Stato dell’arte: organizzazione ospedale-territorio
della SCA-NSTEMI: risultati e criticità
Sindrome coronarica acuta
Ivo Casagranda
Agenda• Introduzione
• I network per migliorare la gestione e la cura
della Sindrome Coronarica Acuta
• I network nello STEMI
• I network nella ACS- NSTE
• Conclusioni
Introduzione
q In recent years, it has become evident that the level of guideline adherence in patients
presenting with acute coronary syndrome (ACS) is highly correlated with patient
outcomes. Unfortunately, guideline adherence is low in some geographic areas and
especially in those patients at high-risk.
q Regional networks including ambulance systems and hospitals with
catheterization laboratories are able to increase guideline adherence and patient
outcomes by streamlining the critical pre- and intra-hospital processes as well as
improving timely access to invasive procedures and recommended medication
Radke PW. Acute Card Care. 2014 Jun;16(2):41-8
q Successful organization of an ACS network requires engagement of multiple
stakeholders to create effective solutions for the specific local setting. There is
no ‘ one-size-fits all ’ strategy to set-up and successfully run an ACS
Radke PW. Acute Card Care. 2014 Jun;16(2):41-8
Agenda
I network per migliorare la gestione e
la cura della Sindrome Coronarica Acuta
Radke PW. Acute Card Care. 2014 Jun;16(2):41-8
Agenda
I Network nello STEMI
Ischaemic time and time to reperfusion are crucial
SEST 118 Proprio mezzo
Lab. Emodinamica
PS STEMI
dolore toracico
Agenda
I Network nella ACS-NSTE
Epidemiology of NSTE-ACS
§ The diagnosis of NSTE-ACS is more difficult to establish than STEMI and therefore its prevalence is harder to estimate.
§ In addition a new definition of MI has been introduced to take into account the use of more sensitive and more specific biomarkers of cell death
§ In this context, the prevalence on NSTE-ACS, relative to STEMI, has been determined for multiple surveys and registries
§ Overall, data suggest that the annual incidence of NSTE-ACS is higher than that of STEMI
§ Overall, from these registries and surveys, it has been shown that the annual incidence of hospital admission for NSTE-ACS is in the range of 3 per 1000 inhabitants
Guidelines for the diagnosis and treatment of NSTE-ACS. ESC 2008
Prognosis of ACS
§ Hospital mortality is higher in patients with STEMI than among those with with NSTE-ACS ( 7 vs. 5%, respectively)
§ At six months the mortality rates are very similar in both conditions (12 vs. 13%respectively)
§ Long term follow upshwed that death rates were higher among those among with NSTE-ACS than with STE-ACS with a two- fold difference at 4 years
§ This difference in mid- and long-term evolution may be due to different patient profile, since NSTE-ACS tend to be older, with more co-morbidities, especially diabetes and renal failure.
Guidelines for the diagnosis and treatment of NSTE-ACS. ESC 2008
Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study.
Wallentin L, Lindhagen L,Ärnström E, Husted S, Janzon M, Johnsen SP, Kontny F, Kempf T, Levin LÅ, Lindahl
B, Stridsberg M, Ståhle E, Venge P, Wollert KC, Swahn E, Lagerqvist B, FRISC-II study group
Lancet. 2016;388(10054):1903. Epub 2016 October.
BACKGROUND The FRISC-II trial was the first randomised trial to show a reduction in
death or myocardial infarction with an early invasive versus a non-invasive treatment
strategy in patients with non-ST-elevation acute coronary syndrome. Here we provide a
remaining lifetime perspective on the effects on all cardiovascular events during 15
years' follow-up.
INTERPRETATION. During 15 years of follow-up, an early invasive treatment strategy
postponed the occurrence of death or next myocardial infarction by an average of 18
months, and the next readmission to hospital for ischaemic heart disease by 37
months, compared with a non-invasive strategy in patients with non-ST-elevation acute
coronary syndrome. This remaining lifetime perspective supports that an early invasive
treatment strategy should be the preferred option in most patients with non-ST-
elevation acute coronary syndrome.
Timing of Angiography and Outcomes in High-Risk Patients With Non-ST-Segment-Elevation Myocardial Infarction Managed Invasively: Insights From the TAO Trial (Treatment of Acute Coronary Syndrome With Otamixaban).Deharo P, Ducrocq G, Bode C, Cohen M, Cuisset T, Mehta SR, Pollack C Jr, Wiviott SD, Elbez Y, Sabatine MS, Steg PG S
Circulation. 2017;136(20):1895. Epub 2017 Sep 11.
BACKGROUND In patients with non-ST-segment-elevation myocardial infarction (NSTEMI) and GRACE (Global Registry of Acute Coronary Events) score>140, coronary angiography (CAG) is recommended by European and American guidelines within 24 hours. We sought to study the association of very early (ie,≤12 hours), early (12-24 hours), and delayed (>24 hours) CAG in patients with NSTEMI with GRACE score>140 with ischemic outcomes.
METHODS The TAO trial (Treatment of Acute Coronary Syndrome With Otamixaban) randomized patients with NSTEMI and CAG scheduled within 72 hours to heparin plus eptifibatide versus otamixaban. In this post hoc analysis, patients with a GRACE score>140 were categorized into 3 groups according to timing of CAG from admission (<12,≥12-<24, and≥24 hours). The primary ischemic outcome was the composite of all-cause death and myocardial infarction within 180 days of randomization.
CONCLUSIONS In patients with high-risk NSTEMI, undergoing CAG within the initial 12 hours after admission (as opposed to later, either 12-24 or≥24 hours) was associated with lower risk of ischemic outcomes at 180 days.
Early Invasive Versus Selective Strategy for NON-ST-Segment Elevation
Acute Coronary Syndrome- The ICTUS Trial
Hoedemaker PG ,et Al.
Among NSTE-ACS only 17 patients (0.8%) were directly referred to the cath-lab. Of
the remaining patients 1157 (53.3%) and 996 (45.9%) subjects were admitted to PPCI
hospitals and no PPCI hospitals,respectively. The rate of patients undergoing invasive
management was higher in low-risk patients compared to those with high-risk profile
(68.5% vs. 50.5%, pb0.001). Patients admitted to PPCI hospitals
were more likely to be managed invasively compared to those admitted
to hospitals without PPCI facilities (59.5% vs. 50.4%, pb0.001)
We identified 3644 patients who received the diagnosis of ACS and reviewed 3555
cases whose medical records could be retrieved:1564 (51.7%) for NSTEMI and
606 (20.1%)for UA
International Journal of Cardiology 2012; 157 (3):419-22
Early mortality in STEMI patients is probably related to the fact that the presence of ST elevation specifically reflects a total coronary occlusion. Differently, late and increasing mortality associated with NSTEMI reflects the worse patients' clinical characteristics. Underutilization of evidence-based medication and of coronary catheterization in thehigher risk group may partly account for the increased long term mortality in NSTEMI patients
CONCLUSIONS. In contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence.
NSTEMI. PTCA entro 2 giorni
STEMI. PTCA entro 2 giorni
Conclusioni
STEMI
SEST 118 Proprio mezzo
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PS
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PS - OBI
Med. Urg
SCA-NSTESCA-NSTESTEMI
dolore toracico