and Ospedale Santa Croce,
Cuneo, Italy (Dr Ribichini
 ESTUDO PCAT
% MORTALITY
20
11 Trials (1989-96)
Thrombolysis
Lytics PTCA
15 PTCA
(N) 1377 1348
Time (min) 172 219
10

5
p < 0.04

0
0 2 4 6 m
 ESTUDO PCAT
%
20
DEATH + MI
Thrombolysis

PTCA
15

10

5
p < 0.0001

0
0 2 4 6 m
 LIÇÕES
LIÇÕES JÁ
JÁ APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
 NRMI
NRMI 1-4:
1-4: Impact
Impact of
of Door
Door to
to
Balloon
Balloon
Time
Time on
on In-hospital
In-hospital Mortality
Mortality
29,222 STEMI pts treated with PCI within 6 hrs of
presentation at 395 hospitals from 1999 to 2002
8
7
6
Mortality Rate (%)

5
In-hospital

3 Ptrend < 0.001

2

0
< 90 > 90 - 120 > 120 - 150 > 150
Door to Balloon Time (min)
 TIME TO TREATMENT
meta-analysis
meta-analysis of
of lytics
lytics trials
trials
ACC / AHA GUIDELINES
EUROPEAN
EUROPEAN HEART
HEART JOURNAL
JOURNAL 2002
2002
;; 23:550-7
23:550-7
 Relationship
Relationship of
of Presentation
Presentation Delay
Delay
and
and Outcome
Outcome forfor Primary
Primary PCI
PCI vs
vs
Fibrinolysis
Fibrinolysis
14,6%
14,6%
15%
15% 15%
15%
6-Month Mortality

10%
10% 10%
10%
7,3%
7,3%
6,7%
6,7%
6,1%
6,1%
5,1%
5,1% 5,4%
5,4%
5%
5% 5%
5%

0%
0% 0%
0%
< 2hr 2-4hr > 4hr < 2hr 2-4hr > 4hr
Sx Onset to Presentation, Sx Onset to Presentation
Primary Angioplasty Fibrinolysis
Zijlstra F, Ribeiro E.
et al, EHJ, 2002
PCAT
PCAT 2:
2: PCI
PCI DELAY
DELAY AND
AND BASELINE-ADJUSTED
BASELINE-ADJUSTED
RISK
RISK OF
OF 30-DAY
30-DAY MORTALITY
MORTALITY

BOERSMA E, RIBEIRO E et al EHJ 2006;27:779-788

Selection criteria used for study
inclusion

Pinto, D. S. et al. Circulation 2006;114:2019-2025

 Relationship between PCI-related delay (minutes; x axis) and in-
hospital mortality (%; y axis) as a continuous function was assessed
as a linear regression model

Pinto, D. S. et al. Circulation 2006;114:2019-2025

 Multivariable analysis estimating the treatment effect of
reperfusion therapy with PCI or fibrinolysis based on increasing
PCI-related delay

Pinto, D. S. et al. Circulation 2006;114:2019-2025

Adjusted analysis illustrating significant heterogeneity in the PCI-related delay (DB-DN time) for
which the mortality rates with primary PCI and fibrinolysis were comparable after the study
population was stratified by prehospital delay, location of infarct, and age

Pinto, D. S. et al. Circulation 2006;114:2019-2025

PCI – related delay
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DA
EXPERIÊNCIA DO SERVIÇO E DO OPERADOR
ACC / AHA GUIDELINES
PHYSICIAN
PHYSICIAN VOLUME
VOLUME -- OUTCOMES
OUTCOMES
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR

 IS PRIMARY
PCI FOR SOME
AS GOOD AS
FOR ALL?
PRIMARY
PRIMARY PCI
PCI MAKES
MAKES THE
THE BIGGEST
BIGGEST
DIFFERENCE
DIFFERENCE IN
IN THE
THE SICKEST
SICKEST
BRODIE BR ey al JACC 2006;47:289-
2006;47:289-95.
CLASSIFICATION AND TREATMENT
EFFECT BASED ON LEVEL OF RISK
Low Risk Intermediate Risk Higj Risk

Age Number of Risk

(years) 0 1 2 3 4
< 50

50 - 59

60 - 69

> 70

Risk Factors
• Anterior myocardial infarction
• Prior myocardial infarction
• Systolic blood pressure < 115 mmHg
• Pulse rate > 85/min
MORTALITY BY LEVEL OF RISK

PTCA 24.1
TT
30 days death + MI (%)

12.7 13.1

7.2 8.0

2.9

Low Intermediate High

Risk group
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR

5. FIBRINOLÍTICOS E TERAPIA ADJUNTA
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR

5. FIBRINOLÍTICOS E TERAPIA ADJUNTA

6. ATC FACILITADA VS ESTRATÉGIA

FARMACOINVASIVA
DiMario , C et al LANCET 2008;371;559-568
 CARESS-in-AMI
Events Rates, 30 Days

