Primary Percutaneous Coronary Intervention in Acute ST Elevation MI

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Primary Percutaneous Coronary Intervention in
Acute ST Elevation MI A Pakistani Perspective
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52 M Presents within 2 h of CP
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• In ER VF Arrest defibrillated

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Cardiac Catheterization
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Cardiac Catheterization
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Cardiac Catheterization
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Case

• 55 M, ex smoker
• Right thalamic infarct one year ago
• Within 2 hours of chest pain

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Initial EKG
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• Offered primary PTCA Taken to cath lab

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Cardiac Catheterization
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Cardiac Catheterization
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Cardiac Catheterization
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Case

• 38 M
• Acute IMI
• Cath Lab

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Cardiac Catheterization
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Cardiac Catheterization
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Cardiac Catheterization
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Case

• 69 physician
• Acute IMI
• Cath Lab

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Cardiac Catheterization
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Cardiac Catheterization
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Terminology
Symptoms
ArrivaltoHospital
ImmediatePCI(Primary)
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Terminology
Thrombolysis
Symptoms
ArrivaltoHospital
RescuePCI
ElectivePCI
ImmediatePCI(Primary)
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Why Ask The Question ?
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Why Ask the Question ?

• There are limitations of thrombolytic therapy

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Limitations of Thrombolytic Therapy
Acute ST Elevation MI
30 Thrombolytic Ineligible

• Bleeding Issues
• Late Presentation
• LBBB
• Too Old

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Limitations of Thrombolytic Therapy
Intracranial Hemorrhage
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Limitations of Thrombolytic Therapy
Mortality Reduction is Time Dependant
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Limitations of Thrombolytic Therapy
Issues with Coronary Patency
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Thrombolytic Eligible Acute ST Elevation MI
100
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Long Term Patent Artery
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Thrombolytic Eligible Acute ST Elevation MI
100
85
TIMI Flow 0 no flow 1 poor flow 2
intermed 3 brisk flow
90 minute Patency
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TIMI 3 Flow
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No Residual Stenosis
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Long Term Patent Artery
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Thrombolytic Eligible Acute ST Elevation MI
100
85
90 minute Patency
No Reperfusion
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TIMI 3 Flow
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Residual Stenosis
No Residual Stenosis
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Late Reocclusion
Long Term Patent Artery
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Residual Stenosis in Infarct Artery at 90 minutes
after Thrombolysis
Am J Cardiol 2000851409-1413
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Thrombolytic Therapy Limitations

• Benefits not clear cut in some subsets
• CABG
• Cardiogenic Shock
• Elderly gt 75

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Thrombolytic Therapy Limitations

• Less effective in some high risk subsets
• Anterior Wall MI

Lundergan et al GUSTO I Angiographic
Investigators JACC 1998 32 648
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What does the data tell us ?
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Weaver et al. JAMA 1997
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Meta analysis of 23 trials
Short Term Outcome
15.0
14.0
0.0002
lt 0.0001
9.0
10.0
8.0
7.0
7.0
5.0
3.0
2.0
1.0
1.0
0.1
0.0
Death
Re-MI
Stroke
ICH
Any event
Keeley, Lancet 200336113
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Lessons Learnt from PTCA vs Thrombolytic Trials

• Improved MORTALITY
• Higher initial reperfusion rates
• Lower recurrence of ischemia
• Less intracranial bleeding

• TIMI 3 flow better but not ideal
• Early recurrent ischemia 10-15
• Restenosis/Reocclusion at 6 months up to 50

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What predicts good or bad outcomes after primary
PCI ?

• Time

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23 trials of PCI versus thrombolysis (n7419)
Mean time delay 39.5 mins (SD 22.1, range
7-104) 0.94 decrease in mortality benefit for
every 10 min delay, p0.006 No evidence of
benefit if delay gt62mins
Absolute difference in 4-6 week mortality ()
PCI-related time delay (mins)
Circles reflect trial sample size Blue line
weighted meta-regression
Nallamothu Bates, Am J Cardiol 200392824
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Time to angioplasty in 27080 patients with acute
myocardial infarction
Multivariate adjusted odds of in-hospital
mortality (95 CI)


plt0.001
Cannon, JAMA 20002832941
Median door to balloon time 116 mins
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ACC/AHA Guidelines
Smith et al. Circulation 2005
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What predicts good or bad outcomes after primary
PCI ?

• Operator experience

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ACC/AHA Guidelines
Smith et al. Circulation 2005
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Aga Khan University Hospital Experience
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Results Baseline Characteristics
Jafary, et al. J Invasive Cardiol 2007
19417-423
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Results Angiographic Procedural
Characteristics
Jafary, et al. J Invasive Cardiol 2007
19417-423
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Results Mortality Rate

• Overall in-hospital mortality rate 8.1

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Results Mortality Rate
Jafary, et al. J Invasive Cardiol 2007
19417-423
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Results Survival
Jafary, et al. J Invasive Cardiol 2007
19417-423
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Predictors of Mortality Multivariate Analysis
Jafary, et al. J Invasive Cardiol 2007
19417-423
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Conclusions

• Primary PCI is the treatment of choice for
  patients presenting with acute STEMI based on
  good randomized trials
• Limitations costs, availability
• Operator experience and time are extremely
  important logistical considerations
• In the largest series on primary PCI for STEMI
  from Pakistan Primary PCI for acute STEMI is
  associated with a high success rate and excellent
  overall in-hospital survival particularly in the
  absence of cardiogenic shock.
• Independent predictors of in-hospital mortality
  include age, prior CABG, requirement for
  intubation, LVEF and cardiogenic shock at
  presentation.
• Our experience suggests that primary PCI is a
  viable and robust therapeutic option for patients
  presenting with acute STEMI in Pakistan.

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Implications for Pakistan - I

• Widespread availability of primary PCI, although
  vigorously promoted, has yet to become a reality,
  even in the developed world.
• We have shown in the first sizeable report from
  the Indo-Pakistan subcontinent that primary PCI
  is a viable therapeutic option and can be
  performed with excellent results
• despite relatively longer chest
  pain-to-presentation and door-to-laboratory
  (surrogate for door-to-balloon) times.
• As Pakistan (and India) brace themselves for a
  cardiovascular epidemic, it is clear that acute
  STEMI will continue to occur, leading to a loss
  in productivity.
• The mean age in our study was just under 55 years
  an age group that comprises the workforce of
  any nation.
• Although fibrinolytic therapy (almost exclusively
  streptokinase) is widely available, at least in
  urban Pakistan, the efficacy of the latter in
  attaining patency with TIMI 3 flow is, at best,
  around 50.

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Implications for Pakistan - II

• Thus, paradoxically, developing countries like
  Pakistan need widespread, expensive primary PCI
  services because such nations cannot afford the
  burden of lost productivity due to inadequate
  myocardial salvage.
• There is no choice the state has to fund these
  programs.
• Preservation of the workforce must be a state
  priority.
• Cost cutting reuse wires, guides cheap bare
  metal stents
• Involvement of tertiary care hospitals (like AKU)
  in training operators to do primary PCI
• Drastic cost-cutting measures including
• NEED community hospitals to do primary PCI in
  every nook and corner . as opposed to elective
  PCI
• Elective PCI has NO mortality benefit, primary
  PCI does

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Thank You