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.
[email protected][email protected] @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
[email protected] @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
[email protected] @LuisAlbertoUrna
GLOBAL AND REGIONAL PATTERNS IN CV MORTALITY FROM 1990 TO 2013
Gregory A. Roth et al. Circulation. 2015;132:1667-1678
[email protected] @LuisAlbertoUrna
¿CUÁNDO DEBERÍAMOS INTERVENIR UN IAMSEST?
¿En qué momentodeberíamos intervenir?
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
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
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
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
[email protected] @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.
European Heart Journal (2016) 37, 267-315
[email protected] @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.
European Heart Journal (2016) 37, 267-315
[email protected] @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.
European Heart Journal (2016) 37, 267-315
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
European Heart Journal (2016) 37, 267-315Neth Heart J (2017) 25:181–185
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
European Heart Journal (2016) 37, 267-315Neth Heart J (2017) 25:181–185
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
J Nucl Cardiol. 2018 Jun;25(3):769-776
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
J Nucl Cardiol. 2018 Jun;25(3):769-776
[email protected] @LuisAlbertoUrna
¿EN QUÉ MOMENTO DEBEMOS INTERVENIR SEGÚN LAS GUÍAS CLÍNICAS?
J Nucl Cardiol. 2018 Jun;25(3):769-776
[email protected] @LuisAlbertoUrna
PREDICTORS OF IN-HOSPITAL MORTALITY IN PATIENTS ADMITTED WITH AMI IN A DEVELOPING COUNTRY
Cardiol Res. 2018 Oct;9(5):293-299. doi: 10.14740/cr772w. Epub 2018 Oct 7
Multivariate predictors of mortality
[email protected] @LuisAlbertoUrna
IMPACT OF AN INVASIVE STRATEGY IN THE ELDERLY HOSPITALIZED WITH ACS WITH EMPHASIS ON THE NONAGENARIANS
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
[email protected] @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends in utilisation of percutaneous coronary angioplasty
[email protected] @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Percentage of percutaneous coronary angioplasty in age groups
[email protected] @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends of in-hospital mortality
[email protected] @LuisAlbertoUrna
PL-ACS: IMPACT OF ROUTINE INVASIVE STRATEGY ON OUTCOMES IN PATIENTS WITH NSTEMI DURING 2005 - 2014
Cardiol J. 2018 Nov 8. doi: 10.5603/CJ.a2018.0136. [Epub ahead of print]
Temporal trends of 12-month mortality
[email protected] @LuisAlbertoUrna
INVASIVE TREATMENT OF NSTEMI PATIENTS IN GERMAN CHEST PAIN UNITS
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
[email protected] @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
Med Princ Pract. 2018;27(5):459-465. doi: 10.1159/000489399. Epub 2018 Apr 19
Independent predictors of MACE: logistic regression analysis
[email protected] @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
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
[email protected] @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
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
[email protected] @LuisAlbertoUrna
KAMIR-NIH: OPTIMAL TIMING OF PCI IN PATIENTS WITH NSTEMI COMPLICATED BY ACUTE DECOMPENSATED HEART FAILURE
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
[email protected] @LuisAlbertoUrna
PERCUTANEOUS CORONARY INTERVENTION VERSUS CONSERVATIVE TREATMENT FOR NSTEMI IN PATIENTS ABOVE 80 YEARS OF AGE
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
[email protected] @LuisAlbertoUrna
EARLY VERSUS DELAYED PCI IN PATIENTS WITH NSTEACS
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)
[email protected] @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
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
[email protected] @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
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
[email protected] @LuisAlbertoUrna
EARLY VERSUS DELAYED INVASIVE STRATEGIES IN HIGH-RISK NSTEACS. A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS OF RCT
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
[email protected] @LuisAlbertoUrna
SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI
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
[email protected] @LuisAlbertoUrna
SWEDEHEART: TIMING OF PCI IN PATIENTS WITH STEMI
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
[email protected] @LuisAlbertoUrna
REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI
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
[email protected] @LuisAlbertoUrna
REVASCULARIZATION TRENDS IN PATIENTS WITH DIABETES MELLITUS AND MULTIVESSEL CORONARY ARTERY DISEASE PRESENTING WITH NSTEMI
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
[email protected] @LuisAlbertoUrna
CABG
No Intervention
SMILE: SINGLE-STAGED COMPARED WITH MULTI-STAGED PCI IN MULTIVESSEL NSTEMI PATIENTS
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
[email protected] @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.
[email protected][email protected] @LuisAlbertoUrna
Ciudad de Panamá, Panamá Santa Cruz, Bolivia
Gracias…