DiMario , C et al LANCET 2008;371;559-568

 7 PUBLISHED RANDOMIZED
TRIALS
1996 pat

PRAGUE, WEST, CARESS-AMI, LEIPZIG

3 MONTHS FU
CAPITAL-AMI, SIAM 3
6 MONTHS FU
GRACIA 1
1 YEAR FU

Stone, G. W. Circulation 2008;118:552-566

 POOLED ANALYSIS OF THE RESULTS FROM 7 PUBLISHED
RANDOMIZED TRIALS IN PAT. TREATED WITH FIBRINOLYTIC
COMPARING IMMEDIATE OR EARLY PCI WITH STENTING X
DELAYED ISCHEMIA-DRIVEN OR ROUTINE PCI WITH STENTING

Stone, G. W. Circulation 2008;118:552-566

** ST segment resolution <50% & persistent chest pain or hemodynamic instability
Cantor ACC 2008
 Primary Endpoint: 30-Day Death, re-MI,
CHF, Severe Recurrent Ischemia, Shock
% of Patients
18 16.6
16
14
OR=0.537 (0.368, 0.783); p=0.0013
12
10.6
10
8
6
4 Standard (n=496)
2 Pharmacoinvasive (n=508)

0
0 5 10 15 20 25 30
Days from Randomization
n=496 422 415 415 414 414 412
n=508 468 466 463 461 460 457
 Components
Components of
of Primary
Primary Endpoint
Endpoint

Standard Pharmacoinvasive
Treatment Strategy P-Value
(n=498) (n=512)
Death 3.6 3.7 0.94
Reinfarction 6.0 3.3 0.044
Recurrent Ischemia 2.2 0.2 0.019
Death/MI/Ischemia 11.7 6.5 0.004
New / worsening CHF 5.2 2.9 0.069
Cardiogenic Shock 2.6 4.5 0.11
 Safety
Safety Endpoints
Endpoints -- Bleeding
Bleeding

Standard Pharmacoinvasive
Treatment Strategy P-Value
(n=498) (n=512)
Intracranial hemorrhage 1.2 0.2 0.066
TIMI scale
Major 4.6 4.3 0.88
Major (non-CABG-related) 3.2 2.2 0.33
GUSTO scale
Moderate 2.2 3.5 0.26
Severe 1.4 0.6 0.22
Severe (non-CABG-related) 1.2 0.6 0.34
Transfusions 5.5 7.1 0.31
 LIÇÕES JJÁ
LIÇÕES Á APRENDIDAS
APRENDIDAS
1. ATC PRIMÁRIA É SUPERIOR A FIBRINOLÍTICO
2. REPERFUSÃO É TEMPO DEPENDENTE
3. OS RESULTADOS DEPENDEM DA EXPERIÊNCIA DO SERVIÇO E DO OPERADOR

4. NOS MAIS GRAVES O BENEFÍCIO É MAIOR

5. FIBRINOLÍTICOS E TERAPIA ADJUNTA

6. ATC FACILITADA VS ESTRATÉGIA

FARMACOINVASIVA

7.CONSIDERAÇÕES FINAIS
A modified algorithm for management of patients with STEMI according to time from symptom
onset to hospital arrival, institutional interventional capability, and potential for interhospital
transfer, emphasizing increasing access to interventional reperfusion therapy

Stone, G. W. Circulation 2008;118:552-566

 UMass STEMI %DTB < 90
minutes vs Mortality

100% 3.5
96.00%
90% 91.70%
89.50%
84.60% 3
80% 81.00%
74.20%
70%
72.00% 2.5

60% 61.50%
57.10% 2

50% 50%
43.50% 1.5
40%

30% 1

20%
0.5
10%

0% 0
Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 07

DTB time < 90 minutes Mortality data

Courtesy of Greg Volturo, MD

 Acute
Acute Medications
Medications
98% 97%
STEMI
STEMI vs
vs NSTEMI
NSTEMI
100% 96%
93% 93%
90%
84%
80% 75%

59%
60%
52%

40%

20%

0%
ASA Beta Blockers Heparin GP llb-llla Clopidogrel
(LMW+UFH) Inhibitors
ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
STEMI NSTEMI STEMI (n=11,854) NSTEMI (n=26,956)
 Discharge
Discharge Medications
Medications
100%
99% 97% STEMI
STEMI vs
97% vs NSTEMI
NSTEMI
95%
89% 91% 90%
86%

80% 76% 74%

60%

40%

20%

0%
ASA Beta Blockers ACE-I or ARB* Statins Clopidogrel

* Ideal Patients
STEMI NSTEMI ACTION/CRUSADE DATA: July 1, 2006 – June 30, 2007
STEMI (n=11,854) NSTEMI (n=26,956)