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Pharmaco Pharmaco - - invasive strategies for acute invasive strategies for acute myocardial infarction: the CARESS myocardial infarction: the CARESS - - in in - - AMI Trial AMI Trial Carlo Di Mario, MD, PhD, FRCP, FACC, FSCAI, FESC Consultant Cardiologist Professor of Clinical Cardiology President Elect EAPCI-ESC Tct Asia Pacific April 24 2008 Imperial College

Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

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Page 1: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

PharmacoPharmaco--invasive strategies for acute invasive strategies for acute myocardial infarction: the CARESSmyocardial infarction: the CARESS--

inin--AMI TrialAMI Trial

Carlo Di Mario, MD, PhD, FRCP, FACC, FSCAI, FESC

Consultant CardiologistProfessor of Clinical Cardiology

President Elect EAPCI-ESC

Tct Asia Pacific

April 24 2008

Imperial College

Page 2: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

STEMISTEMISTEMIAspirin

Clopidogrel/ Prasugrel/ AZD6140/ CangrelorUFH/ LMWH/ Fondaparinux/ Bivalirudin

Beta- blockers

AspirinClopidogrel/ Prasugrel/ AZD6140/ Cangrelor

UFH/ LMWH/ Fondaparinux/ BivalirudinBeta- blockers

<90min to PCI<90min to PCI ≥90min to PCI≥90min to PCI

Primary PCIPrimary PCI

Contraindication to lytics/ late

presenters

Contraindication to lytics/ late

presenters

Accelerated AlteplaseReteplase

Tenecteplase

Accelerated AlteplaseReteplase

Tenecteplase

IIb/IIIaIIb/IIIa

BRAVEBRAVE--33

Rescue PCIRescue PCI

failedfailed

Facilitated PCIIIb/IIIa +/- ½dose lytics

preadministered

Facilitated PCIIIb/IIIa +/- ½dose lytics

preadministered

Accelerated AlteplaseReteplase

TenecteplaseCombo lytics+½IIb/IIIa

Accelerated AlteplaseReteplase

TenecteplaseCombo lytics+½IIb/IIIa

Delayed PCIDelayed PCI Immediate PCIImmediate PCI

PCI post thrombolysis

PCI post thrombolysis

ASSENT 4 PCIASSENT 4 PCIFINESSEFINESSE

Page 3: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Henry, T. D. et al. Circulation 2007;116:721-728

1,345 Pts Consecutively Treated in the Regional PCI System for STEMI Minneapolis-Minnesota Network between 2003 and 2006

<60 miles 60-120 milesn=627 n=421n=297

Patie

nts (

%)

73% Pts Transportedby Helicopter

Page 4: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Dudek, Siudak, Janzon et al. ESC 2007

1,650 consecutive STEMI pts in the EUROTRANSFER Registry ; 7 european countries from 2005 to 2007

Dia

gnos

is-to

-Bal

loon

Tim

e (%

)

Page 5: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

GRACIA-1 499 Pts

Immediate (within 24h) or Deferred PCI after LysisImmediate (within 24h) or Deferred PCI after Lysis

11.611.6

24.424.4

Lytics + angio within 24 hrs Lytics + angio when clinically mandated

99

2121

Fernandez-Aviles et al, Lancet 2004;364:1045-53

12 m †, MI, TLR

25.625.6

50.650.6P<0.001 P<0.04

P<0.00008

Scheller et al, JACC 2003;42:634-41

6 m †, MI, RI,TLR

LeMay et al, JACC 2005;46:417-24

6 m †, MI, UAP, Stroke

SIAM III 163 Pts CAPITAL AMI 170 Pts

Page 6: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Angio+/- PCI Angio+Rescue PCI

Reteplase 5U+5U+Abciximab, UFH

Immediate PCITransfer to PCI Centre

N=299

Assess chest pain, ST↑ resolution at 90 min

ST-elevation MI, High risk

Failed Reperfusion*35.7%

Successful Reperfusion64.3%

Angio for symptoms/ischemia

30.5%

Standard Care/ Rescue PCIN=301

Randomization 1:1

1ary EP: 30day Death/ ReMI/ Recurrent Ischemia

SPOKE HospitalSPOKE Hospital

HUB PCI CentreHUB PCI Centre

Di Mario et al. Lancet Di Mario et al. Lancet 2008;371:5592008;371:559--6868

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Pozzuoli, 22 November 2006, 14:33• 60 Yr old man, type II DM treated with oral antidiabetic

drugs; Heavy smoker (40 cigarettes); Hypertension; Dyslipidaemia; ECG evidence of previous (silent) inferior MI

