The new ESC Guidelines in STEMI - European Society of...

www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215

The new ESC Guidelines in STEMI

Stefan James,

Dept. of Cardiology and Uppsala Clinical Research center

Uppsala Sweden

http://www.escardio.org/guidelines


Potential conflicts of interest

• AstraZeneca Pharmaceuticals Research grant/consultant, Ad board

• Daiichi Sankyo Company Research grant/consultant,

• Eli Lilly and Company Research grant/consultant. Ad board

• Sanofi-Aventis Honoraria. Ad board

• The Medicines Company Honoraria

• BMS Research grant/consultant

• Merck Honoraria/consultant

• Medtronic Research grant/consultant, Ad board

• Boston Scientific Research grant/consultant

• Cordis Honoraria/consultant

• Terumo Inc Research grant/consultant



Indicated

Not

recommendedMay

consider

Should

consider



Logistics of pre-hospital care



Procedural aspects of primary PCI


Death, MI, Stroke or non-CABG major Bleed

Subgroups: Primary OutcomeR I V A L

0.251.00 4.00

Radial better Femoral better

Hazard Ratio (95% CI)

<75≥75

FemaleMale

<2525-35>35

≤70

70-142.5>142.5

Lowest TertileMiddle TertileHighest Tertile

NSTE-ACSSTEMI

Age

Gender

BMI

Radial PCI Volume by Operator

Radial PCI Volume by Centre

Diagnosis at presentation

Overall

0.786

0.356

0.637

0.536

0.021

0.025

Interactionp-value


Procedural aspects of primary PCI


TAPAS, total mortality at 1 year

Vlaar, P.J. et al. NEJM 2008, 371: 1915


SWEDE HEART

SCAAR

Randomized

All primary PCI:s

6846 patients

TASTE

Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia



Periprocedural anti thrombotic medication in

primary PCI


HR 0.84

(0.77–0.92)

p=0.0003

NNT = 54

Days after randomization

0 60 120 180

12

11

10

9

8

7

6

5

4

3

2

1

0

Cu

mu

lati

ve

in

cid

en

ce

(%

)

9.8

11.7Clopidogrel

Ticagrelor

Wallentin L, et al. N Engl J Med. 2009;361:1045-57.

Primary Endpoint

(CV death, MI, Stroke)

CV deathClopidogrel

Ticagrelor

4.0

5.1 HR 0.79

(0.69–0.91)

p=0.001

NNT = 90

N=18,624

0

5

10

15

0 30 60 90 180 270 360 450

HR 0.81

(0.73-0.90)

P=0.0004

Prasugrel

Clopidogrel

Days

En

dp

oin

t (%

)

12.1

9.9

HR 1.32

(1.03-1.68)

P=0.03

Prasugrel

Clopidogrel1.8

2.4

138

events

35

events

Balance of

Efficacy and Safety

CV Death / MI / Stroke

TIMI Major

NonCABG Bleeds

NNT = 46

NNH = 167



primary PCI, con’t



FINESSE

Ellis et a NEJM 2008


Platelet Aggregation results

J.J. Smit et al. Am Heart J 2006

OnTIME-2 HD tirofiban

OnTIME-1 LD tirofiban

HD

R. Hermanides et al. Heart 2010

30 Day Mortality

Number at risk

Bivalirudin 1800 1758 1751 1746 1742 1729 1666

Heparin + GPIIb/IIIa 1802 1764 1748 1736 1728 1707 1630

Death

(%

)

Time in Days

3.1%

2.1%

HR [95%CI] =

0.66 [0.44, 1.00]

P=0.048

Heparin + GPIIb/IIIa inhibitor (n=1802)

Bivalirudin monotherapy (n=1800)

Main Secondary Endpoint (ischemic) Death, Recurrent ACS or Urgent Revascularization

0 5 10 15 20 25 30

0.0

00

.05

0.1

00

.15

Days

Ma

in s

eco

nda

ryE

Pra

te

UFHENOX

Log-Rank Test

p=0.0111.3%

6.7%

30d rate (%)

i41%


Routine therapies in the acute, subacute and long term phase of STEMI


Primary Endpoint

No. at Risk

24-Month Clopidogrel 987 925 884


Overall Death, MI or CVA

24 mo DAPT 6 mo DAPT%

10.0

Hazard Ratio: 0.98 (0.74-1.29)

10.1

0 180 360 540 720

12

8

4

0

P=0.91

CEC adjudicated

Key Safety Endpoint

No. at Risk



Type II, III or V BARC bleeding

24 mo DAPT 6 mo DAPT%

3.5

Hazard Ratio: 0.46 (0.1-0.69)

7.4

P=0.00018

CEC adjudicated

0 180 360 540 720

12

8

4

0

Peterson et al, ACC 2004

Link Between Overall ACC/AHA Guidelines Adherence and Mortality

Every 10% in guidelines adherence

11% in mortality


Conclusion

The STEMI guidelines aim to guide towards

evidenced based therapies

Review them critically

Consider updating your local protocols and

personal preferences

Adherence to guidelines improves outcomes


The new ESC Guidelines in STEMI - European Society of...

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