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

Lab. Emodinamica

PS

dolore toracico

PS - OBI

Med. Urg

SCA-NSTESCA-NSTESTEMI

dolore toracico