Managing AMI – much work still to do?

MONDAY, 28th FEBRUARY – SESSION 3

Patrick Goldstein

EXPERTS WORKSHOP ON EARLY TREATMENT STRATEGIES FOR ACUTE MYOCARDIAL INFARCTIONFOR THE MIDDLE EAST COUNTRIES

FEBRUARY 26TH -28TH 2005 / DUBAI, UAESPONSORED BY BOEHRINGER INGELHEIM

Can We Now Imagine Where Are Our Different Roles in the Modern Management of Acute MI?

on scene

at the dispatching center

at the ER

but is that all ?

The EP Clearly Has a Place in the Treatment

…but the common aim ofa multidisciplinary team implementing a strategy

of participation and collaboration

so

• acting on the emergency call : yes• treating patients on scene : yes• transporting patients in a difficult

position : yes

but

It Is Not a Question of EP or Cardiologists…

Together

• promote clinical research

• create and maintain documentation

• build evaluation tools: common registers

• training for coronary emergencies

• ambulance crews

• paramedics

• nurses

• students

• physicians

• promote media campaigns

• promote new participative and combined strategies

Cardiology and Emergency Medicine

Ann. Emerg. Med 2002 ; 39 : 164-167

united we standdivided we fall

W.B. Gibler Department of Emergency MedicineCincinnati

E.J. Topol Department of CardiologyCleveland

B. Holfroyd Department of Emergency Medicine Edmonton

P.W. Armstrong Department of Emergency MedicineEdmonton

Study Design

RandomiseAMI

open label

ASA UFH (bolus)

No lytic(Group B)

ASAUFH (bolus)

TNK(Group A)

n = 2000

n = 2000

Cath lab

Angiography / PCI(immediate)

Stent / clopidogrel (optional)

Heparin as routinely used

NO GP IIb/IIIa inhibitors, (only bail-out at investig.

discretion)

Angiography / PCI(immediate)

Stent / clopidogrel (optional)

Heparin as routinely used

GP IIb/IIIa inhibitors can beused at investig. discretion

Combined Therapy in the “Real World”

• Organise pre-hospital fibrinolysis

• Define High Volume Centers for rescue PCI

• Availability 24 h / 24 h

• Direct admission to Cath Lab

• Define candidates for combined therapy

• Written protocols

• Risk / Time to Cath Lab / Ambulance or helicopter

• Validate the strategy each year

Proposal

• Education of health care providers

• Clinical investigation

• Improving routine care

• Creation of site-specific and multicenter databases

• Subspecialisation within emergency medicine and cardiology

So...Some Keys to Success

and… € or $

• Enough health care providers

• Comprehensive institutions

• Evaluation

• Training and Teaching

• Information

• and Communication

Total Reperfusion

PCI

Fibrinolysis

(Rogers et al. J Am Coll Cardiol 2000; 36: 2056-63)

Reperfusion During the Last Decade

0

30

10

20

40

90 91 92 93 94 95 96 97 98 99

%

YEARS

p = 0.0001

Cardiologists and Emergency Physicians

Definitive progress for the patients but maybe also for the doctors whose progress together is even better as they get

to know each other better

A lobby or a task force ?

EUROPE AND UAE and may be the planet IS SO SMALL