Page 8: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Pozzuoli 22 November 2006: 16:34, Bolus given• Aspirin 150 mg + Clopidogrel 300• Reteplase 5 U• Heparin 40 mg/Kg• Abciximab 25 µg/Kg

Page 9: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

On the Road: 55 min transfer time, arrival 17:58

‘‘

Reteplase 5 U 2nd bolus after 30 mReteplase 5 U 2nd bolus after 30 m’’Heparin 7 U/Kg/hourHeparin 7 U/Kg/hourAbciximab 0.125 mcg/Kg/minAbciximab 0.125 mcg/Kg/minChest pain disappearsChest pain disappears

Page 10: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

18:11 First Angio Naples Before PTCA: TIMI 3 AFTER Taxus

stent 3.5 x 16 mm

Page 11: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

ECG 90 minutes after PCI• AngioSeal 6 Fr: no haematoma• Uneventful hospital stay• Discharged after 4 days

Page 12: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

CARESSCARESS--inin--AMIAMI

60 48 36 24 12 0 12 24 36 48 60

0

60

120

180

240

300

360

420

480

540

600

660

7201440

0

60

120

180

240

300

360

420

480

540

600

660

7201440

Tim

e, m

inut

es

Immediate PCI Standard/Rescue PCI

Symptom onset to thrombolysis

N=298 N=300

80 64 48 32 16 0 16 32 48 64 80

0

60

120

180

240

300

360

420

480

540

600

660

7201440

0

60

120

180

240

300

360

420

480

540

600

660

7201440

Tim

e, m

inut

es

Immediate PCI Standard/Rescue PCI

Thrombolysis to angiography/PCI

N=289 N=107

Di Mario et al. Lancet Di Mario et al. Lancet 2008;371:5592008;371:559--6868

171 m’ 169 136212 m’

Symptom Onset to Reteplase Reteplase to AngiographyT

ime

(min

, med

ians

+ IQ

R)

Tim

e (m

in, m

edia

ns +

IQR

)

ImmediatePCI Standard/Rescue PCI

298 Pts 300 Pts 298 Pts 107 Pts

Page 13: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

TIMI flow pre in CARESS and FINESS TIMI flow pre in CARESS and FINESS Reteplase to AngioReteplase to Angio

72 min72 minReteplase to Angio Reteplase to Angio

132 mins132 mins

Di Mario et al. Lancet 2008;371:559Di Mario et al. Lancet 2008;371:559--68 Ellis et al. NEJM 2008 in press68 Ellis et al. NEJM 2008 in press

Page 14: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

CARESSCARESS--inin--AMIAMI

0 5 10 15 20 25 30

Primary Endpoint

0 5 10 15 20 25 30

Time from randomization (days)

Cum

ulat

ive

inci

denc

e o

f 1ar

y en

dpoi

nt (%

)

0

2

4

6

8

10

12Standard Care/ Rescue PCI

Immediate PCI

Logrank p=0.004

300

298

283

292

275

287

273

285

269

285

268

284

268

284

Standard/Rescue

Immediate PCI

Di Mario et al. Lancet Di Mario et al. Lancet 2008;371:5592008;371:559--6868

4.1%

11.1%Death, re-MI, refractory ischaemia

OR 0.34

(95%CI 0.17-0.68)

P=0.001

Page 15: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

CARESSCARESS--inin--AMIAMIp=0.005

p=0.003

Di Mario et al. Lancet Di Mario et al. Lancet 2008;371:5592008;371:559--6868

4.4% (n13)

P=0.403

3.1% (n=9) P=0.104

11.1%

4.1%

Page 16: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

CARESSCARESS--inin--AMIAMI

* p=0.002

*

Di Mario et al. Lancet Di Mario et al. Lancet 2008;371:5592008;371:559--6868

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Criticisms & Comments

Neither clopidogrel nor LMWHclopidogrel nor LMWH were usedEarly PCI after lytics is clearly beneficial but when: 17 hours as in GRACIA-1 or immediate?

F. Verheugt, commentator ESC 2007

The trial suggests a benefit but it was stopped before scheduled rectuitment was completed and numbers are too low to confirm it

N.Danchin, Editorial Comment, Lancet 2008;

Combo therapy with 2b-3a inhibitors is not a recommended lytic regimen in Guidelines. An approved lytic type and dose should be tested

Owen, Letter, Lancet 2008, in press

Page 18: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Clopidogrel trials in comparisonClopidogrel trials in comparison

COMMIT/COMMIT/CCSCCS--22

-1ary EP: Mortality, Death/MI/CVA- n=46000!- MI < 24 hrs-≤ 100 years!- ~50% Fibrinolytic (also SK)- No loading dose - Non-invasive Strategy- China

- 1ary EP: TIMI flow on angio- n=3500- MI < 12 hrs-≤ 75 years- 100% Fibrinolytic- Loading dose 300mg- Angio 2-8 days- Europe / North America

CLARITYCLARITY

Page 19: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

OR 0.64, 95% CI 0.53-0.76, p<0.0001

Sabatine et al. N Engl J Med 2005;352:1179Sabatine et al. N Engl J Med 2005;352:1179--89.89.

