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DISEASE
Mirco Baccino
Cardiologia
Ospedale Santa Corona – Pietra L.
Maggio 2009
MAKE A DECISION
GOOD THERAPY BAD THERAPY
Arrhythmic damage
Reduct damage Left ventricle remodelling
Clinic improvement Heart faliure/shock
ECG signal reduction mortality increase
Fast markers evolution
ABORTED AMI
TROMBOLITHIC TERAPY
PTCA PRIMARY/RESCUE
Pathogenetic components of
acute coronary syndromes
White/red Hemodynamic
thrombus stress
Inflammation
Vascular damage
RISK FACTORS
Diabetes
Gender (male)
Age
Smoke
Hypertension
Dislipidemia
Obesity
Sedentary life
Coronary artery disease clinical pattern
Two ways:
CHRONIC
ACUTE
CAD
Damage’s consequences
Systolic dysfunction
EF reduction
Heart failure
Shock
Arrhythmia
CAD
UNSTABLE ANGINA
SYMPTOMS
ECG
MARKERS
CLINICAL ESTIMATE
IMAGING:
Coronary Angiography – Computed Tomography –
Cardiovascular Magnetic Resonance – Nuclear
Cardiology
- Echocardiography
TIME in diagnosis and terapia
SYMPTOMS
Pallor / sweat
- ST depression
Myocardial infarction
• ST elevation
Subendocardial ischemia
Anteriore AMI
Inferiore AMI
Basal ECG and prognosis
10%
ST ↓
8%
ST ↑
Mortality
6%
4% T wave
inversion
2%
0%
0 30 60 90 120 150 180
Days
AMI Markers
time
AMI Markers
TnT and in-hospital
outcome in UA (n=84)
35
30
In-hospital D/MI (%)
25
20
15
10
5
0
TnT<0.2mcg/l (n=51) TnT>0.2mcg/l (n=34)
(Hamm et al, NEJM 1992)
CRP on admission and
in-hospital
( outcome in UA
20
Death
16
AMI
Urgent MR
12
0
CRP < 3mg/l (n=11) CRP > 3mg/l (n=20)
(Liuzzo et al, NEJM 1994)
TnT, CRP and Prognosis in UA
(n=102)
60
MI/death at 3 months (%)
50
40
30
20
10
0
Tn- and CRP- Tn+ or CRP+ Tn+ and CRP+
(n=46) (n=45) (n=11)
(Rebuzzi et al, AJC 1998)
KILLIP CLASS
clinical evidence % AMI mortality
20% of patients
no CAD
19% of segments
uninterpretable
(4 slice MSCT)
94% negative
predictive value
MSCT cannot be recommended at this moment as a
substitute for conventional coronary angiography in
properly risk stratified patients with UAP
RCA LCX
CORONARY ANGIOGRAPHY
Coronary
abgiography
+
PCA
AMI therapy
FIBRINOLYSIS
(prehospital/hospital)
PRIMARY PCA
RESCUE PCA
Fibrinolysis vs. primary PCI
Non-STE ACS Invasive vs Conservative
Strategies: Mortality at 6 to 12 months
Non-invasive
6
Invasive
4.6%
3.9% 3.9%
4 3.5%
3.3%
%
2.5% 2.5%
2.2%*
2
0
RITA-3 TACTICS FRISC II ICTUS
N = 1810 N = 2220 N = 2457 N = 1200
*P < 0.05.
Aborted Myocardial Infarction
Definition of aborted infarction
Time gained by Prehospital Thrombolysis
MITI
MITI 33
33 min.
min.
REPAIR
REPAIR 47
47 min.
min.
EMIP
EMIP 55
55 min.
min. Median 63 min.
GREAT
GREAT 130
130 min.
min.
Nijmegen
Nijmegen 63
63 min
min..
Percentage of patients treated from time of
onset of chest pain
100%
home
in hospital
50%
0:00 0:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 hrs
USIC. Circulation 2004;110:1909-1915
Conclusions
Diagnosis
Risk score
Therapy (choise,
timing)
Evolution (EF!)
Prognosis
Follow up
OPTIMAL REPERFUSION THERAPY 2009
Conclusions