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Dr Satyam Rajvanshi
PGIMER & RML Hospital
New Delhi
LATE PRESENTERS
(symptom duration more than 12 hours)
EHJ 2009;30:1322–30
EHJ 2006;27:779–88
(LATE) Lancet 1993;342:759–766
(EMERAS) Lancet 1993;342:767–772
FACTORS RELATED TO
rd
NO REPERFUSION THERAPY – 1/3 patients!
• Age >75 years
• Prior CHF/MI/CABG
• DELAYED PRESENTATION
• Female gender
• Diabetes
• Pulmonary edema
• Systolic pressure <100 mm Hg
(GRACE) Lancet 2002;359:373–377
• CIns to PCI/thrombolysis (<3%)
(NRMI) Am Heart J 2008;156:1035-1044
• Spontaneous reperfusion (11%)
“An open IRA may be beneficial,
by preventing LV dilatation and
improving survival by limiting infarct size
and associated deterioration of LV function,
by mechanisms such as -
Prevention of adverse LV remodelling
Electrical stability
Collaterals to remaining viable myocardium”
REAL LIFE SCENARIOS
Mr. A
54/Male
Smoker
Ongoing chest pain since 14 hours
STE in V2-V6, Intermittent NSVT
98/64
RWMA in LAD territory; Moderate LVSD
Troponin positive
Mrs. B
62/Female
Uncontrolled diabetes, Hypertensive, Obese
Ghabraahat with sweating last night 16 hours back – now minimal
Sinus tachycardia, QS in V2-V3, STE in V2-V6
154/88
RWMA in LAD territory; Moderate LVSD
Troponin positive
What does the evidence say?
Severe Angina
Intermediate or high risk positive pre-discharge stress test
(SWISSI-2) JAMA 2007;297:1985–91
(DANAMI) Circulation 1997;96:748 –55
Approach is tricky!
EVIDENCE for Mrs. B ?
BRAVE-2
365 STEMI pts 12-48 hrs after onset
WITHOUT persistent symptoms
Randomised to PCI/Med Rx
Randomised to PCI/Med Rx
Randomised to PCI/Med Rx
PE – 12 mo All-cause mortality
Polish registry
PE – Death/MI/Class IV HF
PE – Death/MI/Class IV HF
PE – Death/MI/Class IV HF
PE – Death/MI/Class IV HF
PE – Death/MI/Class IV HF
EHJ 2009;30:1322–30
396 STEMI pts 30 min-72 hours after
symptom onset
EHJ 2006;27:1900-1907
5 RCTs; 648 hemodynamically stable pts >12 hours to 6 weeks post MI
With totally occluded IRA
YES, WE CAN!
10 RCTs; 3560 hemodynamically stable pts >12 hours to 60 days post MI
JACC 2008;51:956-64
JACC 2008;51:956-64
JACC 2008;51:956-64
• Stable patient presenting <72 hrs – CAG with intent for revascularization
(Mild or No Symptoms / Stable Hemodynamics)
• A practical approach
• Stable patient presenting <72 hrs – CAG with intent for revascularization
(Mild or No Symptoms / Stable Hemodynamics)