SHOULD THE 2012 STEMI GUIDELINES BE UPDATED?

Frans Van de Werf, MD, PhD, FESCUniversity of Leuven

Belgium

Disclosures

• Research grants and speaking feesfrom Boehringer Ingelheim

History of ESC STEMI guidelines

11/14/2014

1996 2003

2008 2012

ESC STEMI guidelines almost 20 years ago……

Task Force Chair Julian D. Eur Heart J 1996. STEMI, ST-elevation myocardial infarction

CathPCI and Medicare data (USA):Door-to-balloon times and 30-day unadjusted mortality

Menees DS, et al. N Engl J Med 2013;369:901-909.

No. of patients

Median door-to-balloon time

4013 4700 5078 6167 6244

Deaths 311 360 398 369 388

Morta

lity (%

)

Media

n do

or-to

-ball

oon

time

(min)

Median door-to-balloon time (p<0.001)30-day mortality (p=0.64)

Year of procedure

Menees et al. N Engl J Med 2013;369:901-909. PCI, percutaneous coronary intervention

FAST-MI: Five-year cumulative survival in patients with STEMI according to reperfusion therapy

Danchin et al. Circulation 2014;129:1629-1636.

Numbers at risk

No reperfusion 462 314 277 248

Pre-hospital lysis 294 276 265 249

In-hospital lysis 153 137 130 114

PPCI 583 524 476 439

100

80

60

40

20

00 12 24 36 48 60

Months

% S

urviv

al

Adjusted HR [95% CI] (reference PPCI)PH fibrinolysis 0.57 [0.36-0.88]IH fibrinolysis 1.19 [0.72-1.96]

PHTIHTPPCI

No reperfusion

Numbers at risk

No reperfusion 462 314 277 248

Lysis 447 413 395 362

PPCI 583 524 476 439

PHT, pre-hospital thrombolysis; IHT, in-hospital thrombolysis; PPCI, primary percutaneous coronary intervention; HR, hazard ratio; IV, intravenous

Adjusted HR [95% CI] (reference no reperfusion)Primary PCI 0.57 [0.43-0.74]IV fibrinolysis 0.48 [0.35-0.68]

Adjusted HR [95% CI] fibrinolysis vs PPCI0.73 [0.50-1.06]

100

80

60

40

20

00 12 24 36 48 60

Months

% S

urviv

al

PPCI

No reperfusion

Fibrinolysis

Conclusions

• The lack of further reductions in mortality with current primary PCI strategies AND….

• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIb LOE A )

• Whether the dose of tenecteplase should be halved in all elderly patients needs more study

PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence

Conclusions

• The lack of further reductions in mortality with current primary PCI strategies AND….

• The favourable results obtained with a pharmaco-invasive strategy in CAPTIM, WEST, Minnesota (US) and recently in FAST-MI and STREAM, justify the recommendation to consider a pharmaco-invasive strategy in early presenting STEMI patients who cannot get primary PCI within 1 hour of first medical contact (Class IIa LOE A )

• Whether the dose of tenecteplase should be halved in all elderly patients needs more study

PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; LOE, level of evidence

Medical School of the University of Leuven