La tempistica nella rivascolarizzazione

La tempistica nella
rivascolarizzazione
A. Nicolino
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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1
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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2
ECG
Ecocardiogramma
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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Stratificazione del Rischio
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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RISK Score
 Strumento (statisticamente derivato) per misurare
(quantitativamente) il rischio clinico al fine di scegliere la miglior
strategia
Countries
Hospitals
Patients
30
247
102,341
Derivato da TIMI 11B ed ESSENCE;
validato in TIMI 3B, TACTICS-TIMI 18,
MERLIN-TIMI 36,CURE.
89,000 Pts da "real-world"
Score di Rischio
Quadro Clinico
Anamnesi
Remota
TIMI
Età
Ipertensione Arteriosa
Diabete Mellito
Fumo
Colesterolo
Familiarita’ per CAD
Pregressa CAD
Angina recidiva
Aspirina in terapia
Incremento Enzimi
Alterazioni ST
GRACE
Età
Frequenza Cardiaca
Pressione Sistolica
Aumento creatinina
Scompenso Cardiaco
Arresto Cardiaco
Incremento Enzimi
Alterazioni ST
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
7
7
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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8
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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Beneficio della strategia “early invasive”
Diminuzione di IMA a 2 anni
Diminuzione di MORTE a 2 anni
Ma quanto Early???
NSTEMI è IMA piccolo???
Dal 2006 al 2012  2,191,772 NSTEMI tra cui 53,800 (2.5%) Shock.
Am J Cardiol 2015
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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11
Tutti gli NSTEMi “in Sala” oggi??
• Meta-analysis: 7 RCTs  5370 NSTE-ACS e 4 Studi osservazionali (77 499 pt)
• early (24 h) vs delayed
8,0%
7,0%
6,0%
5,0%
4,0%
3,0%
2,0%
1,0%
0,0%
Morte
IMA
Sanguinamento
entro 24h
Angina
dopo 24 h
Ann Intern Med 2013;158:261–270.
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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Tutti gli NSTEMI “in Sala” subito??
• Meta-analysis: 4 RCTs  4013 NSTE-ACS early ( 1.16–14 h) vs delayed (20.8–86 h).
ABOARD
ELISA
D
Tempo (h)
1,16
20,8
5,9
50,2
2,4
86
14
50
Morte
2,9%
1,1%
2,8%
5,4%
5,4%
4,8
4,8%
5,9%
MI
9,1%
4,5%
7,3%
6,3%
7,9%
13%
4,8%
5,7%
Bleeding
4%
6,8%
7,3%
12,6%
3%
3,9%
3,41%
3,5%
1%
Morte,
IMA,
3,3% Stroke,
Ischemia
12%
18,6%
11,9%
D
12,6%
E
TIMACS
E
Ischemia
E
ISAR-COOL
13,3%
D
1,8%
E
D
28%
European Heart Journal 2011 32,32–40
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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Ruolo della Coronarografia
•
•
•
•
•
“Central role”
Confermare la diagnosi
Guidare la terapia antitrombotica
Identificare la culprit lesion
Stabilire la miglior modalità di rivascolarizzazione
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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• For or against pretreatment with P2Y12 inhibitors  controversial.
• The optimal timing of ticagrelor or clopidogrel administration in
NSTE-ACS patients scheduled for an invasive strategy  not
investigated
• Based on the ACCOAST results, pretreatment with prasugrel is not
recommended.
• In NSTE-ACS patients planned for conservative management 
as soon as the diagnosis is confirmed.
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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DES per tutti?????
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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You are on duty in the Cath Lab on Friday afternoon.
Because of staff availability, you are able to perform only
one additional non-emergent case, with additional patients
scheduled for Monday. The ER attending informs the
cardiology fellow on call that an early invasive strategy is
indicated in two of his patients: patient A, a 75-year-old
woman with NSTEMI, and patient B, a 45-year-old man with
unstable angina. Which one would you give priority?
Patient A, because the short-term
risk of death and the benefit from
an early invasive strategy are
more pronounced in NSTEMI as
compared with unstable angina. If
patient B is admitted to the
hospital, he may undergo noninvasive stress testing or coronary
angiography on Monday.
Cardiac Catheterization & Interventional Cardiovascular Unit
Santa Corona General Hospital
Pietra Ligure-Savona, Italy
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La Tempistica giusta????
• Correlata al Rischio
• Maggiore è il Rischio minore è l’attesa
• PCI precoce diminuisce il Rischio
(bleeding) e tailorizza la DAPT