CLARITY CLARITY n=3500n=3500

COMMIT/CCSCOMMIT/CCS--22n=46000n=46000

Bleeds nsBleeds ns

Lancet. 2005 Nov 5;366(9497):1607Lancet. 2005 Nov 5;366(9497):1607--2121

Death ReMI Stroke before discharge

%

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LMWH in AMI: EXTRACT TIMILMWH in AMI: EXTRACT TIMI--2525STEMI

Fibrinolysis with SK/TNK/Atleplase/Reteplase

Clopidogrel at operators discretion

STEMIFibrinolysis with

SK/TNK/Atleplase/ReteplaseClopidogrel at operators discretion

ENOXAPARINUntil discharge or <8days

n=10256

ENOXAPARINUntil discharge or <8days

n=10256

UFH≥48h

n=10223

UFH≥48h

n=10223

Median treatment 7 daysMedian treatment 7 days Median treatment 2 daysMedian treatment 2 days

Antman et al. N Engl J Med 2006;354:1477Antman et al. N Engl J Med 2006;354:1477--88.88.

1ary EP=Death/ reMI 30days

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ASSENT 4: Facilitated PCIASSENT 4: Facilitated PCISTEMI≤6h

PCI delay1-3hASA, UFH bolus (no infusion)

STEMI≤6hPCI delay1-3h

ASA, UFH bolus (no infusion)

PCIN=833

PCIN=833

TNK+PCIN=829

TNK+PCIN=829

1ary EP: 90day Death/ CHF/ ShockPlanned 4000 pts: Stopped due to ↑in-hospital mortality

1ary EP: 90day Death/ CHF/ ShockPlanned 4000 pts: Stopped due to ↑in-hospital mortality

Lancet 2006; 367: 569Lancet 2006; 367: 569––7878

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Prothrombotic effect of thrombolysisProthrombotic effect of thrombolysis

GRACIA-1 (rtPA)

16h 42min.

The Krakow Network (1/2 tPA + abciximab= combo lytic)

2h 31min.

ASSENT-4 PCI (TNK)

1h 44min.

↑ F1,2 fragments== ↑ prothrombin activation

2h 12min (≥40min)

Merlini et al. Am J Cardiol 2004;93:195Merlini et al. Am J Cardiol 2004;93:195––198198

2h 25min (≥90min)

4 hours

Page 23: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

tPA (10+10U)Heparin 5000+1000U/h

tPA (10+10U)Heparin 5000+1000U/h

Abciximab 12h+tPA (5+5U)UFH 60 U/kg → 7 U/kg

Abciximab 12h+tPA (5+5U)UFH 60 U/kg → 7 U/kg

At discretion of investigator:Angiography+/-PCI At discretion of investigator:Angiography+/-PCI

1ary EP: All-cause mortaltiySafety EP: Severe Bleeding (hemodynamic compromise), moderate (transfusion), mild (other)

1ary EP: All-cause mortaltiySafety EP: Severe Bleeding (hemodynamic compromise), moderate (transfusion), mild (other)

GUSTO VGUSTO VSTEMI<12hNo age limitSTEMI<12hNo age limit

in the ED

GUSTO V. Lancet 2001; 357: 1905–14

TIMI14

All-cause mortality at 30 days (5·9 vs5·6%) test forsuperiority, p=0·43; for non-inferiority, relative risk

0·95 [95% CI 0·84–1·08]).

