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SHOULD THE 2012 STEMI GUIDELINES BE UPDATED?
Frans Van de Werf, MD, PhD, FESCUniversity of Leuven
Belgium
Disclosures
• Research grants and speaking feesfrom Boehringer Ingelheim
History of ESC STEMI guidelines
11/14/2014
1996 2003
2008 2012
ESC STEMI guidelines almost 20 years ago……
Task Force Chair Julian D. Eur Heart J 1996. STEMI, ST-elevation myocardial infarction
CathPCI and Medicare data (USA):Door-to-balloon times and 30-day unadjusted mortality
Menees DS, et al. N Engl J Med 2013;369:901-909.
No. of patients
Median door-to-balloon time
4013 4700 5078 6167 6244
Deaths 311 360 398 369 388
Morta
lity (%
)
Media
n do
or-to
-ball
oon
time
(min)
Median door-to-balloon time (p<0.001)30-day mortality (p=0.64)
Year of procedure
Menees et al. N Engl J Med 2013;369:901-909. PCI, percutaneous coronary intervention
FAST-MI: Five-year cumulative survival in patients with STEMI according to reperfusion therapy
Danchin et al. Circulation 2014;129:1629-1636.
Numbers at risk
No reperfusion 462 314 277 248
Pre-hospital lysis 294 276 265 249
In-hospital lysis 153 137 130 114
PPCI 583 524 476 439
100
80
60
40
20
00 12 24 36 48 60
Months
% S
urviv
al
Adjusted HR [95% CI] (reference PPCI)PH fibrinolysis 0.57 [0.36-0.88]IH fibrinolysis 1.19 [0.72-1.96]
PHTIHTPPCI
No reperfusion
Numbers at risk
No reperfusion 462 314 277 248
Lysis 447 413 395 362
PPCI 583 524 476 439
PHT, pre-hospital thrombolysis; IHT, in-hospital thrombolysis; PPCI, primary percutaneous coronary intervention; HR, hazard ratio; IV, intravenous
Adjusted HR [95% CI] (reference no reperfusion)Primary PCI 0.57 [0.43-0.74]IV fibrinolysis 0.48 [0.35-0.68]
Adjusted HR [95% CI] fibrinolysis vs PPCI0.73 [0.50-1.06]
100
80
60
40
20
00 12 24 36 48 60
Months
% S
urviv
al
PPCI
No reperfusion
Fibrinolysis
Conclusions
• The lack of further reductions in mortality with current primary PCI strategies AND….
• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIb LOE A )
• Whether the dose of tenecteplase should be halved in all elderly patients needs more study
PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence
Conclusions
• The lack of further reductions in mortality with current primary PCI strategies AND….
• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIa LOE A )
• Whether the dose of tenecteplase should be halved in all elderly patients needs more study
PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence
Medical School of the University of Leuven