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IAMSEST en el 2019¿Cuándo debemos intervenir?
LUIS ALBERTO URNA HERBAS, MD. MSc.
2019
Ciudad de Panamá, Panamá Santa Cruz, Bolivia
DECLARACIÓN DE CONFLICTOS DE INTERÉS
• Sin conflictos de interés.
dr_luis_urna@outlook.comdr_luis_urna@outlook.com @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
dr_luis_urna@outlook.com
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
dr_luis_urna@outlook.com @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
dr_luis_urna@outlook.com
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
dr_luis_urna@outlook.com @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
dr_luis_urna@outlook.com
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿CUÁNDO DEBERÍAMOS INTERVENIR UN IAMSEST?
dr_luis_urna@outlook.com
¿En qué momentodeberíamos intervenir?
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
Revista Argentina de Cardiología Vol. 82, Supl. 1, Octubre 2014Sociedade Brasileira de Cardiologia Vol 102, Nro. 3, Supl. 1, Marzo 2014Sociedade Brasileira de Cardiologia Vol 109, Nro. 1, Supl. 1, Julho 2017
2017: DIRETRIZ DA SBC E DA SBHCI SOBRE INTERVENÇÃO CORONÁRIA PERCUTÂNEA
2014: DIRETRIZ DA SBC SOBRE ANGINA INESTÁVEL E INFARTO AGUDO DO MIOCÁRDIO SEM SUPRADESNIVEL DO SEGMENTO ST
2014: CONSENSO PARA EL MANEJO DE PACIENTES CON SCA SIN SUPRADESNIVEL DEL SEGMENTO ST
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
JACC Vol. 64, Nº 24, e139-228, December 23 2014European Heart Journal (2016) 37, 267-315European Heart Journal (2018) 00, 1-96
2018: ESC/EACTS GUIDELINES ON MYOCARDIAL REVASCULARIZATION
2015: GUIDELINES FOR THE MANAGEMENT OF ACS IN PATIENTS PRESENTING WITHOUT PERSISTENT ST-SEGMENT ELEVATION
2014: GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH NON-ST-ELEVATION ACUTE CORONARY SYNDROMES
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
• < 2 Horas: ESTRATEGIA INVASIVA INMEDIATA (I-C)
• Shock cardiogénico o inestabilidad hemodinámica.
• Angina recurrente o refractaria a tratamiento médico.
• Paro cardiaco o arritmias que amenacen la vida.
• Insuficiencia cardiaca con angina refractaria o desvío del segmento ST.
• Cambios dinámicos recurrentes del segmento ST u ondaT, principalmente con supradesnivel intermitente del segmento ST.
dr_luis_urna@outlook.com
European Heart Journal (2016) 37, 267-315
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
• < 24 Horas: ESTRATEGIA INVASIVA TEMPRANA (I-A)
• Incremento o descenso de la troponina.
• Cambios dinámicos del segmento ST u onda T, sean sintomáticos o silentes.
• GRACE Score >140 puntos.
dr_luis_urna@outlook.com
European Heart Journal (2016) 37, 267-315
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
• < 72 Horas: ESTRATEGIA INVASIVA (I-A)
• Diabetes mellitus.
• Insuficiencia renal (eGFR <60 mL/min/1.73 m2).
• FEVI <40% o insuficiencia cardiaca aguda.
• APIAM.
• Angioplastia reciente.
• CRM previa.
• GRACE Score >109 puntos, y <140 puntos.
• Sintomas recurrentes o evidencia de isquemia.