Page 24: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

GUSTO V: GUSTO V: BleedingBleeding

0

0.5

1

1.5

2

2.5

3

3.5

4

Severe

Mod

erate

ICH

ICH>75

year

sIC

H<75ye

ar

%rtPArtPA+Abcx

P<0.0001

P<0.0001

P=0.27

P=0.069

P=0.79

Page 25: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

PCI CentrePCI CentreCath LabCath Lab

CommunityCommunityHospitalHospitalEmergencyEmergencyDepartmentDepartment

Cath / PCI within 6 hrs regardless of reperfusion

status

Cath / PCI within 6 hrs regardless of reperfusion

status

TNK + ASA + Heparin / Enoxaparin + ClopidogrelTNK + ASA + Heparin / Enoxaparin + Clopidogrel

“PharmacoinvasiveStrategy”

Urgent Transfer to PCI CentreN=522

“PharmacoinvasiveStrategy”

Urgent Transfer to PCI CentreN=522 Assess chest pain, ST↑ resolution

at 60-90 minutes after randomization

‘High Risk’ ST Elevation MI within 12 hours of symptom onset‘High Risk’ ST Elevation MI within 12 hours of symptom onset

Successful Reperfusion

Elective Cath ± PCI

24 hrs later

“Standard Treatment”

N=508

“Standard Treatment”

N=508

* ST segment resolution < 50% & persistent chest pain, or hemodynamic instability

Repatriation of stable patients within 24 hrs of PCIRepatriation of stable patients within 24 hrs of PCI

Randomization stratified by age (≤75 vs. > 75) and by enrolling site

Cath and Rescue PCI ±GP IIb/IIIa Inhibitor

Cath and Rescue PCI ±GP IIb/IIIa Inhibitor

Failed Reperfusion*Failed Reperfusion*

PCI within 12h from thrombolysis=47%

PCI within 12h from thrombolysis=47%

Cantor ACC Cantor ACC 20082008

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0 5 1 0 1 5 2 0 2 5 3 00 5 1 0 1 5 2 0 2 5 3 0

T im e fro m ra ndo m iza tio n (da ys )

Cum

ulat

ive

inci

denc

e o

f 1ar

y en

dpoi

nt (%

)

0

2

4

6

8

1 0

1 2

1 4

1 6

1 8 TRANSFER MI STANDARD

CARESS STANDARD/RESCUE

TRANSFER MI PHARMACOINVASIVE

CARESS IMMEDIATE PCI

CARESSCARESS--inin--AMI vs TRANSFERAMI vs TRANSFER--MIMIIn TRANSFERIn TRANSFER--AMI endpoint included CHF + shock at 30 daysAMI endpoint included CHF + shock at 30 days

Cantor, ACC 2008. www.cardiosource.com Cantor, ACC 2008. www.cardiosource.com Di Mario et al. Lancet 2008;371:559Di Mario et al. Lancet 2008;371:559--6868

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CARESSCARESS--inin--AMI & TRANSFERAMI & TRANSFER--AMIAMI

Cantor, ACC 2008. www.cardiosource.com Cantor, ACC 2008. www.cardiosource.com Di Mario et al. Lancet 2008;371:559Di Mario et al. Lancet 2008;371:559--6868

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P=0.066P=0.066

CARESSCARESS--inin--AMI & TRANSFERAMI & TRANSFER--AMIAMIBleedingBleeding

Cantor, ACC 2008. www.cardiosource.com Cantor, ACC 2008. www.cardiosource.com Di Mario et al. Lancet 2008;371:559Di Mario et al. Lancet 2008;371:559--6868

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Pharmacologic strategies in AMIPharmacologic strategies in AMI

ANTIPLATELET- Aspirin

- Clopidogrel- Prasugrel-Cangrelor-AZD6140

- GP IIb/IIIa Inhibitors

ANTITHROMBOTIC- UFH

- LMWH- Bivalirudin

THROMBOLYTICS

COMBINATION THERAPY (thrombolytics+GP IIb IIIa)

Primary PCI possible within 90 minutes

Primary PCI NOT possible within 90 minutes

Rescue

Recommended Under evaluation Discouraged

Page 30: Pharmaco-invasive strategies for acute myocardial ... · UFH/ LMWH/ Fondaparinux/ Bivalirudin Beta- blockers Aspirin Clopidogrel/ Prasugrel/ AZD6140/ Cangrelor UFH/ LMWH/ Fondaparinux

Individual 30 day outcomesIndividual 30 day outcomesRescue/Medical Treatment Only DividedRescue/Medical Treatment Only Divided

4.4% 4.4% (n=13)(n=13)

Facilitated PCI (n=294) Med. Treatment/ Rescue (n=298)

DEATH

P<0.002

P=0.403

Re-MI/Refractory Ischaemia

3.1% 3.1% (n=9)(n=9)

10.6% 10.6% (n=11)(n=11)

1.0% 1.0% (n=2)(n=2)

1.0% 1.0% (n=3)(n=3)

9.4% 9.4% (n=18)(n=18)

Rescue PCI (n=106) Med. Treatment Only (n=192)

1.9% 1.9% (n=2)(n=2)

6.7% 6.7% (n=20)(n=20)