Kỹ thuật nào là tốt nhất cho can thiệp mạch vành cấp

What is the Best Technology for Primary PCI? Adj Assoc Prof Yeo Khung Keong Senior Consultant, Cardiology Oct 2016 Best Technology Cath Lab Stent Balloon Drugs Team! STEMI Guidelines • ESC: 2012, 2014 • ACC/AHA: 2013, 2015 Best Technology • • • • Drugs Culprit vs non-culprit PCI Aspiration thrombectomy DES vs BMS Antiplatelet therapy Other Antithrombotics • Heparin or bivalirudin • Glycoprotein IIb/IIIa antagonist with heparin or bivalirudin (Class IIA indication) Aspiration Thrombectomy 10 Key points • Staged PCI ‘discouraged’ • Immediate PCI of lesions >50% • Vs No further PCI 33 34 35 36 Cvlprit – total mortality, recurrent MI, heart failure, revascularisation Gershlick et al ESC 2014 37 The Third DANish Study of Optimal Acute Treatment of Patients with STsegment Elevation Myocardial Infarction PRImary PCI in MULTIvessel Disease - DANAMI3-PRIMULTI Thomas Engstrøm, MD, DMSci, PhD Rigshospitalet, University of Copenhagen, Denmark 38 DANAMI3-TRIAL PROGRAM 2239 STEMI < 12 hours Randomise conventional PPCI, iPOST, defer stenting 2212 Successful infarct related artery PCI 627 Multivessel disease (>50% stenosis in non IRA > mm suitable for PCI) Randomise 313 IRA PCI only 314 FFR guided complete revascularisation PCI before discharge 39 Primary endpoint Composite • All-cause mortality • Nonfatal myocardial infarction • Ischemia driven revascularization of non IRA lesions Assessed when the last included patient had been followed for year DANAMI3-PRIMULTI 40 Complications DANAMI3-PRIMULTI 41 Primary endpoint DANAMI3-PRIMULTI 42 Individual components of primary endpoint Composite Non fatal MI Revascularisation All cause death DANAMI3-PRIMULTI 43 DANAMI3-PRIMULTI • Complete FFR guided revascularisation of multivessel disease, staged within the index admission, reduced primary endpoint of death, re-MI and revascularisation • Reduction driven by repeat revascularisations • Although complete revascularisation should be recommended, any condition that makes complex PCI unattractive may support a more conservative strategy of IRA PCI only 44 Conclusion • Revascularization of non-culprit vessel reasonable but not mandated • Consider FFR guidance • Consider individual patient and anatomical characteristics • If possible, within index admission 45 Summary • Use appropriate adjunctive medical therapy including antiplatelets • DES if cost not concern • Aspiration thrombectomy: no longer routine but on case-by-case basis • PCI of non-culprit vessel: FFR guided, case-bycase basis 46 47 47 ... • • 13 Open label, RCT, Registry-based N=7244 Primary end-point: all cause mortality No significant difference 14 15 • N=10732, RCT • Primary: composite of CV death, MI, shock or NYHA IV (in