Toekomst van de reanimatie: standpunt van de cardiolooog. Prof dr Johan Bosmans Interventiecardioloog Universitair Ziekenhuis Antwerpen

Toekomst van de reanimatie: standpunt van de cardiolooog Prof dr Johan Bosmans Interventiecardioloog Universitair Ziekenhuis Antwerpen

Toekomst van de reanimatie: voorkomen is beter dan (misschien) genezen

Sterftecijfer Vlaanderen 2002 verdeling doodsoorzaken mannen 9% 2% 7% 1% 33% 2% diabetes 1% hart- en vaatziekten kanker longziekten dementie 13% cirrose? ongevallen/zelfmoord 32% andere

Sterftecijfer Vlaanderen 2002 verdeling doodsoorzaken vrouwen 12% hart- en vaatziekten kanker 4% 3% longziekten 1% diabetes 4% 2% 40% dementie cirrose 11%? ongevallen/zelfmoord 23% andere

Het ACUTE Hartinfarct

40 min Progressie myocardnecrose ischemie necrose 100 80 % viabel myocard 3 u 1 dag % 60 40 20 0 0 6 12 18 tijd na coronaire occlusie

Infarct artery patency and prognosis 10 30 d. mortality 8,9 70 Ejection fraction 8 6 4 2 7,5 ** 4 65 60 55 55 56 ** 62 0 TIMI 0-1 TIMI 2 TIMI 3 n=317 n=275 n=370 bij 90 min 50 TIMI 0-1 TIMI 2 TIMI 3 Gusto angiographic study, NEJM 1993

Time-Dependent Benefit of Reperfusion Therapy Absoluut benefit/1000 treatments 100 80 Reimer/Jennings 1977 Bergmann 1982 GISSI-I 1986 60 40 20 0 0 2 4 6 8 10 12 Reperfusion Time (hours) Adapted from Tiefenbrunn AJ, Sobel BE. Circulation. 1992;85:2311-2315.

Contra-indicaties thrombolyse Absolute contra-indicaties Hemorrhagische CVA, Ischemisch CVA <6maanden majeur trauma/chirurgie < 3 maand G-I bloeding < 1maand Aorta dissectie Gekende stollingsstoornis Aorta dissectie Gekende stollingsstoornis Relatieve contra-indicaties TIA <6 maand, refractaire hypertensie Orale antico, niet comprimeerbare puncties Actief peptisch ulcus, ernstig leverlijden Endocarditis, traumatische rescuscitatie Zwangerschap of post partum (1 week)

Rescue PTCA na trombolyse Reperfusie criteria Rescue PTCA ST daling > 5O% Serum merkers: verhouding t 60 /t 0 myoglobine: > 4 CK-MB : > 3.3 ctni: > 2 85-90% TIMI 2-3 Geen tekens van reperfusie Hemodynamische labiliteit Groot infarct best < 6h na begin van symptomen. Tanasijevic et al, JACC,1999

Rescue PCI : REACT - trial R-PCI 93.8% (ci 89.8%-97.7%) Conserv 87.2% (ci 81.7%-92.7%) R-Lysis 87.3% (ci 81.9%-92.8%) p=0.13 Gershlick. NEJM 2005;353:2758

Behandeling Acuut Hartinfarct Urgente Ballondilatatie

Casus primaire PCI akuut inferolateraal infarct

The 90 Minute Wall: Rates of TIMI Grade 3 Flow 100 85 % TIMI 3 Flow 80 60 40 20 60 60 57 63 0 tpa rpa NPA TNK 40 PTCA

Primary PCI vs. thrombolytic therapy 25 PTCA Lysis p<0.0001 21 Frequency (%) 20 15 10 5 0 p=0.0002 9 7 Death p=0.0003 5 Death excl. Shock p<0.0001 7 6,8 2,5 Nonfatal MI 6 Recurrent ischemia p=0.0004 1 2 Total CVA p<0.0001 1,1 0,05 Hemorr. CVA p=0.032 6,8 5,3 Major bleeds p<0.0001 8 14 Death/ CVA/AMI Keeley Lancet 2003;361:13

Reperfusie therapie : acuut hartinfarct % mort. 10 8 6 4 2 no treatment streptokinase accelerated t-pa primaire PCI PCI+adjuvante therapie(?) 20 40 60 80 100 % TIMI 3 flow

Primary PCI and time 30 minutes delay increases 1-year mortality by 7.5% De Luca, Circulation 2004

Primaire PTCA and hospital time % mort. 7 6 6,4 5 4 3 3,7 4 2 1 0 1 t<60 min 61-75 min 76-90 min t>90 min Time to PTCA N =104 n = 109 n = 76 n = 14O Berger et al, Circulation, 1999 (Gusto II substudy)

NRMI-2: Primary PCI Institutional Volume vs. Mortality Mortality (%) 10 8 6 4 8,0 6,2 N=27,080 P < 0.00001 4,7 2 0 <1 1-3 >3 Institutional Monthly Volume of Primary Angioplasty Cases

ST- Elevation AMI : management 1. Check intake ASA / nitrates SL 2. Give Beta blockers 3. Initiate Reperfusion therapy Thrombolyse PTCA

DENMARK DANAMI-2 5.4 mill. inhabitants 5 PCI centers 24 referral hospitals 62% of Danish population Transport distance up to 95 US miles (mean 35 miles) 100 US miles

DANAMI-2 Referral hospitals Planned: 1,100 pts. Angioplasty centers Planned: 800 pts. Fibrinolysis PCI Fibrinolysis PCI (front loaded tpa) (front loaded tpa) Incl. 1,129 pts. 443 pts.

DANAMI-2 Time from onset of symptoms to treatment (1,572 patients) Hospitals Referral Invasive Referral Invasive Pre-hospital Pre-hospital Pre-hospital Pre-hospital Door-to-needle Door-to-needle In-door-out-door Transportation Door-to-balloon Door-toballoon 0 60 120 180 240 Min.

Primary end points within 30 days 15 1,572 patients p=0.0003 13.7 DANAMI-2 10 p=0.35 p<0.0001 7.6 6.6 6.3 8.0 NNT=18 5 p=0.15 0 1.6 2.0 1.1 Death Reinfarction Disabling stroke Combined Fibrinolysis PCI

Events during transportation (n=559) DANAMI-2 A trial fibrillation 2.5% V T 0.2% V F 1.4% 2-3 o A V block 2.3% Intubation (n) 0 D eath (n) 0

ST elevation MI (<12 h after onset of pain) Aspirin heparin nitrate * Admission in PCI-center Admission in non-pci-center or first medical contact outside hospital Transfer ** PCI center YES Hemodynamic instability (shock / cardiac failure/ malignant arrythmias) contra-indication thrombolysis Transfer to PCI center NO OR Thrombolysis start clopidogrel Primary PCI ** First medical contact-to-balloon time < 90±30 min Consider IIB-IIIa antagonists Pro transfer: transfer time<60, ischemia >3u Pro thrombolysis: transfer time>60, ischemia<3u Failed *** Rescue PCI * nitrate SL unless systolic bloodpressure<100mmhg and/ or heart rate<50bpm ** Consider pre-pci lytic therapy if transfer time>60 min *** Electrocardiographic and clinical evaluation 60-90 min after initiation of thrombolysis

Case-Fatality in Ghent during 1983-1999 in men 25-69 years Case-Fatality Rate (%) 60 All Hospitalised cases 50 40 30 20 10 0 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Year Prof. G. De Backer, Ghent