dr_luis_urna@outlook.com
European Heart Journal (2016) 37, 267-315
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
European Heart Journal (2016) 37, 267-315Neth Heart J (2017) 25:181–185
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
European Heart Journal (2016) 37, 267-315Neth Heart J (2017) 25:181–185
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
J Nucl Cardiol. 2018 Jun;25(3):769-776
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
J Nucl Cardiol. 2018 Jun;25(3):769-776
dr_luis_urna@outlook.com @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
dr_luis_urna@outlook.com
J Nucl Cardiol. 2018 Jun;25(3):769-776
dr_luis_urna@outlook.com @LuisAlbertoUrna
PREDICTORS OF IN-HOSPITAL MORTALITY IN PATIENTS ADMITTED WITH AMI IN A DEVELOPING COUNTRY
dr_luis_urna@outlook.com
Cardiol Res. 2018 Oct;9(5):293-299. doi: 10.14740/cr772w. Epub 2018 Oct 7
Multivariate predictors of mortality
dr_luis_urna@outlook.com @LuisAlbertoUrna
IMPACT OF AN INVASIVE STRATEGY IN THE ELDERLY HOSPITALIZED WITH ACS WITH EMPHASIS ON THE NONAGENARIANS
dr_luis_urna@outlook.com
Catheter Cardiovasc Interv. 2018 Sep 30. doi: 10.1002/ccd.27877
Adjusted risk for in-hospital all-cause and cardiovascular mortality stratified by the revascularization strategy
DEATH CARDIOVASCULAR DEATH
dr_luis_urna@outlook.com @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
dr_luis_urna@outlook.com
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends in utilisation of percutaneous coronary angioplasty
dr_luis_urna@outlook.com @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
dr_luis_urna@outlook.com
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Percentage of percutaneous coronary angioplasty in age groups
dr_luis_urna@outlook.com @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
dr_luis_urna@outlook.com
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends of in-hospital mortality
dr_luis_urna@outlook.com @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
dr_luis_urna@outlook.com
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends of 12-month mortality
dr_luis_urna@outlook.com @LuisAlbertoUrna
INVASIVE TREATMENT OF NSTEMI PATIENTS IN GERMAN CHEST PAIN UNITS
dr_luis_urna@outlook.com
Int J Cardiol. 2018 Mar 15;255:15-19. doi: 10.1016/j.ijcard.2017.11.018
Kaplan-Meier survival curves for HIGHER (A) and LOWER (B) risk group
dr_luis_urna@outlook.com @LuisAlbertoUrna
- Mortality.- Myocardial infarction.- Recurrent angina.
COMPARISON OF THE PREDICTIVE ROLES OF RISK SCORES OF IN-HOSPITAL MAJOR ADVERSE CARDIOVASCULAR EVENTS IN PATIENTS WITH NSTEMI UNDERGOING PCI
dr_luis_urna@outlook.com
Med Princ Pract. 2018;27(5):459-465. doi: 10.1159/000489399. Epub 2018 Apr 19
Independent predictors of MACE: logistic regression analysis
dr_luis_urna@outlook.com @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
dr_luis_urna@outlook.com
Am J Cardiol. 2018 Jun 1;121(11):1285-1292. doi: 10.1016/j.amjcard.2018.01.051. Epub 2018 Mar 1
Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI <2 vs. ≥ 2 hours after admission
dr_luis_urna@outlook.com @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
dr_luis_urna@outlook.com
Am J Cardiol. 2018 Jun 1;121(11):1285-1292. doi: 10.1016/j.amjcard.2018.01.051. Epub 2018 Mar 1
Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI 2 - 24 hours (< 24) vs. ≥ 24 hours after admission
dr_luis_urna@outlook.com @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
dr_luis_urna@outlook.com
Am J Cardiol. 2018 Jun 1;121(11):1285-1292. doi: 10.1016/j.amjcard.2018.01.051. Epub 2018 Mar 1
Kaplan-Meier curves for 1-month, and 12-month death-free survival in patients who received PCI 24 - 72 hours (< 72) vs. ≥ 72 hours after admission
