Zorg voor het acute myocardinfarct: van locaal initiatief tot landelijke organisatie. Gert van Houwelingen interventiecardioloog

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1 Zorg voor het acute myocardinfarct: van locaal initiatief tot landelijke organisatie Gert van Houwelingen interventiecardioloog

2 Samenwerken in de keten: expertgroep myocardinfarct

3 Prehistorie: geen keten, geen overleg

4 Willem Einthoven

5 Snaargalvanometer 1901

6 Eerste ECG Einthoven W. Über die Form des menschlichen Electrocardiogramms. Pfügers Archiv maart 1895, pagina

7 1925

8 Eerste CCU 1965

9 1967

10 Moderne CCU

11 Morfine Coumarines Heparine Digoxine Lidocaine Procainamide Aspirine Nitroglycerine Beta blokkers Vroeger.

12 Geruptureerde plaque

13 Thrombus

14 Thrombolyse tijdperk Amery et al.(52) reported on a randomized series of 167 patients in which streptokinase did not reduce mortality as compared with heparin. A number of these same investigators subsequently conducted a larger trial with 764 patients.(51) In the latter trial, overall mortality was significantly lower in the streptokinase treated group than the heparin-treated group (18.5 vs 26.3%; P> 0.01), although in contrast to the German study (49) there was not a significant difference in the mortality within the first 24 hours. 51. HEIKINHEIMo R, AHRENBERG P, HON KAPOHJA H, IISALO E, KALLIO V, KONTTINEN Y, LESKINEN 0, MUSTANIEMI H, REINIKAINEN M, SIITONEN L: Fibrinolytic treatment in acute myocardial infarction: A preliminary report. Advances Cardiol 4: 241, AMERY A, ROEBER G, VERMEULEN HJ, VERSTRAETE M: Single-blind randomized multicentre trial comparing heparin and streptokinase treatment in recent myocardial infarction. Acta Med Scand (suppl 505): 1, 1969

15 STANFORD WESSLER and LAURENCE A. SHERMAN Antiplatelet Aggregant Agents and Thrombolytic Compounds in Myocardial Infarction: Current Status Circulation 1972;45; Mortality Rate Variations. Institutional mortality rates vary from 10 to 45% among patients hospitalized with acute myocardial infarction. Mechanisms of Death. In hospitals without coronary care units approximately 45% of deaths from acute myocardial infarction are caused by primary arrhythmias, 40% by pump failure, 10% from cardiac rupture (a form of pump failure), 3% from pulmonary or systemic arterial embolization, and 2% from noncardiovascular causes such as infection, hemorhage, or renal failure.

16 ISIS 2: 1985, n= placebo vs aspirine vs STK vs combinatie

17 ISIS 3: 1991, n= STK vs tpa vs APSAC

18 Primaire PCI (spoedinterventie)

19 Drip or ship? Danami Prague

20 Meta analyse Keeley Lancet 2003 Meta-analysis of 23 randomised trials of primary angioplasty versus thrombolysis - short term clinical outcome Key: PCI = percutaneous coronary intervention; MI = myocardial infarction; CVA = cerebrovascular accident Adapted from Keeley EC, Boura JA, Grines CL. N = 7739.

21 Harde eindpunten

22 September 2004: start regionaal overleg

23 Na 2008: ROAZ focusgroep AMI

24 Hartinfarct per regio

25 2015: Euregio expertgroep MICK

26 Time = muscle

27 ON TIME 2 Acute myocardial infarction diagnosed in ambulance or referral center ASA+600 mg Clopidogrel N=984 6/ /2007 Placebo Tirofiban * Transportation Angiogram PCI centre Angiogram Tirofiban provisional PCI Tirofiban cont d *Bolus: 25 µg/kg & 0.15 µg/kg/min infusion

28 Ongoing Tirofiban In Myocardial Infaction Evaluation Ischemic Time 60 min d-t-b 35 min Ischemic Time (min) SO-1st Contact Preparation Transportation Door-Angio Angio-Balloon [ Mean transport distance: 25 km/ 17 miles ]

29 On Time 2 studie in het MST Secondary Endpoint 30 day N=126 1 year N=124 Death Cardiac death Non cardiac Recurrent MI Death/rec. MI Card death/mi 3/ % 5/ % 2/ % 3/ % 2/ % 6/ % 3/ %

30 On Time 2 mortaliteit naar leeftijd 1 yr mortality HDTirofiban Placebo Age > 66 yr 17/ % 29/ % Age < 65 yr 8/ % 9/ %

31 Mortaliteit na het acute myocardinfarct

32 Sterfte aan kanker en hart en vaatziekten, per 1000 mannen/vrouwen, gestandaardiseerd,

33 ACACIA studie (MJA 2008; 188 (12) )

34 ACACIA (2)

35 organisatie Regionaal overleg Stichting Hartcentrum Twente ROAZ focusgroep myocardinfarct Acute Zorg Euregio focusgroep MICK NVVC Connect

36 Uw hart onze zorg! De patient staat nu centraal!

37 Nieuwe samenwerkingsverbanden

38 Euregionaal

39 Egypte

40 Noord Amerika

41 Intergallactisch..

42 Vragen?

43