stemi patient and hypothermia - static.livemedia.gr · the ideal stemi patient for with hypothermia...
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STEMI patient and Hypothermia
Grigoris Karamasis
Consultant Interventional Cardiologist
Essex Cardiothoracic Centre, UK
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• I do not have any disclosures
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Cardio-protection against myocardial reperfusion injury
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Infarct Size and Prognosis
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Partial List of pharmacologic studies toreduce Reperfusion Injury that failed!
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Hypothermia for cardio-protection in experimental MI
> 150 publications
Abendschein DR, Tacker WA Jr, Babbs CF. Protection of ischemic myocardium by whole-body hypothermia after
coronary artery occlusion in dogs. Am Heart J 1978;96:772–780.
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Hypothermia prior to reperfusion!
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Delay of reperfusion, but benefit in IS
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Hypothermia in STEMI patientsEarly studies
• Primary endpoints not achieved
• Only 1/3 of the patients reached ≤35°C at the time of reperfusion
• In anterior STEMI patients cooled to ≤35ºC before reperfusion, a trend for
reduction in ISO’Neil et al. TCT 2003
Grines et al. TCT 2004
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CHILL – MI trial
• Randomised control trial
• 120 anterior + inferior STEMIs < 6h
• Rapid intravascular cooling + infusion cold saline
• Primary endpoint: Infarct Size/Myocardium at Risk at 4±2 days
Erlinge et al. JACC 2014 13;63:1857-65
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CHILL-MI: Infarct size by location when symptom onset < 4 hrs
Erlinge, ECS 2015
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The ideal STEMI patient for with hypothermia treatment
• Early presenter (4-6h)
• Large area at risk (anterior STEMI)
• Fast cooling
• Low T prior to reperfusion
Erlinge et al. Ther Hypothermia Temp Manag. 2015 ;5:77-84.
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COOL AMI EU Pilot study
Conclusions:
• Rapid cooling of anterior STEMIs is
feasible and safe
• Reperfusion T was 33.6oC ( ≥1.1oC
than previous studies)
• No AE, except self terminating AF
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COOL-AMI EU Pivotal Trial
• Multicenter, Prospective, Randomized-Controlled Trial
• Primary PCI + Hypothermia vs. primary PCI alone
• Intravascular Hypothermia with ZOLL Proteus IVTM System
• 18 minutes of cooling prior to reperfusion
• Sample size : 468 anterior STEMIs < 6h
• Primary endpoint: IS in CMR 4-6 days
• ClinicalTrials.gov: NCT03173313
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COOL AMI EU program in Greece
Alexandra Hospital, Athens
PI: Ass. Prof. Kimon Stamatelopoulos
University Hospital, Ioannina
PI: Prof. Lampros Michalis
University Hospital,
Patra
PI: Prof. George Hahalis
Ippokrateio Hospital, Athens
PI: Prof. Petros Nihoyannopoulos
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ZOLL Proteus Intravascular Temperature Management system (1)
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ZOLL Proteus Intravascular Temperature Management system (2)
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Anti-shivering treatment
• Initiated before start of cooling
• Buspirone 60 mg p.o.
• Pethidine bolus + infusion
• Bair Hugger® for skin counter-warming
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Case 1
• 51 year old male
• BG: NIDDM, Smoker
• Sudden onset of typical cardiac chest pain at 06:30 am
• ECG : Inferior STEMI
• Recruited in COOL AMI EU pilot
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Case 1 Diagnostic coronary angiography
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Case 1 PCI results, d/c, f/up
• Self-terminated asymptomatic AF (100-115 b/min) during cooling
• Patient discharged on day 3
• Asymptomatic in 12 months f/up
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Case 1
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Baked Alaska
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Case 2
• 39 year old male
• No past medical history
• Ex-smoker
• Sudden onset of typical cardiac chest pain at 12:50 pm
• ECG: anterior STEMI
• Recruited in COOL AMI EU pilot
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Case 2 Diagnostic coronary angiography
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Case 2 However...
• VF arrest
• Multiple DCCV
• DCCV and patient agitation hadcaused loss of guide catheterposition
• LAD occluded at fist angio shot
• Attempts to wire LAD challengingdue to anatomy and on-going e-CPR
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Case 2
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Case 2
• 30 minutes CPR
• Back to ROSC after stent deployment
• Transferred intubated to ITU
• Ex-tubated day 1
• Angio for stent optimisation IVUS guided – day 4
• D/c home day 6
• Asymptomatic at 12 months f/up
• Cause of VF arrest (advisory & safety board) : vessel re-occlusion
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Intra-coronary coolingAn alternative ?
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Conclusions
• Hypothermia consistently reduces infarct size in animal models
• Hypothermia in STEMI is feasible and safe
• Previous clinical trials: benefit of hypothermia in specific sub groups (early presenters with anterior STEMI , lower temperature at reperfusion)
• COOL-AMI EU Pivotal on going multicenter RCT
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Hypothermia and Stent Thrombosis
• CA patients with AMI undergoing PCI 2006 – 2011
• 49,109 CA patients
• 1,193 (2.4%) underwent TH
• ST : 3.9% vs. 4.7%, p = 0.61
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