dr_luis_urna@outlook.com @LuisAlbertoUrna
PERCUTANEOUS CORONARY INTERVENTION VERSUS CONSERVATIVE TREATMENT FOR NSTEMI IN PATIENTS ABOVE 80 YEARS OF AGE
dr_luis_urna@outlook.com
Int J Cardiol. 2018 Sep 15;267:57-61. doi: 10.1016/j.ijcard.2018.05.078. Epub 2018 May 24
Age-adjusted Kaplan Meier Survival curves comparing survival functions of patients undergoing PCI vs conventional treatment
PCI
Conservative Treatment
dr_luis_urna@outlook.com @LuisAlbertoUrna
EARLY VERSUS DELAYED PCI IN PATIENTS WITH NSTEACS
dr_luis_urna@outlook.com
Coron Artery Dis. 2016 Aug;27(5):344-9. doi: 10.1097/MCA.0000000000000374
Clinical outcomes at 30 days and 12 months in stable high risk patients who went for EARLY PCI (<24 hours) or DELAYED PCI (>24 hours)
dr_luis_urna@outlook.com @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
dr_luis_urna@outlook.com
Heart Lung Circ. 2017 Nov;26(11):1142-1159. doi: 10.1016/j.hlc.2017.02.031. Epub 2017 Apr 11
Forest plot for recurrent myocardial infarction
dr_luis_urna@outlook.com @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
dr_luis_urna@outlook.com
Heart Lung Circ. 2017 Nov;26(11):1142-1159. doi: 10.1016/j.hlc.2017.02.031. Epub 2017 Apr 11
Forest plot for early mortality
dr_luis_urna@outlook.com @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
dr_luis_urna@outlook.com
Heart Lung Circ. 2017 Nov;26(11):1142-1159. doi: 10.1016/j.hlc.2017.02.031. Epub 2017 Apr 11
Forest plot for recurrent ischaemia
dr_luis_urna@outlook.com @LuisAlbertoUrna
SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI
dr_luis_urna@outlook.com
Eur Heart J Qual Care Clin Outcomes. 2017 Jan 1;3(1):53-60. doi: 10.1093/ehjqcco/qcw044
One-day cut-off—Outcomes for All-cause death (A) and Myocardial infarction (B)
Delay PCI
Early PCI
Delay PCI
Early PCI
dr_luis_urna@outlook.com @LuisAlbertoUrna
SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI
dr_luis_urna@outlook.com
Eur Heart J Qual Care Clin Outcomes. 2017 Jan 1;3(1):53-60. doi: 10.1093/ehjqcco/qcw044
Outcomes at 1 year in relation to delay of percutaneous coronary intervention procedure
dr_luis_urna@outlook.com @LuisAlbertoUrna
REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI
dr_luis_urna@outlook.com
Circ Cardiovasc Qual Outcomes. 2016 May;9(3):197-205. doi: 10.1161/CIRCOUTCOMES.115.002084. Epub 2016 May 10.
Trends in use of PCI, CABG, and medical management in NSTEMI patients with diabetes mellitus and multivessel coronary artery disease. 2008 - 2014
PCI rate
CABG rate
No Intervention
dr_luis_urna@outlook.com @LuisAlbertoUrna
REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI
dr_luis_urna@outlook.com
Circ Cardiovasc Qual Outcomes. 2016 May;9(3):197-205. doi: 10.1161/CIRCOUTCOMES.115.002084. Epub 2016 May 10.
Proportional use of different revascularization strategies across patient subgroups stratified by the angiographic severity of CAD. 2008 - 2014
P
C
I
P
C
I
P
C
I
P
C
I
dr_luis_urna@outlook.com @LuisAlbertoUrna
CABG
No Intervention
SMILE: SINGLE-STAGED COMPARED WITH MULTI-STAGED PCI IN MULTIVESSEL NSTEMI PATIENTS
dr_luis_urna@outlook.com
J Am Coll Cardiol. 2016 Jan 26;67(3):264-72. doi: 10.1016/j.jacc.2015.10.082
1-Year Clinical Events According to Randomized Allocation
dr_luis_urna@outlook.com @LuisAlbertoUrna
CONCLUSIONES
• ¿Cuándo deberíamos intervenir un IAMSEST?
• Siempre.
• ¿En qué momento deberíamos hacerlo?
• Dependerá de la estratificación de riesgo del paciente.
• Recordar que el IAMSEST es el infarto que se presenta con más frecuencia.
dr_luis_urna@outlook.comdr_luis_urna@outlook.com @LuisAlbertoUrna
Ciudad de Panamá, Panamá Santa Cruz, Bolivia
Gracias…
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